Anglonautes > Vocapedia > English words, vocabulary, dictionary, encyclopedia > 2000s - 2010s - 2020s > UK, USA > Subject, topic > Mental health, Psychology, Psychiatry > Psychologists, Psychoanalysts, Psychotherapy, Psychiatrists, DSM

I was giving a lecture in New York not all that long ago. I was talking about ideals. The audience was made up of therapists and therapists in training at the eminent William Alanson White Institute on the Upper West Side. After the talk was over, I was asked a remarkable question. Certainly it was the best-posed question that I have ever gotten at a talk.

The question came from a man wearing an elegant but disheveled suit. It was the end of the day, after all. His tie was loose around his collar. He had an air of friendly exasperation on his face. He was clearly a psychotherapist of some kind. What he said went something like this:

“You’ve been talking to us tonight about ideals and you’ve been trying to make a case for them. You talked about the hero, as he exists in Homer and Virgil. You talked about Aeneas and Hector and Achilles, and described them as three instances of the heroic ideal. Then you went on to talk about what you wanted to call the saint. You pointed to Jesus and Buddha and Confucius. You said they exemplified the compassionate ideal. Then there was one more: the contemplative ideal. And that was exemplified by Plato. Plato, you said, was a figure who tried to get at the whole truth, the eternal truth and nothing but the truth.”

I could see that my questioner was now working a little harder to hold back his impatience. There was something he didn’t like in what I was saying — that he really didn’t like. But he was doing his best to control himself. He wanted to keep matters urbane and he was doing a good job. As to me, I was taking what I thought of as tantric breaths.

My questioner continued:

“And you’re saying that these ideals of yours — courage and compassion and contemplation — aren’t relics of the ancient world. You want us to see them as real possibilities, here and now. You concede that we in the West live in a culture that rewards pragmatism and skepticism. But you think that young people in particular ought to consider arranging their lives around these ideals. This young man might be a thinker; this young woman a warrior; another young person might live for compassion. Is that right?”

I admitted that this was the case. I said that I wanted to use these great works of the past, and the idealist tradition, to help young people (and all people, really) to think about their lives and maybe to change them. I wanted to use what I knew — and all that I knew I knew through others — to help create what the philosopher William James thought of as “living options.”

My questioner was a genial man, clearly. But he was beginning to steam. Now was the moment for him to deliver the bad news.

“If someone came into my office,” he said, “and told me that he wanted to find the enduring truth, or become saintly, or be a heroic warrior, I know exactly what I’d say to him. I’d say, ‘You are suffering from neurosis (at the very least) and you are in need of therapy, the sooner the better.’ For there are no true ideals, only idealizations. Your so-called ideals are merely sources of delusion.”

The room murmured its assent. Actually it more than murmured assent; it all but broke into applause.

O.K., so he really wasn’t asking a question. It was more like an indictment. My talk, and my teaching from which the talk arose, were apparently inducements to mental illness, minor or major. Ideals were myths, and they could lead you into serious trouble. This was Freud’s view, I understood, and though psychotherapy has veered from Freud in many regards, it will not be easy for anyone to find a therapist who will tell you that the best way to overcome your psychological difficulties is to embrace an ideal.

What’s so bad about ideals from this point of view? A psychotherapist might say that ideals make you feel too good, at least at the outset. Embracing an ideal can produce what we might call unity of being. All of a sudden, you know (or think you know) what life is all about. You know what to do in the world. This brings a sense of confidence and purpose. You always know what you are supposed to do. Be brave! Be compassionate! Think and find the truth! You may not live up to these ideals all the time, but knowing what you are supposed to be and do confers an assurance and stability that you probably did not have before.

Most of the time, the descendants of Freud tell us, we are fractured beings. Our various desires move in disparate directions, and often contrary directions at that. For the therapist, we are not one self, but two or three. Psychoanalysts speak of the ego and the id, and also of the superego. These three internal powers desire different results in the world, and they often, to say the least, get in each other’s way. To put it crudely, the superego wants perfection; the ego wants balance and calm; the id wants everything it can get: power and money and sex and maybe a little more sex afterward.

So what’s so bad about a form of belief and commitment that stabilizes the self? What’s so bad about the unity that ideals can bring by drawing all of the individual’s energy in one direction?

To this, psychotherapy has an abrupt answer: It doesn’t work. What you’re calling ideals are really intoxicating untruths. Ideals make you drunk, and the hangover that follows is bitter. To use Wordsworth for a moment: “As high as we have mounted in delight/ In our dejection do we sink as low.” To which the therapist might reply: “As low? I’d say far lower.”

Ideals don’t work, says the therapist. If you follow the compassionate ideal, open your heart completely and say that there is no difference between you and others in the world, people will take advantage of you. And you’ll outrage your own sense of entitlement to the good things in life. You’ll see that your compassionate ministrations don’t do much good for others and that they wear you out.

You’ll discover too that subscribing to the heroic ideal may well get you killed or maimed in a war that is unjust. When you come home, if you come home, people will treat you with indifference and maybe even disdain. What a sucker you were. And the deep motivation of so-called heroes, Freud tells us, is not really courage; it is the narcissistic belief that though others may well be doomed to die, you are immortal.

As to the Platonic desire to know the truth for all time, it is also a form of narcissism, a prideful aspiration. Psychoanalysis even has a name for it: epistemophilia. (Worse than the flu, no doubt.) Though Freud himself may have had a touch of this malady, it is clear that psychotherapy overall considers the claim to know all that is truly worth knowing to be at least on the border of pathology.

Who is right, the idealists or the therapists?

Well, if you judge by our present cultural climate, you would have to say that the therapists are. Though surely there are people who commit themselves to being compassionate, or being brave, or getting at the truth, most people in the West do not. They seek a decent life that is reasonably prosperous and secure and is oriented to family and stability. They try to balance their desires. Even if they don’t use psychoanalytical terms, I think it is fair to say that they try to do a little something every day for the id and for the superego and for the ego. The psyche, says Carl Jung, must learn how to make deals.

The idealist is the one who will not make deals. He puts all his resources on one spot — courage or compassion or truth — and then goes for it. He may triumph. He may crash and burn. He may, in time, do both.

What the great tradition of Plato and Homer and Buddha and the rest tells us is that the measured, modulated life is not for everyone. Some of us need to risk more in order to gain more: “spending for vast returns,” as Whitman said. Certain people who are deprived of the chance to do so will grow weary and sick of life. They need to play for higher stakes than most of their contemporaries.

This game is not for everyone, to be sure. Many of us, perhaps most, need the life of the balanced self. This is the life that therapists have done a great deal to make available to us. But when the therapist says that ideals are a form of pathology, then I think he is overreaching, cutting off chances for people and maybe even contributing something to making them ill in spirit.

I told my perceptive questioner all this, or something much like it. He sat down and smiled a therapist’s benevolent smile, secure no doubt that in time, I would learn.

But then again, maybe he will.

Mark Edmundson, a professor of English
at the University of Virginia,
is the author of “Self and Soul: A Defense of Ideals.”

The Idealist Versus the Therapist,
AUGUST 18, 2015,
NYT,
https://archive.nytimes.com/opinionator.blogs.nytimes.com/2015/08/18/
the-idealist-versus-the-therapist/

Psychotherapy’s Image Problem

September 29, 2013

The New York Times

By BRANDON A. GAUDIANO

PROVIDENCE, R.I. — PSYCHOTHERAPY is in decline. In the United States, from 1998 to 2007, the number of patients in outpatient mental health facilities receiving psychotherapy alone fell by 34 percent, while the number receiving medication alone increased by 23 percent.

This is not necessarily for a lack of interest. A recent analysis of 33 studies found that patients expressed a three-times-greater preference for psychotherapy over medications.

As well they should: for patients with the most common conditions, like depression and anxiety, empirically supported psychotherapies — that is, those shown to be safe and effective in randomized controlled trials — are indeed the best treatments of first choice. Medications, because of their potential side effects, should in most cases be considered only if therapy either doesn’t work well or if the patient isn’t willing to try counseling.

So what explains the gap between what people might prefer and benefit from, and what they get?

The answer is that psychotherapy has an image problem. Primary care physicians, insurers, policy makers, the public and even many therapists are largely unaware of the high level of research support that psychotherapy has. The situation is exacerbated by an assumption of greater scientific rigor in the biologically based practices of the pharmaceutical industries — industries that, not incidentally, also have the money to aggressively market and lobby for those practices.

For the sake of patients and the health care system itself, psychotherapy needs to overhaul its image, more aggressively embracing, formalizing and promoting its empirically supported methods.

My colleague Ivan W. Miller and I recently surveyed the empirical literature on psychotherapy in a series of papers we edited for the November edition of the journal Clinical Psychology Review. It is clear that a variety of therapies have strong evidentiary support, including cognitive-behavioral, mindfulness, interpersonal, family and even brief psychodynamic therapies (e.g., 20 sessions).

In the short term, these therapies are about as effective as medications in reducing symptoms of clinical depression or anxiety disorders. They can also produce better long-term results for patients and their family members, in that they often improve functioning in social and work contexts and prevent relapse better than medications.

Given the chronic nature of many psychiatric conditions, the more lasting benefits of psychotherapy could help reduce our health care costs and climbing disability rates, which haven’t been significantly affected by the large increases in psychotropic medication prescribing in recent decades.

Psychotherapy faces an uphill battle in making this case to the public. There is no Big Therapy to counteract Big Pharma, with its billions of dollars spent on lobbying, advertising and research and development efforts. Most psychotherapies come from humble beginnings, born from an initial insight in the consulting office or a research finding that is quietly tested and refined in larger studies.

The fact that medications have a clearer, better marketed evidence base leads to more reliable insurance coverage than psychotherapy has. It also means more prescriptions and fewer referrals to psychotherapy.

But psychotherapy’s problems come as much from within as from without. Many therapists are contributing to the problem by failing to recognize and use evidence-based psychotherapies (and by sometimes proffering patently outlandish ideas). There has been a disappointing reluctance among psychotherapists to make the hard choices about which therapies are effective and which — like some old-fashioned Freudian therapies — should be abandoned.

There is a lot of organizational catching up to do. Groups like the American Psychiatric Association, which typically promote medications as treatments of first choice, have been publishing practice guidelines for more than two decades, providing recommendations for which treatments to use under what circumstances. The American Psychological Association, which promotes psychotherapeutic approaches, only recently formed a committee to begin developing treatment guidelines.

Professional psychotherapy organizations also must devote more of their membership dues and resources to lobbying efforts as well as to marketing campaigns targeting consumers, primary care providers and insurers.

If psychotherapeutic services and expenditures are not based on the best available research, the profession will be further squeezed out by a health care system that increasingly — and rightly — favors evidence-based medicine. Many of psychotherapy’s practices already meet such standards. For the good of its patients, the profession must fight for the parity it deserves.

Brandon A. Gaudiano is a clinical psychologist

and assistant professor of psychiatry

and human behavior

at the Alpert Medical School at Brown University.

Psychotherapy’s Image Problem,
NYT,
29.9.2013,
http://www.nytimes.com/2013/09/30/opinion/psychotherapys-image-problem.html

George A. Miller,

a Pioneer in Cognitive Psychology,

Is Dead at 92

August 1, 2012
The New York Times
By PAUL VITELLO

Psychological research was in a kind of rut in 1955 when George A. Miller, a professor at Harvard, delivered a paper titled “The Magical Number Seven, Plus or Minus Two,” which helped set off an explosion of new thinking about thinking and opened a new field of research known as cognitive psychology.

The dominant form of psychological study at the time, behaviorism, had rejected Freud’s theories of “the mind” as too intangible, untestable and vaguely mystical. Its researchers instead studied behavior in laboratories, observing and recording test subjects’ responses to carefully administered stimuli. Mainly, they studied rats.

Dr. Miller, who died on July 22 at his home in Plainsboro, N.J., at the age of 92, revolutionized the world of psychology by showing in his paper that the human mind, though invisible, could also be observed and tested in the lab.

“George Miller, more than anyone else, deserves credit for the existence of the modern science of mind,” the Harvard psychologist and author Steven Pinker said in an interview. “He was certainly among the most influential experimental psychologists of the 20th century.”

Dr. Miller borrowed a testing model from the emerging science of computer programming in the early 1950s to show that humans’ short-term memory, when encountering the unfamiliar, could absorb roughly seven new things at a time.

When asked to repeat a random list of letters, words or numbers, he wrote, people got stuck “somewhere in the neighborhood of seven.”

Some people could recall nine items on the list, some fewer than seven. But regardless of the things being recalled — color-words, food-words, numbers with decimals, numbers without decimals, consonants, vowels — seven was the statistical average for short-term storage. (Long-term memory, which followed another cognitive formula, was virtually unlimited.)

Dr. Miller could not say why it was seven. He speculated that survival might have favored early humans who could retain “a little information about a lot of things” rather than “a lot of information about a small segment of the environment.”

But that, he concluded, was beside the point. He had articulated an idea that was to become a touchstone of cognitive science: that whatever else the brain might be, it was an information processor, with systems that obeyed mathematical rules, that could be studied.

Dr. Miller, who was trained in behaviorism, was among the first of many researchers and theorists to challenge its scientific principles in the 1950s. He and a colleague, Jerome S. Bruner, gave a name to the new research field when they established a psychology lab of their own, the Center for Cognitive Studies, at Harvard in 1960. Just by employing the word “cognitive,” considered taboo among behaviorists, they signaled a break with the old school.

“Using ‘cognitive’ was an act of defiance,” Dr. Miller wrote in 2006. “For someone raised to respect reductionist science, ‘cognitive psychology’ made a definite statement. It meant that I was interested in the mind.”

That new approach to psychological research came to be known as the cognitive revolution.

Dr. Miller’s first and most enduring interest as a scientist was language. His first book, “Language and Communication” (1951), is widely considered a foundational work in psycholinguistics, the study of how people learn, use and invent language. He collaborated with the linguist Noam Chomsky in groundbreaking papers on the mathematics of language and the computational problems involved in interpreting syntax.

He conducted some of the first experiments on how people understand words and sentences, the basis of computer speech-recognition technology. “Plans and the Structure of Behavior” (1960), written with Eugene Galanter and Karl H. Pribram, was an effort to synthesize artificial-intelligence research with psychological research on how humans initiate action — basically, a book about how to build a better robot. Beginning in 1986, he oversaw the development of WordNet, an electronic reference databank intended to help computers understand human language.

Colleagues said he had a role in framing many of his era’s most audacious thoughts about human and artificial thinking; typically, he then moved on to other projects.

“Like most great scientists, he became interested in some phenomenon or other and then simply jumped in to try to illuminate the problem,” said Michael S. Gazzaniga, a leading researcher in cognitive neuroscience at the University of California, Santa Barbara. Dr. Miller helped create the field of cognitive neuroscience in the late 1980s, he said. “He was exceptionally generous.”

George Armitage Miller was born on Feb. 3, 1920, in Charleston, W.Va., the only child of Florence and George Miller, who divorced when he was a child. His father was a steel company executive.

Mr. Miller and his first wife, Katherine, who died in 1996, married while both were undergraduates at the University of Alabama. After graduating with a bachelor’s degree in English and speech, Mr. Miller received his master’s degree and Ph.D. in psychology at Harvard, serving in the Army Signal Corps during World War II in between.

He taught at Harvard beginning in 1955, heading its psychology department from 1964 until 1967, and later taught at Rockefeller University in New York and at the Massachusetts Institute of Technology. He joined the faculty of Princeton in 1979, founded the Cognitive Science Laboratory there and became a professor emeritus in 1990.

His survivors include his wife, Margaret, whom he married in 2008; a son, Donnally; a daughter, Nancy Saunders; and three grandchildren.

Dr. Miller’s paper on the number seven, which he read on April 5, 1955, at a meeting of the Eastern Psychological Association in Philadelphia, opened with a memorable line: “My problem is that I have been persecuted by an integer.”

He went on to make a topical reference to the Communist scare of the McCarthy era: “The persistence with which this number plagues me is far more than a random accident. There is, to quote a famous senator, a design behind it.”

The paper’s ground-shifting implications made it one of the most frequently quoted texts in the canon of modern psychology (and by Dr. Miller’s account, one of the most misquoted). For better or worse, “The Magical Number Seven” came to haunt his scientific career, overshadowing his many other accomplishments.

It resonated more playfully in his golf game. “He made the one and only hole-in-one of his life at the age of 77, on the seventh green” at the Springdale Golf Club in Princeton, his daughter said. “He made it with a seven iron. He loved that.”

    George A. Miller, a Pioneer in Cognitive Psychology, Is Dead at 92,
    NYT, 1.8.2012,
    http://www.nytimes.com/2012/08/02/us/
    george-a-miller-cognitive-psychology-pioneer-dies-at-92.html

When Your Therapist

Is Only a Click Away

September 23, 2011
The New York Times
By JAN HOFFMAN

THE event reminder on Melissa Weinblatt’s iPhone buzzed: 15 minutes till her shrink appointment.

She mixed herself a mojito, added a sprig of mint, put on her sunglasses and headed outside to her friend’s pool. Settling into a lounge chair, she tapped the Skype app on her phone. Hundreds of miles away, her face popped up on her therapist’s computer monitor; he smiled back on her phone’s screen.

She took a sip of her cocktail. The session began.

Ms. Weinblatt, a 30-year-old high school teacher in Oregon, used to be in treatment the conventional way — with face-to-face office appointments. Now, with her new doctor, she said: “I can have a Skype therapy session with my morning coffee or before a night on the town with the girls. I can take a break from shopping for a session. I took my doctor with me through three states this summer!”

And, she added, “I even e-mailed him that I was panicked about a first date, and he wrote back and said we could do a 20-minute mini-session.”

Since telepsychiatry was introduced decades ago, video conferencing has been an increasingly accepted way to reach patients in hospitals, prisons, veterans’ health care facilities and rural clinics — all supervised sites.

But today Skype, and encrypted digital software through third-party sites like CaliforniaLiveVisit.com, have made online private practice accessible for a broader swath of patients, including those who shun office treatment or who simply like the convenience of therapy on the fly.

One third-party online therapy site, Breakthrough.com, said it has signed up 900 psychiatrists, psychologists, counselors and coaches in just two years. Another indication that online treatment is migrating into mainstream sensibility: “Web Therapy,” the Lisa Kudrow comedy that started online and pokes fun at three-minute webcam therapy sessions, moved to cable (Showtime) this summer.

“In three years, this will take off like a rocket,” said Eric A. Harris, a lawyer and psychologist who consults with the American Psychological Association Insurance Trust. “Everyone will have real-time audiovisual availability. There will be a group of true believers who will think that being in a room with a client is special and you can’t replicate that by remote involvement. But a lot of people, especially younger clinicians, will feel there is no basis for thinking this. Still, appropriate professional standards will have to be followed.”

The pragmatic benefits are obvious. “No parking necessary!” touts one online therapist. Some therapists charge less for sessions since they, too, can do it from home, saving on gas and office rent. Blizzards, broken legs and business trips no longer cancel appointments. The anxiety of shrink-less August could be, dare one say ... curable?

Ms. Weinblatt came to the approach through geographical necessity. When her therapist moved, she was apprehensive about transferring to the other psychologist in her small town, who would certainly know her prominent ex-boyfriend. So her therapist referred her to another doctor, whose practice was a day’s drive away. But he was willing to use Skype with long-distance patients. She was game.

Now she prefers these sessions to the old-fashioned kind.

But does knowing that your therapist is just a phone tap or mouse click away create a 21st-century version of shrink-neediness?

“There’s that comfort of carrying your doctor around with you like a security blanket,” Ms. Weinblatt acknowledged. “But,” she added, “because he’s more accessible, I feel like I need him less.”

The technology does have its speed bumps. Online treatment upends a basic element of therapeutic connection: eye contact.

Patient and therapist typically look at each other’s faces on a computer screen. But in many setups, the camera is perched atop a monitor. Their gazes are then off-kilter.

“So patients can think you’re not looking them in the eye,” said Lynn Bufka, a staff psychologist with the American Psychological Association. “You need to acknowledge that upfront to the patient, or the provider has to be trained to look at the camera instead of the screen.”

The quirkiness of Internet connections can also be an impediment. “You have to prepare vulnerable people for the possibility that just when they are saying something that’s difficult, the screen can go blank,” said DeeAnna Merz Nagel, a psychotherapist licensed in New Jersey and New York. “So I always say, ‘I will never disconnect from you online on purpose.’ You make arrangements ahead of time to call each other if that happens.”

Still, opportunities for exploitation, especially by those with sketchy credentials, are rife. Solo providers who hang out virtual shingles are a growing phenomenon. In the Wild Web West, one site sponsored a contest asking readers to post why they would seek therapy; the person with the most popular answer would receive six months of free treatment. When the blogosphere erupted with outrage from patients and professionals alike, the site quickly made the applications private.

Other questions abound. How should insurance reimburse online therapy? Is the therapist complying with licensing laws that govern practice in different states? Are videoconferencing sessions recorded? Hack-proof?

Another draw and danger of online therapy: anonymity. Many people avoid treatment for reasons of shame or privacy. Some online therapists do not require patients to fully identify themselves. What if those patients have breakdowns? How can the therapist get emergency help to an anonymous patient? “A lot of patients start therapy and feel worse before they feel better,” noted Marlene M. Maheu, founder of the TeleMental Health Institute, which trains providers and who has served on task forces to address these questions. “It’s more complex than people imagine. A provider’s Web site may say, ‘I won’t deal with patients who are feeling suicidal.’ But it’s our job to assess patients, not to ask them to self-diagnose.” She practices online therapy, but advocates consumer protections and rigorous training of therapists.

Psychologists say certain conditions might be well-suited for treatment online, including agoraphobia, anxiety, depression and obsessive-compulsive disorder. Some doctors suggest that Internet addiction or other addictive behaviors could be treated through videoconferencing.

Others disagree. As one doctor said, “If I’m treating an alcoholic, I can’t smell his breath over Skype.”

Cognitive behavioral therapy, which can require homework rather than tunneling into the patient’s past, seems another candidate. Tech-savvy teenagers resistant to office visits might brighten at seeing a therapist through a computer monitor in their bedroom. Home court advantage.

Therapists who have tried online therapy range from evangelizing standard-bearers, planting their stake in the new future, to those who, after a few sessions, have backed away. Elaine Ducharme, a psychologist in Glastonbury, Conn., uses Skype with patients from her former Florida practice, but finds it disconcerting when a patient’s face becomes pixilated. Dr. Ducharme, who is licensed in both states, will not videoconference with a patient she has not met in person. She flies to Florida every three months for office visits with her Skype patients.

“There is definitely something important about bearing witness,” she said. “There is so much that happens in a room that I can’t see on Skype.”

Dr. Heath Canfield, a psychiatrist in Colorado Springs, also uses Skype to continue therapy with some patients from his former West Coast practice. He is licensed in both locations. “If you’re doing therapy, pauses are important and telling, and Skype isn’t fast enough to keep up in real time,” Dr. Canfield said. He wears a headset. “I want patients to know that their sound isn’t going through walls but into my ears. I speak into a microphone so they don’t feel like I’m shouting at the computer. It’s not the same as being there, but it’s better than nothing. And I wouldn’t treat people this way who are severely mentally ill.”

Indeed, the pitfalls of videoconferencing with the severely mentally ill became apparent to Michael Terry, a psychiatric nurse practitioner, when he did psychological evaluations for patients throughout Alaska’s Eastern Aleutian Islands. “Once I was wearing a white jacket and the wall behind me was white,” recalled Dr. Terry, an associate clinical professor at the University of San Diego. “My face looked very dark because of the contrast, and the patient thought he was talking to the devil.”

Another time, lighting caused a halo effect. “An adolescent thought he was talking to the Holy Spirit, that he had God on the line. It fit right into his delusions.”

Johanna Herwitz, a Manhattan psychologist, tried Skype to augment face-to-face therapy. “It creates this perverse lower version of intimacy,” she said. “Skype doesn’t therapeutically disinhibit patients so that they let down their guard and take emotional risks. I’ve decided not to do it anymore.”

Several studies have concluded that patient satisfaction with face-to-face interaction and online therapy (often preceded by in-person contact) was statistically similar. Lynn, a patient who prefers not to reveal her full identity, had been seeing her therapist for years. Their work deepened into psychoanalysis. Then her psychotherapist retired, moving out of state.

Now, four times a week, Lynn carries her laptop to an analyst’s unoccupied office (her insurance requires that a local provider have some oversight). She logs on to an encrypted program at Breakthrough.com and clicks through until she reads an alert: “Talk now!”

Hundreds of miles away, so does her analyst. Their faces loom, side by side on each other’s monitors. They say hello. Then Lynn puts her laptop on a chair and lies down on the couch. Just the top of her head is visible to her analyst.

Fifty minutes later the session ends. “The screen is asleep so I wake it up and see her face,” Lynn said. “I say goodbye and she says goodbye. Then we lean in to press a button and exit.”

As attenuated as this all may seem, Lynn said, “I’m just grateful we can continue to do this.”

This article has been revised

to reflect the following correction:

Correction: September 24, 2011

A caption on a picture

in an earlier version of this article

incorrectly described the technology

used by Marlene M. Maheu

to communicate remotely with patients.

She uses video conferencing, not Skype.

When Your Therapist Is Only a Click Away, NYT, 23.9.2011,
http://www.nytimes.com/2011/09/25/
fashion/therapists-are-seeing-patients-online.html

Maurice M. Rapport,

Who Studied Serotonin,

Dies at 91

September 2, 2011
The New York Times
By WILLIAM GRIMES

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,
http://www.nytimes.com/2011/09/03/health/03rapport.html

Alfred Freedman,

a Leader in Psychiatry,

Dies at 94

April 20, 2011
The New York Times
By WILLIAM GRIMES

Dr. Alfred M. Freedman, a psychiatrist and social reformer who led the American Psychiatric Association in 1973 when, overturning a century-old policy, it declared that homosexuality was not a mental illness, died on Sunday in Manhattan. He was 94.

The cause was complications of surgery to treat a fractured hip, his son Dan said.

In 1972, with pressure mounting from gay rights groups and from an increasing number of psychiatrists to destigmatize homosexuality, Dr. Freedman was elected president of the association, which he later described as a conservative “old boys’ club.” Its 20,000 members were deeply divided about its policy on homosexuality, which its Diagnostic and Statistical Manual of Mental Disorders II classified as a “sexual deviation” in the same class as fetishism, voyeurism, pedophilia and exhibitionism.

Well known as the chairman of the department of psychiatry at New York Medical College and a strong proponent of community-oriented psychiatric and social services, Dr. Freedman was approached by a group of young reformers, the Committee of Concerned Psychiatrists, who persuaded him to run as a petition candidate for the presidency of the psychiatric association.

Dr. Freedman, much to his surprise, won what may have been the first contested election in the organization’s history — by 3 votes out of more than 9,000 cast. Immediately on taking office, he threw his support behind a resolution, drafted by Robert L. Spitzer of Columbia University, to remove homosexuality from the list of mental disorders.

On Dec. 15, 1973, the board of trustees, many of them newly elected younger psychiatrists, voted 13 to 0, with two abstentions, in favor of the resolution, which stated that “by itself, homosexuality does not meet the criteria for being a psychiatric disorder.”

It went on: “We will no longer insist on a label of sickness for individuals who insist that they are well and demonstrate no generalized impairment in social effectiveness.”

The board stopped short of declaring homosexuality “a normal variant of human sexuality,” as the association’s task force on nomenclature had recommended.

The recently formed National Gay Task Force (now the National Gay and Lesbian Task Force) hailed the resolution as “the greatest gay victory,” one that removed “the cornerstone of oppression for one-tenth of our population.” Among other things, the resolution helped reassure gay men and women in need of treatment for mental problems that doctors would not have any authorization to try to change their sexual orientation, or to identify homosexuality as the root cause of their difficulties.

An equally important companion resolution condemned discrimination against gays in such areas as housing and employment. In addition, it called on local, state and federal lawmakers to pass legislation guaranteeing gay citizens the same protections as other Americans, and to repeal all criminal statutes penalizing sex between consenting adults.

The resolution served as a model for professional and religious organizations that took similar positions in the years to come.

“It was a huge victory for a movement that in 1973 was young, small, very underfunded and had not yet had this kind of political validation,” said Sue Hyde, who organizes the annual conference of the National Gay and Lesbian Task Force. “It is the single most important event in the history of what would become the lesbian, gay, bisexual and transgender movement.”

In a 2007 interview Dr. Freedman said, “I felt at the time that that decision was the most important thing we accomplished.”

Alfred Mordecai Freedman was born on Jan. 7, 1917, in Albany. He won scholarships to study at Cornell, where he earned a bachelor’s degree in 1937. He earned a medical degree from the University of Minnesota in 1941 but cut short his internship at Harlem Hospital to enlist in the Army Air Corps.

During World War II he served as a laboratory officer in Miami and chief of laboratories at the Air Corps hospital in Gulfport, Miss. He left the corps with the rank of major.

After doing research on neuropsychology with Harold E. Himwich at Edgewood Arsenal in Maryland, he became interested in the development of human cognition. He underwent training in general and child psychiatry and began a residency at Bellevue Hospital in Manhattan, where he became a senior child psychiatrist.

He was the chief psychiatrist in the pediatrics department at the Downstate College of Medicine of the State University of New York for five years before becoming the first full-time chairman of the department of psychiatry at New York Medical College, then in East Harlem and now in Valhalla, N.Y.

In his 30 years at the college he built the department into an important teaching institution with a large residency program. He greatly expanded the psychiatric services offered at nearby Metropolitan Hospital, which is affiliated with the school and where he was director of psychiatry.

To address social problems in East Harlem, Dr. Freedman created a treatment program for adult drug addicts at the hospital in 1959 and the next year established a similar program for adolescents. These were among the earliest drug addiction programs to be conducted by a medical school and to be based in a general hospital. He also founded a division of social and community psychiatry at the school to serve neighborhood residents.

With Harold I. Kaplan, he edited “Comprehensive Textbook of Psychiatry,” which became adopted as a standard text on its publication in 1967 and is now in its ninth edition.

During his one-year term as president of the American Psychiatric Association, Dr. Freedman made the misuse of psychiatry in the Soviet Union one of the organization’s main issues. He challenged the Soviet government to answer charges that it routinely held political dissidents in psychiatric hospitals, and he led a delegation of American psychiatrists to the Soviet Union to visit mental hospitals and confer with Soviet psychiatrists.

After retiring from New York Medical College, Dr. Freedman turned his attention to the role that psychiatry played in death penalty cases. With his colleague Abraham L. Halpern, he lobbied the American Medical Association to enforce the provision in its code of ethics barring physicians from taking part in executions, and he campaigned against the practice of using psychopharmacologic drugs on psychotic death-row prisoners so that they could be declared competent to be executed.

In addition to his son Dan, of Silver Spring, Md., he is survived by his wife, Marcia; another son, Paul, of Pelham, N.Y.; and three grandchildren.

Alfred Freedman, a Leader in Psychiatry, Dies at 94, NYT, 20.4.2011,
http://www.nytimes.com/2011/04/21/health/21freedman.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

Getting Someone

to Psychiatric Treatment

Can Be Difficult and Inconclusive

January 18, 2011
The New York Times
By A. G. SULZBERGER
and BENEDICT CAREY

TUCSON —What are you supposed to do with someone like Jared L. Loughner?

That question is as difficult to answer today as it was in the years and months and days leading up to the shooting here that left 6 dead and 13 wounded.

Millions of Americans have wondered about a troubled loved one, friend or co-worker, fearing not so much an act of violence, but — far more likely — self-inflicted harm, landing in the streets, in jail or on suicide watch. But those in a position to help often struggle with how to distinguish ominous behavior from the merely odd, the red flags from the red herrings.

In Mr. Loughner’s case there is no evidence that he ever received a formal diagnosis of mental illness, let alone treatment. Yet many psychiatrists say that the warning sings of a descent into psychosis were there for months, and perhaps far longer.

Moving a person who is resistant into treatment is an emotional, sometimes exhausting process that in the end may not lead to real changes in behavior. Mental health resources are scarce in most states, laws make it difficult to commit an adult involuntarily, and even after receiving treatment, patients frequently stop taking their medication or seeing a therapist, believing that they are no longer ill.

The Virginia Tech gunman was committed involuntarily before killing 32 people in a 2007 rampage.

With Mr. Loughner, dozens of people apparently saw warning signs: the classmates who listened as his dogmatic language grew more detached from reality. The police officers who nervously advised that he could not return to college without a medical note stating that he was not dangerous. His father, who chased him into the desert hours before the attack as Mr. Loughner carried a black bag full of ammunition.

“This isn’t an isolated incident,” said Daniel J. Ranieri, president of La Frontera Center, a nonprofit group that provides mental health services. “There are lots of people who are operating on the fringes who I would describe as pretty combustible. And most of them aren’t known to the mental health system.”

Dr. Jack McClellan, an adult and child psychiatrist at the University of Washington, said he advises people who are worried that someone is struggling with a mental disorder to watch for three things — a sudden change in personality, in thought processes, or in daily living. “This is not about whether someone is acting bizarrely; many people, especially young people, experiment with all sorts of strange beliefs and counterculture ideas,” Dr. McLellan said. “We’re talking about a real change. Is this the same person you knew three months ago?”

Those who have watched the mental unraveling of a loved one say that recognizing the signs is only the first step in an emotional, often confusing, process. About half of people with mental illnesses do not receive treatment, experts estimate, in part because many of them do not recognize that they even have an illness.

Pushing such a person into treatment is legally difficult in most states, especially when he or she is an adult — and the attempt itself can shatter the trust between a troubled soul and the one who is most desperate to help. Others, though, later express gratitude.

“If the reason is love, don’t worry if they’ll be mad at you,” said Robbie Alvarez, 28, who received a diagnosis of schizophrenia after being involuntarily committed when his increasingly erratic behavior led to a suicide attempt. At the time, he said, he was living in Phoenix with his parents, who he was convinced were trying to kill him. In Arizona it is easier to obtain an involuntary commitment than in many states because anyone can request an evaluation if they observe behavior that suggests a person may present a danger or is severely disabled (often state laws require some evidence of imminent danger to self or others).

But there are also questions about whether the system can accommodate an influx of new patients. Arizona’s mental health system has been badly strained by recent budget cuts that left those without Medicaid stripped of most of their services, including counseling and residential treatment, though eligibility remains for emergency services like involuntary commitment. And the state is trying to change eligibility requirements for Medicaid, which would potentially reduce financing further and leave more with limited services.

Still, people who have been through the experience argue that it is better to act sooner rather than later. “It’s not easy to know when we could or should intervene but I would rather err on the side of safety than not,” said H. Clarke Romans, executive director of the local chapter of the National Alliance on Mental Illness, an advocacy group, who had a son with schizophrenia.

The collective failure to move Mr. Loughner into treatment, either voluntarily or not, will never be fully understood, because those who knew the young man presumably wrestled separately and privately about whether to take action. But the inaction has certainly provoked second-guessing. Sheriff Clarence Dupnik of Pima County told CNN last Wednesday that Mr. Loughner’s parents were as shocked as everyone else. “It’s been very, very devastating for them,” he said. “They had absolutely no way to predict this kind of behavior.”

Linda Rosenberg, president of the National Council for Community Behavioral Healthcare, said, “The failure here is that we ignored someone for a long time who was clearly in tremendous distress.” Ms. Rosenberg, whose group is a nonprofit agency leading a campaign to teach people how to recognize and respond to signs of mental illness, added, “He wasn’t someone who could ask for help because his thinking was affected, and as a community no one said, let’s stop and make sure he gets help.”

At the University of Arizona, where a nursing student killed three instructors on campus eight years ago before killing himself, feelings of sadness and anger initially mixed with some guilt as the university examined the missed warning signs.

The overhauled process for addressing concerns is now more responsive, even if there are sometimes false alarms, said Melissa M. Vito, vice president for student affairs. “I guess I’d rather explain why I called someone’s parents than why I didn’t do something,” she said.

Many others feel the same way.

Four years ago Susan Junck watched her 18-year-old son return from community college to their Phoenix home one afternoon and, after preparing a snack, repeatedly call the police to accuse his mother of poisoning him. She assumed it was an isolated outburst, maybe connected to his marijuana use. In the coming months, though, her son’s behavior grew more alarming, culminating in an arrest for assaulting his girlfriend, who was at the center of a number of his conspiracy theories.

“I knew something was wrong but I literally just did not understand what,” Ms. Junck, 49, said in a recent interview. “It probably took a year before I realized my son has a mental illness. This isn’t drug related, this isn’t bad behavior, this isn’t teenage stuff. This is a serious mental illness.”

Fearful and desperate, she brought her son to an urgent psychiatric center and — after a five-hour wait — agreed to sign paperwork to have him involuntarily committed as a danger to himself or others. Her son screamed for her help as he was carried off. He was diagnosed with paranoid schizophrenia and remains in a residential treatment facility.

This week Erin Adams Goldman, a suicide prevention specialist with a mental health nonprofit organization in Tucson, is teaching the first local installment of a course that is being promoted around the country called mental health first aid, which instructs participants how to recognize and respond to the signs of mental illness.

A central tenet is that if a person has suspicions about mental illness it is better to open the conversation, either by approaching the individual directly, someone else who knows the person well or by asking for a professional evaluation.

“There is so much fear and mystery around mental illness that people are not even aware of how to recognize it and what to do about it,” Ms. Goldman said. “But we get a feeling when something is not right. And what we teach is to follow your gut and take some action.”

A. G. Sulzberger reported from Tucson,

and Benedict Carey from New York.

Getting Someone to Psychiatric Treatment
Can Be Difficult and Inconclusive,
NYT, 18.1.2011,
http://www.nytimes.com/2011/01/19/us/19mental.html

Revising Book

on Disorders of the Mind

February 10, 2010
The New York Times
By BENEDICT CAREY

Far fewer children would get a diagnosis of bipolar disorder. “Binge eating disorder” and “hypersexuality” might become part of the everyday language. And the way many mental disorders are diagnosed and treated would be sharply revised.

These are a few of the changes proposed on Tuesday by doctors charged with revising psychiatry’s encyclopedia of mental disorders, the guidebook that largely determines where society draws the line between normal and not normal, between eccentricity and illness, between self-indulgence and self-destruction — and, by extension, when and how patients should be treated.

The eagerly awaited revisions — to be published, if adopted, in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders, due in 2013 — would be the first in a decade.

For months they have been the subject of intense speculation and lobbying by advocacy groups, and some proposed changes have already been widely discussed — including folding the diagnosis of Asperger’s syndrome into a broader category, autism spectrum disorder.

But others, including a proposed alternative for bipolar disorder in many children, were unveiled on Tuesday. Experts said the recommendations, posted online at DSM5.org for public comment, could bring rapid change in several areas.

“Anything you put in that book, any little change you make, has huge implications not only for psychiatry but for pharmaceutical marketing, research, for the legal system, for who’s considered to be normal or not, for who’s considered disabled,” said Dr. Michael First, a professor of psychiatry at Columbia University who edited the fourth edition of the manual but is not involved in the fifth.

“And it has huge implications for stigma,” Dr. First continued, “because the more disorders you put in, the more people get labels, and the higher the risk that some get inappropriate treatment.”

One significant change would be adding a childhood disorder called temper dysregulation disorder with dysphoria, a recommendation that grew out of recent findings that many wildly aggressive, irritable children who have been given a diagnosis of bipolar disorder do not have it.

The misdiagnosis led many children to be given powerful antipsychotic drugs, which have serious side effects, including metabolic changes.

“The treatment of bipolar disorder is meds first, meds second and meds third,” said Dr. Jack McClellan, a psychiatrist at the University of Washington who is not working on the manual. “Whereas if these kids have a behavior disorder, then behavioral treatment should be considered the primary treatment.”

Some diagnoses of bipolar disorder have been in children as young as 2, and there have been widespread reports that doctors promoting the diagnosis received consulting and speaking fees from the makers of the drugs.

In a conference call on Tuesday, Dr. David Shaffer, a child psychiatrist at Columbia, said he and his colleagues on the panel working on the manual “wanted to come up with a diagnosis that captures the behavioral disturbance and mood upset, and hope the people contemplating a diagnosis of bipolar for these patients would think again.”

Experts gave the American Psychiatric Association, which publishes the manual, predictably mixed reviews. Some were relieved that the task force working on the manual — which includes neurologists and psychologists as well as psychiatrists — had revised the previous version rather than trying to rewrite it.

Others criticized the authors, saying many diagnoses in the manual would still lack a rigorous scientific basis.

The good news, said Edward Shorter, a historian of psychiatry who has been critical of the manual, is that most patients will be spared the confusion of a changed diagnosis. But “the bad news,” he added, “is that the scientific status of the main diseases in previous editions of the D.S.M. — the keystones of the vault of psychiatry — is fragile.”

To more completely characterize all patients, the authors propose using measures of severity, from mild to severe, and ratings of symptoms, like anxiety, that are found as often with personality disorders as with depression.

“In the current version of the manual, people either meet the threshold by having a certain number of symptoms, or they don’t,” said Dr. Darrel A. Regier, the psychiatric association’s research director and, with Dr. David J. Kupfer of the University of Pittsburgh, the co-chairman of the task force. “But often that doesn’t fit reality. Someone with schizophrenia might have symptoms of insomnia, of anxiety; these aren’t the diagnostic criteria for schizophrenia, but they affect the patient’s life, and we’d like to have a standard way of measuring them.”

In a conference call on Tuesday, Dr. Regier, Dr. Kupfer and several other members of the task force outlined their favored revisions. The task force favored making semantic changes that some psychiatrists have long argued for, trading the term “mental retardation” for “intellectual disability,” for instance, and “substance abuse” for “addiction.”

One of the most controversial proposals was to identify “risk syndromes,” that is, a risk of developing a disorder like schizophrenia or dementia. Studies of teenagers identified as at high risk of developing psychosis, for instance, find that 70 percent or more in fact do not come down with the disorder.

“I completely understand the idea of trying to catch something early,” Dr. First said, “but there’s a huge potential that many unusual, semi-deviant, creative kids could fall under this umbrella and carry this label for the rest of their lives.”

Dr. William T. Carpenter, a psychiatrist at the University of Maryland and part of the group proposing the idea, said it needed more testing. “Concerns about stigma and excessive treatment must be there,” he said. “But keep in mind that these are individuals seeking help, who have distress, and the question is, What’s wrong with them?”

The panel proposed adding several disorders with a high likelihood of entering the pop vernacular. One, a new description of sex addiction, is “hypersexuality,” which, in part, is when “a great deal of time is consumed by sexual fantasies and urges; and in planning for and engaging in sexual behavior.”

Another is “binge eating disorder,” defined as at least one binge a week for three months — eating platefuls of food, fast, and to the point of discomfort — accompanied by severe guilt and plunges in mood.

“This is not the normative overeating that we all do, by any means,” said Dr. B. Timothy Walsh, a psychiatrist at Columbia and the New York State Psychiatric Institute who is working on the manual. “It involves much more loss of control, more distress, deeper feelings of guilt and unhappiness.”

Revising Book on Disorders of the Mind, NYT, 11.2.2010
http://www.nytimes.com/2010/02/10/health/10psych.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

Brendan Smialowski for The New York Times

Dr. Darrel A. Regier

is co-chairman of a panel compiling the latest

Diagnostic and Statistical Manual of Mental Disorders

Psychiatrists Revising the Book of Human Troubles

NYT

18 December 2008

https://www.nytimes.com/2008/12/18/
health/18psych.html

Psychiatrists

Revising the Book of Human Troubles

December 18, 2008
The New York Times
By BENEDICT CAREY

The book is at least three years away from publication, but it is already stirring bitter debates over a new set of possible psychiatric disorders.

Is compulsive shopping a mental problem? Do children who continually recoil from sights and sounds suffer from sensory problems — or just need extra attention? Should a fetish be considered a mental disorder, as many now are?

Panels of psychiatrists are hashing out just such questions, and their answers — to be published in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders — will have consequences for insurance reimbursement, research and individuals’ psychological identity for years to come.

The process has become such a contentious social and scientific exercise that for the first time the book’s publisher, the American Psychiatric Association, has required its contributors to sign a nondisclosure agreement.

The debate is particularly intense because the manual is both a medical guidebook and a cultural institution. It helps doctors make a diagnosis and provides insurance companies with diagnostic codes without which the insurers will not reimburse patients’ claims for treatment.

The manual — known by its initials and edition number, DSM-V — often organizes symptoms under an evocative name. Labels like obsessive-compulsive disorder have connotations in the wider culture and for an individual’s self-perception.

“This is not cardiology or nephrology, where the basic diseases are well known,” said Edward Shorter, a leading historian of psychiatry whose latest book, “Before Prozac,” is critical of the manual. “In psychiatry no one knows the causes of anything, so classification can be driven by all sorts of factors” — political, social and financial.

“What you have in the end,” Mr. Shorter said, “is this process of sorting the deck of symptoms into syndromes, and the outcome all depends on how the cards fall.”

Psychiatrists involved in preparing the new manual contend that it is too early to say for sure which cards will be added and which dropped.

The current edition of the manual, which was published in 2000, describes 283 disorders — about triple the number in the first edition, published in 1952.

The scientists updating the manual have been meeting in small groups focusing on categories like mood disorders and substance abuse — poring over the latest scientific studies to clarify what qualifies as a disorder and what might distinguish one disorder from another. They have much more work to do, members say, before providing recommendations to a 28-member panel that will gather in closed meetings to make the final editorial changes.

Experts say that some of the most crucial debates are likely to include gender identity, diagnoses of illness involving children, and addictions like shopping and eating.

“Many of these are going to involve huge fights, I expect,” said Dr. Michael First, a professor of psychiatry at Columbia who edited the fourth edition of the manual but is not involved in the fifth.

One example, Dr. First said, is binge eating, now in the manual’s appendix as a tentative category.

“A lot of people want that included in the manual,” Dr. First said, “and there’s some research out there, some evidence that drugs are helpful. But binge eating is also a normal behavior, and you run the risk of labeling up to 30 percent of people with a disorder they don’t really have.”

The debate over gender identity, characterized in the manual as “strong and persistent cross-gender identification,” is already burning hot among transgender people. Soon after the psychiatric association named the group of researchers working on sexual and gender identity, advocates circulated online petitions objecting to two members whose work they considered demeaning.

Transgender people are themselves divided about their place in the manual. Some transgender men and women want nothing to do with psychiatry and demand that the diagnosis be dropped. Others prefer that it remain, in some form, because a doctor’s written diagnosis is needed to obtain insurance coverage for treatment or surgery.

“The language needs to be reformed, at a minimum,” said Mara Keisling, executive director of the National Center for Transgender Equity. “Right now, the manual implies that you cannot be a happy transgender person, that you have to be a social wreck.”

Dr. Jack Drescher, a New York psychoanalyst and member of the sexual disorders work group, said that, in some ways, the gender identity debate echoed efforts to remove homosexuality from the manual in the 1970s.

After protests by gay activists provoked a scientific review, the “homosexuality” diagnosis was dropped in 1973. It was replaced by “sexual orientation disturbance” and then “ego-dystonic homosexuality” before being dropped in 1987.

“You had, in my opinion, what was a social issue, not a medical one; and, in some sense, psychiatry evolved through interaction with the wider culture,” Dr. Drescher said.

The American Psychiatric Association says the contributors’ nondisclosure agreement is meant to allow the revisions to begin without distraction and to prevent authors from making deals to write casebooks or engage in other projects based on the deliberations without working through the association.

In a phone interview, Dr. Darrel A. Regier, the psychiatric association’s research director, who with Dr. David Kupfer of the University of Pittsburgh is co-chairman of the task force, said that experts working on the manual had presented much of their work in scientific conferences.

“But you need to synthesize what you’re doing and make it coherent before having that discussion,” Dr. Regier said. “Nobody wants to put a rough draft or raw data up on the Web.”

Some critics, however, say the secrecy is inappropriate.

“When I first heard about this agreement, I just went bonkers,” said Dr. Robert Spitzer, a psychiatry professor at Columbia and the architect of the third edition of the manual. “Transparency is necessary if the document is to have credibility, and, in time, you’re going to have people complaining all over the place that they didn’t have the opportunity to challenge anything.”

Scientists who accepted the invitation to work on the new manual — a prestigious assignment — agreed to limit their income from drug makers and other sources to $10,000 a year for the duration of the job. “That’s more conservative” than the rules at many agencies and universities, Dr. Regier said.

This being the diagnostic manual, where virtually every sentence is likely to be scrutinized, critics have said that the policy is not strict enough. They have long suspected that pharmaceutical money subtly influences authors’ decisions.

Industry influence was questioned after a surge in diagnoses of bipolar disorder in young children. Once thought to affect only adults and adolescents, the disorder in children was recently promoted by psychiatrists on drug makers’ payrolls.

The team working on childhood disorders is expected to debate the merits of adding pediatric bipolar as a distinct diagnosis, experts say. It is also expected to discuss whether Asperger’s syndrome, a developmental disorder, should be merged with high-functioning autism. The two are virtually identical, but bear different social connotations.

The same team is likely to make a recommendation on so-called sensory processing disorder, a vague label for a poorly understood but disabling childhood behavior. Parent groups and some researchers want recognition in the manual in order to help raise money for research and obtain insurance coverage of expensive treatments.

“I know that some are pushing very hard to get that in,” Dr. First said, “and they believe they have been warmly received. But you just never know for sure, of course, until the thing is published.”

In all, it is a combination of suspense, mystery and prepublication controversy that many publishers would die for. The psychiatric association knows it has a corner on the market and a blockbuster series. The last two editions sold more than 830,000 copies each.

Psychiatrists Revising the Book of Human Troubles, NYT, 18.12.2008,
http://www.nytimes.com/2008/12/18/health/18psych.html

Standing in Someone Else’s Shoes,

Almost for Real

December 2, 2008
The New York Times
By BENEDICT CAREY

From the outside, psychotherapy can look like an exercise in self-absorption. In fact, though, therapists often work to pull people out of themselves: to see their behavior from the perspective of a loved one, for example, or to observe their own thinking habits from a neutral distance.

Marriage counselors have couples role-play, each one taking the other spouse’s part. Psychologists have rapists and other criminals describe their crime from the point of view of the victim. Like novelists or moviemakers, their purpose is to transport people, mentally, into the mind of another.

Now, neuroscientists have shown that they can make this experience physical, creating a “body swapping” illusion that could have a profound effect on a range of therapeutic techniques. At the annual meeting of the Society for Neuroscience last month, Swedish researchers presented evidence that the brain, when tricked by optical and sensory illusions, can quickly adopt any other human form, no matter how different, as its own.

“You can see the possibilities, putting a male in a female body, young in old, white in black and vice versa,” said Dr. Henrik Ehrsson of the Karolinska Institute in Stockholm, who with his colleague Valeria Petkova described the work to other scientists at the meeting. Their full study is to appear online this week in the journal PLoS One. .

The technique is simple. A subject stands or sits opposite the scientist, as if engaged in an interview.. Both are wearing headsets, with special goggles, the scientist’s containing small film cameras. The goggles are rigged so the subject sees what the scientist sees: to the right and left are the scientist’s arms, and below is the scientist’s body.

To add a physical element, the researchers have each person squeeze the other’s hand, as if in a handshake. Now the subject can see and “feel” the new body. In a matter of seconds, the illusion is complete. In a series of studies, using mannequins and stroking both bodies’ bellies simultaneously, the Karolinska researchers have found that men and women say they not only feel they have taken on the new body, but also unconsciously cringe when it is poked or threatened.

In previous work, neuroscientists have induced various kinds of out-of-body experiences using similar techniques. The brain is so easily tricked, they say, precisely because it has spent a lifetime in its own body. It builds models of the world instantaneously, based on lived experience and using split-second assumptions — namely, that the eyes are attached to the skull.

Therapists say the body-swapping effect is so odd that it could be risky for anyone in real mental distress. People suffering from the delusions of schizophrenia or the grandiose mania of bipolar disorder are not likely to benefit from more disorientation, no matter the intent.

But those who seek help for relationship problems, in particular, often begin to moderate their behavior only after they have worked to see the encounters in their daily life from others’ point of view.

“This is especially true for adolescents, who are so self-involved, and also for people who come in with anger problems and are more interested in changing everyone else in their life than themselves,” said Kristene Doyle, director of clinical services at the Albert Ellis Institute in New York.

One important goal of therapy in such cases, Dr. Doyle said, is to get people to generate alternative explanations for others’ behavior — before they themselves react.

The evidence that inhabiting another’s perspective can change behavior comes in part from virtual-reality experiments. In these studies, researchers create avatars that mimic a person’s every movement. After watching their “reflection” in a virtual mirror, people mentally inhabit this avatar at some level, regardless of its sex, race or appearance. In several studies, for instance, researchers have shown that white people who spend time interacting virtually as black avatars become less anxious about racial differences.

Jeremy Bailenson, director of the Virtual Human Interaction Lab at Stanford University, and his colleague Nick Yee call this the Proteus effect, after the Greek god who can embody many different self-representations.

In one experiment, the Stanford team found that people inhabiting physically attractive avatars were far more socially intimate in virtual interactions than those who had less appealing ones. The effect was subconscious: the study participants were not aware that they were especially good-looking, or that in virtual conversations they moved three feet closer to virtual conversation partners and revealed more about themselves than others did. This confidence lingered even after the experiment was over, when the virtual lookers picked more attractive partners as matches for a date.

Similar studies have found that people agree to contribute more to retirement accounts when they are virtually “age-morphed” to look older; and that they will exercise more after inhabiting an avatar that works out and loses weight.

Adding a physical body-swapping element, as the Swedish team did, is likely to amplify such changes. “It has video quality, it looks and feels more realistic than what we can do in virtual environments, so is likely to be much more persuasive,” Dr. Bailenson said in a telephone interview.

Perhaps too persuasive for some purposes. “It may be like the difference between a good book, where you can project yourself into a character by filling in with your imagination, and a movie, where the specific actor gets in the way of identifying strongly,” he went on.

And above and beyond any therapeutic purposes, the sensation is downright strange. In the experiments, said Dr. Ehrsson, the Swedish researcher, “even the feeling from the squeezing hand is felt in the scientist’s hand and not in your own; this is perhaps the strangest aspect of the experience.”

Standing in Someone Else’s Shoes, Almost for Real, NYT, 2.12.2008,
http://www.nytimes.com/2008/12/02/health/02mind.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

Daring to Think Differently

About Schizophrenia

February 24, 2008
The New York Times
By ALEX BERENSON

NORTH WALES, Pa. — SCIENTISTS who develop drugs are familiar with disappointment — brilliant theories that don’t pan out or promising compounds derailed by unexpected side effects. They are accustomed to small steps and wrong turns, to failure after failure — until, in a moment, with hard work, brainpower and a lot of luck, all those little failures turn into one big success.

For Darryle D. Schoepp, that moment came one evening in October 2006, while he was seated at his desk in Indianapolis.

At the time, he was overseeing early-stage neuroscience research at Eli Lilly & Company and colleagues had just given him the results from a human trial of a new schizophrenia drug that worked differently than all other treatments. From the start, their work had been a long shot. Schizophrenia is notoriously difficult to treat, and Lilly’s drug — known only as LY2140023 — relied on a promising but unproved theory about how to combat the disorder.

When Dr. Schoepp saw the results, he leapt up in excitement. The drug had reduced schizophrenic symptoms, validating the efforts of hundreds of scientists, inside and outside of Lilly, who had labored together for almost two decades trying to unravel the disorder’s biological underpinnings.

The trial results were a major breakthrough in neuroscience, says Dr. Thomas R. Insel, director of the National Institute of Mental Health. For 50 years, all medicines for the disease had worked the same way — until Dr. Schoepp and other scientists took a different path.

“This drug really looks like it’s quite a different animal,” Dr. Insel says. “This is actually pretty innovative.”

Dr. Schoepp and other scientists had focused their attention on the way that glutamate, a powerful neurotransmitter, tied together the brain’s most complex circuits. Every other schizophrenia drug now on the market aims at a different neurotransmitter, dopamine.

The Lilly results have fueled a wave of pharmaceutical industry research into glutamate. Companies are searching for new treatments, not just for schizophrenia, but also for depression and Alzheimer’s disease and other unseen demons of the brain that torment tens of millions of people worldwide.

Driving the industry’s interest is the huge market for drugs for brain and psychiatric diseases. Worldwide sales total almost $50 billion annually, even though existing medicines have moderate efficacy and have side effects that range from reduced libido to diabetes.

The glutamate researchers warn that their quest for new treatments for schizophrenia is far from complete. The results of the Lilly trial covered only 196 patients and must be validated by much larger trials, the last of which may not be finished until at least 2011. Other glutamate drugs are even further away from approval. And even if the drugs win that approval, they may be viewed skeptically by doctors who have been disappointed by side effects in other drugs that were once been hailed as breakthroughs.

Still, for Dr. Schoepp, the drug’s progress so far is cause for celebration — and relief.

“I don’t think people appreciate how much money, time and good technical research goes into what we do,” he says. “Sometimes, people think the idea is the thing. I think the idea can be the easy part.”

LILLY continues to develop LY2140023 and has begun a trial of 870 patients that is scheduled to be completed in January 2009. But Dr. Schoepp is no longer involved in its development. He left Lilly in April to become senior vice president and head of neuroscience research at Merck, where he oversees a division of 300 researchers and support staff members.

Dr. Schoepp’s new base is a modest office on the top floor of a four-story Merck building here in North Wales, north of Philadelphia. He has a view of the building’s big front lawn and a busy two-lane road called the Sumneytown Pike. The huge Merck research complex called West Point, where 4,000 scientists and support staff members work, is less than a mile to the north.

For Dr. Schoepp, 52, the Merck job is the latest stop in a research career that began at Osco Drug’s store No. 807 in downtown Bismarck, N.D. He grew up in Bismarck in a working-class family; at 16, he started working at the Osco, which has since closed. He quickly decided to become a scientist.

“I just found it fascinating,” he says. “I was hungry for science.” While reading a magazine for pharmacists, he noticed an ad for a free pamphlet published by Merck called “Pharmacists in Industry.” He wrote away for the pamphlet, which convinced him that he could have a career developing medicines.

He applied to North Dakota State University, where he focused on psychopharmacology, a discipline that studies the way chemicals affect the brain. “I was really interested in psychiatric disorders,” he says. “I fell in love with dopamine.”

His love affair was so consuming that his wife joked that “dopamine” would be his daughter’s first word.

Although scientists sometimes decide to study a disease because of problems it has caused among family members, Dr. Schoepp says his fascination with mental illness has been purely academic. “My family has more heart disease than anything else,” he says.

After graduating from North Dakota State, he received a scholarship to a doctoral program in pharmacology and toxicology at West Virginia University. He graduated in 1982. Nearly five years later, he joined Lilly, which was about to introduce Prozac, the first modern antidepressant — a drug that changed both psychiatry and the public perception of depression and mental illness.

Prozac became a blockbuster almost instantly after Lilly introduced it in 1987, making the company one of the most visible players in Big Pharma and giving it room to invest in long-shot scientific research. Ray Fuller, a Lilly scientist who was a co-discoverer of Prozac, encouraged Dr. Schoepp to focus his attention on glutamate.

Glutamate is a pivotal transmitter in the brain, the crucial link in circuits involved in memory, learning and perception. Too much glutamate leads to seizures and the death of brain cells. Excessive glutamate release is also one of the main reasons that people have brain damage after strokes. Too little glutamate can cause psychosis, coma and death.

“The main thoroughfare of communication in the brain is glutamate,” says Dr. John Krystal, a psychiatry professor at Yale and a research scientist with the VA Connecticut Health Care System.

Along with Bita Moghaddam, a neuroscientist who was at Yale and is now at the University of Pittsburgh, Dr. Krystal has been responsible for some of the fundamental research into how glutamate works in the brain and how it may be implicated in schizophrenia.

Schizophrenia affects about 2.5 million Americans, about 1 percent of the adult population, and it usually develops in the late teens or early to mid-20s. It is believed to result from a mix of causes, including genetic and environmental triggers that cause the brain to develop abnormally.

The first schizophrenia medicines were developed accidentally about a half-century ago, when Henri Laborit, a French military surgeon, noticed that an antinausea drug called chlorpromazine helped to control hallucinations in psychotic patients. Chlorpromazine, sold under the brand name Thorazine, blocks the brain’s dopamine receptors. That led the way in the 1960s for drug companies to introduce other medicines that worked the same way.

The medicines, called antipsychotics, gave many patients relief from the worst of their hallucinations and delusions. But they also can cause shaking, stiffness and facial tics, and did not help the cognitive problems or the so-called negative symptoms like social withdrawal associated with schizophrenia.

In the 1980s, drug companies looked for new ways to treat the disease with fewer side effects. By the mid-1990s, they had introduced several new schizophrenia medicines, including Zyprexa, from Lilly, and Risperdal, from Johnson & Johnson. At the time, the new medicines were hailed as a major advance — and the companies marketed them that way to doctors and patients.

In fact, the new medicines, called second-generation antipsychotics, had much in common with the older drugs. Both worked mainly by blocking dopamine and had little effect on negative or cognitive symptoms. The newer medicines caused fewer movement disorders, but had side effects of their own, including huge weight gain for many patients. Many doctors now complain that the companies oversold the second-generation compounds and that new treatments are badly needed.

“People say that there are drugs to treat schizophrenia,” says Dr. Carol A. Tamminga, professor of psychiatry at the University of Texas Southwestern, in Dallas. “In fact, the treatment for schizophrenia is at best partial and inadequate. You have a cadre of cognitively impaired people who can’t fit in.”

WHILE most of the industry focused on second-generation medicines during the 1980s and 1990s, a handful of academic and industry researchers found intriguing hints that glutamate might provide an alternative treatment pathway.

Psychiatrists and neuroscientists have wondered about a possible connection between glutamate and schizophrenia since the early ’80s, when they first learned that phencyclidine, the street drug commonly called PCP, blocks the release of glutamate.

People who use PCP often have the hallucinations, delusions, cognitive problems and emotional flatness that are characteristic of schizophrenia. Psychiatrists noted PCP’s side effects as early as the late 1950s. But they lacked the tools to determine how PCP affected the brain until 1979, when they found that it blocked a glutamate receptor, called the NMDA receptor, that is at the center of the transmission of nerve impulses in the brain.

The PCP finding led a few scientists to begin researching glutamate’s role in psychosis and other brain disorders. By the early 1990s, they discovered that besides triggering the primary glutamate receptors — NMDA and AMPA — glutamate also triggered several other receptors.

They called these newly found receptors “metabotropic,” because the receptors modified the amount of glutamate that cells released rather than simply turning circuits on or off. Because glutamate is so central to the brain’s activity, directly blocking or triggering the NMDA and AMPA receptors can be very dangerous. The metabotropic receptors appeared to be better targets for drug treatment.

“Rather than acting as an all-or-nothing signal, they fine-tune that signal and modulate that signal,” said P. Jeffrey Conn, director of a Vanderbilt University drug research program. “It’s really an attempt to be very subtle in the way that you regulate the system.”

During the 1990s, molecular biologists discovered genes for eight metabotropic glutamate receptors, which were located at different places inside nerve cells and had different structures. The finding allowed for the possibility that drug companies could create chemicals to turn them on and off selectively, rather than hitting all of them at once.

For Dr. Schoepp and others, finding the receptors was only the first part of the struggle. They also had to find chemicals that would either block or trigger the receptors selectively. At the same time, the chemicals had to be relatively easy to formulate and capable of crossing the blood-brain barrier, which protects the brain from being easily penetrated by outside agents.

The work was arduous, but the Lilly scientists made slow progress. In 1999, Dr. Schoepp and two other scientists published a 46-page research paper that detailed scores of different chemicals that produced reactions at the glutamate sites.

At about the same time, scientists at Yale, led by Dr. Moghaddam, were demonstrating that activating metabotropic glutamate receptors in rats could reverse the effects of PCP — a seminal finding, providing the first proof that altering the path of glutamate transmission in the brain might help relieve the symptoms of psychosis.

Although the finding in rats was promising, developing animal models for schizophrenia and other brain diseases is extremely difficult, said Paul Greengard, professor of molecular and cellular neuroscience at Rockefeller University.

Even when compared with diseases like cancer, brain disorders are notoriously complex. Scientists have only a limited understanding of the chemistry of consciousness, or of how problems in the brain’s electrical circuitry affect the ability to form memories, learn or think.

“We do not know with any of these neuropsychiatric disorders what the ultimate basis is,” Dr. Greengard says. “Let’s say you could find that too much of protein X was involved in schizophrenia. Would you then know what schizophrenia is? You would not.”

Nonetheless, the findings in rats were promising. Those studies, as well as Dr. Krystal’s tests in 2001 of volunteers given ketamine, a drug that has effects similar to PCP, hinted that the glutamate drugs might help to treat the cognitive and negative symptoms of schizophrenia. Drugs currently on the market do little to treat those symptoms.

Even before the findings at Yale, Lilly had put its first metabotropic glutamate receptor compound into human testing. Researchers initially tested the drug on patients with panic disorder, and it showed some positive results. But Lilly stopped human testing of the drug in 2001 when long-term testing in animals showed that it caused seizures.

Even so, Lilly decided that it had enough evidence to justify tests of another chemical compound, LY404039, that affected the same receptors.

“They had to take a risk on letting these drugs be tested on models or for disorders that were justified purely on pretty basic science,” Dr. Krystal says. “There is nothing with these drugs that is straightforward or makes developing them a basic path.”

When it tried to test LY404039 in humans, the company ran into yet another hurdle. The human body didn’t easily absorb it. So Lilly created a drug that the body could absorb, LY2140023, which is metabolized into LY404039 in the body.

Bingo. LY2140023 was the drug that got Dr. Schoepp jumping out of his office chair in 2006, nearly three years after the first trials in humans began. In the Lilly test, the drug was slightly less effective over all than Zyprexa, which is considered the most effective among the widely used schizophrenia treatments.

But LY2140023 also appeared to have fewer side effects than Zyprexa, which can cause severe weight gain and diabetes. The new drug also appeared to improve cognition, something that existing treatments don’t do, said Dr. Insel of the National Institute of Mental Health.

IF Lilly’s new round of tests confirms the drug’s efficacy by early next year, the company is likely to move ahead to an even larger clinical trial, involving thousands of patients, that could lead to federal approval for the compound. Still, approval is at least three to four years away, and other big drug makers are already scrambling to compete with Lilly.

In January, Pfizer agreed to pay Taisho Pharmaceutical, a Japanese company, $22 million for the rights to develop Taisho’s glutamate drug for schizophrenia. Taisho will receive more payments if the drug moves forward in development.

Since it hired Dr. Schoepp, Merck has also been moving aggressively. It has struck two deals since December to work with Addex Pharmaceuticals, a Swiss company, to develop glutamate drugs for schizophrenia, Parkinson’s and other diseases. Merck has paid Addex $25 million so far, with more payments to come if the drugs move forward.

Another glutamate drug, meanwhile, has been shown in preclinical studies to reverse mental retardation in adult rats, a finding that previously appeared impossible, Dr. Insel said.

Dr. Steven M. Paul, the president of Lilly Research Laboratories, says Lilly expects competition in glutamate research to intensify. “We’d like to believe we have a head start here, and hopefully a good head start,” he says. “But this area will heat up here; this will be an area where there will be a lot of investment.”

For Dr. Schoepp, the sudden interest in glutamate is exciting, and he acknowledges that he eagerly awaits the results of the large Lilly trial early next year. And what if the drug fails in that trial, after all the work that he and scientists around the world have put in?

“I would probably go out and have a beer,” he says. “You have to define failure. If you collect information and it tells you what you need to know, you’re not a failure.”

Daring to Think Differently About Schizophrenia, NYT, 24.2.2008,
http://www.nytimes.com/2008/02/24/business/24drug.html

Vicious Killing

Where Troubled Seek a Listener

February 14, 2008
The New York Times
By AL BAKER

It was just after 8 p.m. in a suite of mental health offices at East 79th Street and York Avenue. One doctor was seeing patients; another was working in her study.

It is a common scene in the offices of countless Manhattan therapists after dark: The lights stay on as paperwork is done and patients are treated into the evening.

Then a middle-aged man in a black cap and sneakers came in from the freezing rain, toting two pieces of black luggage. He said he was there to see a psychiatrist named Kent D. Shinbach. But Dr. Shinbach had another patient, a woman, waiting for him, so the man sat on a couch and made small talk. Then he disappeared into the office of the other doctor, Kathryn Faughey, the police said.

And there — in what investigators described as a furious swirl of violence on Tuesday night — the man stabbed Dr. Faughey in the head, face and chest. Hearing her screams, Dr. Shinbach rushed in and saw her lying still and bleeding on the tan carpet by the foot of her desk.

The attacker turned on him, stabbing him in the face, head and hands, the police said. Dr. Faughey, 56, was declared dead at the scene; Dr. Shinbach, who is in his 70s, survived, but was left in critical condition.

A day later, the police said they did not know the motive for the frenzied attack nor the identity of the killer, though investigators are pursuing the possibility that he was a patient at the offices, where five health care professionals work, or that he was a relative of a patient there or was somehow involved with one.

But even before a motive had been determined, psychiatrists, psychologists and social workers who work in Manhattan — a place long linked in the public imagination with the stereotypical image of an urbanite on a couch discussing his worries — reacted with alarm. Several said the violence in the office at 435 East 79th Street reminded them of the dangers inherent in a career spent helping people, particularly those in emotional pain.

Dr. Faughey grew up in Sunnyside, Queens, and lived across the street from her office. Her husband of 25 years, Walter Adam, said he became worried about 8:30 p.m. because his wife was late. He looked out the window of their 17th-floor apartment and noticed that the light was still on in her office. He called and got no answer. Then he saw police cars on the block.

“I thought it was an automobile accident,” he said. “Finally I said, ‘I better go over and see what’s going on.’ ”

He heard the news from a police officer: His wife had been killed.

“She’s taken very good care of me,” Mr. Adam said. “She’s looked after me. She’s a good and decent woman. Never harmed anyone.”

Police Commissioner Raymond W. Kelly said that after stabbing both doctors, the attacker pinned Dr. Shinbach against the wall with a spindled chair, took $90 from his wallet and fled to the building’s neatly painted basement and out a service exit. He left his two suitcases behind in the basement, where the police found a smear of blood on the door. The woman who had been waiting to see Dr. Shinbach had gone into his office at one point and was unharmed.

During the attack on Dr. Shinbach, which lasted about 10 minutes, the attacker told him, “She’s dead,” the police said, adding that other comments he made did not shed light on his actions.

Mr. Kelly said a key part of the investigation was to determine whether the killer “was a patient of any of the health care professionals in that suite of offices.”

Three knives were later found: one at Dr. Faughey’s left foot; another, a 9-inch blade that was bent in the attack, underneath her desk; and a meat cleaver, also bent and with a broken handle, lying in front of a wall of books. Blood was splashed on the walls and floor. “It was obvious a fierce struggle had taken place,” said Paul J. Browne, the Police Department’s chief spokesman.

Investigators found that the larger suitcase, which had wheels and a handle, held women’s slippers and a blouse, as well as disposable diapers for adults. Inside the smaller bag were eight knives — mostly kitchen knives — three lengths of rope and rolls of duct tape.

Dr. Faughey received a doctorate in clinical psychology from the Ferkauf Graduate School of Psychology at Yeshiva University in 1981. She had been practicing cognitive behavior psychotherapy on the Upper East Side for more than 20 years, according to her Web site.

“My approach is focused and solution-oriented,” according to a quotation on the site. “My sessions move quickly. I am interactive, and I give feedback.”

Mr. Adam said his wife achieved tremendous results for her patients. “The way she turned around people’s lives, saved people’s lives,” he said.

“She was always a person who was reading and studying,” said Kevin Faughey, Dr. Faughey’s oldest brother and one of her six siblings. “She always had goals in her life that she wanted to do something for humanity, in some way, shape or form to help.”

Dr. Shinbach has admitted patients to Beth Israel Medical Center and Gracie Square Hospital, said Dr. Michael Serby, an associate chairman of Beth Israel. “Clearly he’s a brave individual and a hero.”

Dr. Frederick J. Long, a Manhattan psychiatrist who has known Dr. Shinbach for 14 years, described him as dedicated and caring. “He is the best mentor I’ve ever had,” Dr. Long said, adding that Dr. Shinbach was among the first psychiatrists to take an interest in elderly patients.

Another colleague said Dr. Shinbach’s relationship with Dr. Faughey was limited to the shared office space; they did not see each other’s patients.

The attacker’s entrance and departure were captured by security cameras. He arrived at the first-floor offices just after 8 p.m. He left at 8:59 p.m. through the basement door, on which investigators found blood. Investigators said the attacker might have cut his hand. It is common in such furious attacks, when blood can make the weapons slick. The police said DNA tests would be conducted to determine whose the blood was, but it was unclear how long the tests would take.

In the videotape, the man’s arrival is seen as a doorman holds a glass door open for him; he briskly walks in, stating that he was there to see Dr. Shinbach. Pulling his bags, he then goes up a short set of steps from the lobby to the professional offices.

The videotape of the man leaving shows him from behind, as he rounds a corner in the basement and disappears out the exit, onto 79th Street between First and York Avenues. The police are checking security videos from businesses in the area to see if they can pick up images of him.

At a news conference, Mr. Kelly held up a sketch of the suspect that was based on descriptions provided by witnesses who saw the man before the attack.

Dr. Shinbach, who was interviewed by detectives after undergoing surgery at NewYork-Presbyterian Hospital/Weill Cornell Medical Center, did not recognize his attacker.

Mr. Kelly described the killer as a man in his 40s, about 5-foot-9, with brownish or blond hair. He was wearing a three-quarter-length green coat and sneakers. A baseball cap believed to be the killer’s was found in Dr. Faughey’s office, the police said.

After the attack, Dr. Shinbach yelled for help from Dr. Faughey’s office window. The building’s doorman had left just left on a break and heard his cries.

Later, the doorman, Frank Batista, said he was almost certain he could identify the attacker — “99.9 percent.”

Reporting was contributed by John Eligon, Dmitry Kiper,

Robin Stein, Stacey Stowe, Andrew Tangel

and Carolyn Wilder.

Vicious Killing Where Troubled Seek a Listener, NYT, 14.2.2008,
http://www.nytimes.com/2008/02/14/nyregion/14slay.html

Working in Mental Health,

the Prospect of Violence

Is a Part of the Job

February 14, 2008
The New York Times
By JAMES BARRON

Therapists — psychiatrists, psychotherapists, psychiatric social workers and other mental health professionals — are as much part of the New York landscape as hot dog vendors. And they have discovered, sometimes the hard way, that delving deeply into people’s feelings can be dangerous.

As police detectives searched on Wednesday for a man who killed a psychologist with a meat cleaver and other knives — and seriously injured another therapist, who heard their struggle from his nearby office and went to help — therapists said they had learned to develop their own physical and psychological defenses against violence.

But they conceded that a shrewd and determined attacker who appears normal could fool them.

“You do this work long enough, and you pretty much see everything, even in Manhattan,” said Dr. Robert H. Reiner, the executive director of Behavioral Associates, a private outpatient psychotherapy institute on the Upper East Side.

The identity of the attacker in Tuesday’s killing was not known, and the police said it was not clear if he was a patient or a patient’s relative, or if he had some other connection to the victims.

Still, therapists said they recognized the inherent risk in treating some types of patients. Dr. Reiner said most of the patients he saw, in six to eight “intake interviews” a day, had anxiety disorders that carried a low risk of violence. But every so often, he realizes that a patient has a severe psychosis.

“Often as not, it’s someone who’s walking around like you and me, and the psychosis is well disguised, and I realize they could be dangerous,” Dr. Reiner said. “And I look at the window and I think, ‘How quick can I get out?’ Every psychotherapist in an urban area knows this feeling.”

Just how much violence is directed at therapists is an open question. Of a dozen therapists in private practice in New York City who were interviewed on Wednesday, only one said he had ever seen violence in his office, and he was not the target: A father and son came to blows, he said.

But when Christina E. Newhill, an associate professor at the University of Pittsburgh, surveyed 1,129 therapeutic workers nationwide in 2003, 58 percent said they had had to deal with violence, though only 24 percent of those said they had actually been attacked. Twenty-five percent of those who had to deal with violence said clients had damaged or destroyed property, while half said the episodes did not go beyond threats.

Gary Arthur, a professor emeritus at Georgia State University, surveyed all 6,400 licensed therapists in Georgia in 2001. Of the 1,132 who responded, 14 had been shot at, 6 attacked with a knife, 209 pushed or shoved, 112 slapped and 87 hit by objects thrown at them. None of the therapists who said they had been shot at were struck by the bullets, he said.

“The results were scary,” he said in an interview. “Our profession remains very high on the list for risk of danger.”

Twice in his years as a psychologist, Dr. Alan Hilfer, now the chief psychologist at Maimonides Medical Center in Brooklyn, has had to deal with violent patients: once when a father and son got into a knock-down-drag-out brawl in his consultation room, and once when a teenager threw a paperweight at the therapist in the next office.

Dr. Hilfer said therapists were not taught precautions — like where to position oneself during a consultation — during training.

He recalled being asked, early in his career, to interview a man seeking treatment. “I allowed him to come between me and the door” in the consultation room, Dr. Hilfer said. “He became agitated and threatening, and I couldn’t get out of the room.”

In some group practices or in hospitals, he said, therapists leave the door open during a first encounter with a patient. They also alert a colleague, who listens for sounds of a disturbance.

Dr. Newhill teaches a class that tells prospective therapists how to do risk assessments and handle patients who turn violent. In a telephone interview, she said she started the class because of a murder in California in 1989. A therapist at a mental health clinic in Santa Monica was stabbed 31 times in her office by a patient, a street person who Dr. Newhill said was delusional.

“Violence is an interaction between the person and their environment,” she said, adding that the best predictor of future violence is a recent history of violence. She tells her students to work out, in advance, a plan that includes a way to signal for help. Some therapists install silent alarms. Others work out a phrase that lets a colleague know help is needed: “Please cancel my appointment for 3 o’clock” could mean “Call 911,” for example.

Dr. Reiner, of Behavioral Associates, said patients who turn violent had often “scoped things out in advance.” He said they would figure out whether a therapist worked alone or in an office with secretaries, other therapists or even video surveillance cameras.

But therapists who work by themselves, as many do in Manhattan, cannot turn to a colleague or a subordinate for assistance when a session degenerates.

“There is no warning system” for solo practitioners, Dr. Hilfer said. “We can try to use our clinical awareness and our knowledge of the patient, and if we are concerned about a patient, we will send them for a consult with someone. But in terms of protection, there’s none. It underscores the vulnerability that many of us understand.”

John Eligon and Anthony Ramirez

contributed reporting.

Working in Mental Health,
the Prospect of Violence Is a Part of the Job,
NYT, 14.2.2008,
http://www.nytimes.com/2008/02/14/nyregion/14pysch.html

Man Sought

in Psychologist’s Stabbing

February 13, 2008
The New York Times
By AL BAKER

Armed with a suitcase full of knives, an unidentified middle-aged man unleashed a rampage of violence inside the offices of an Upper East Side psychiatry practice on Tuesday night, fatally stabbing and slashing a well-known psychologist before wounding her colleague when he tried to come to her aid, officials said on Wednesday.

The assailant had not been identified as of Wednesday afternoon, the police said, though investigators were pursuing a theory that he was either a patient at the suite of offices, at 440 East 79th Street, or that he had some kind of ties to the establishment or the services it provided.

Originally, the assailant had arrived at the offices, about five seconds after 8 p.m. on Tuesday, asking to visit Dr. Kent T. Shinbach, 70, a psychiatrist there, the police said.

But at some point he disappeared inside the office of another counselor there, Kathryn Faughey, 56, the police said.

There, he unleashed a barrage of violence, fatally stabbing Dr. Faughey. At some point, when Dr. Shinbach heard the attack and went to the office of his colleague, the assailant turned on him and Dr. Shinbach was seriously injured, officials said.

The scene was marked by blood and upended furniture, the police and neighbors said.

“We could see in the office where the blinds had been ripped off and were hanging at a strange angle and the entire office was in disarray,” said Alexandra Pike, 20, a student who could see into the office where the attack occurred from the window of her apartment across the street. “Papers were strewn around and there was overturned furniture. And it was clear there was some kind of scuffle.”

It is unclear what the man’s motive was, and Police Commissioner Raymond W. Kelly released a sketch of the suspect after a news conference at 1 Police Plaza on Wednesday, saying detectives were seeking him. The sketch was based on descriptions provided to detectives of those who saw the man in the moments before the attack — including the surviving victim — but who could not identify him by name.

“Obviously there is a forensic evidence aspect to this case,” Mr. Kelly said. “We’re getting information from the doctor and other medical professionals in the suite to determine if they have any information to add as the investigation goes forward.”

He added: “We’re fully engaged on several fronts.”

Mr. Kelly described the assailant as a man in his 40’s, about 5 feet 9 inches, with brownish or blond hair. He was wearing a three-quarter length green coat, with sneakers and a baseball cap, said Mr. Kelly, as he held up the sketch before a bank of television cameras.

The first sign of the man’s entrance at the building was captured on videotape —as he walked in the front door about five seconds after 8 p.m., passed by a doorman and went into the counselors’ suite of offices, the police said. He was inside for about an hour: A videotape showed him leaving through a basement door about 8:54 p.m., the police said, and it showed a view of him from his back.

Blood was found on the door — a panic door that locks on its own when it shuts — indicating the assailant might have been wounded.

Before he fled, the assailant left two suitcases in the basement. Inside one was assorted women’s clothing — some shoes, a top, as well as diapers for adults. He other had about eight knives, the police said. Upstairs in the room of Ms. Faughey, investigators found three other weapons, including two knives and a cleaver with a broken handle, the police said.

A female patient was in the lobby of the counselors’ suite when the assailant showed up, the police said. She apparently left before the attack on Dr. Faughey became known, but detectives tracked her down and interviewed her, the police said. Dr. Shinbach was also interviewed after undergoing surgery at New York Hospital/Weill Cornell Medical Center.

Man Sought in Psychologist’s Stabbing,
NYT,
13.2.2008,
http://www.nytimes.com/2008/02/13/nyregion/13doc.html

Albert Ellis, 93,

Influential Psychotherapist,

Dies

July 25, 2007

The New York Times

By MICHAEL T. KAUFMAN

Albert Ellis, whose innovative straight-talk approach to psychotherapy made him one of the most influential and provocative figures in modern psychology, died yesterday at his home above the institute he founded in Manhattan. He was 93.

The cause, after extended illness, was kidney and heart failure, said a friend and spokeswoman, Gayle Rosellini.

Dr. Ellis (he had a doctorate but not a medical degree) called his approach rational emotive behavior therapy, or R.E.B.T. Developed in the 1950s, it challenged the deliberate, slow-moving methodology of Sigmund Freud, the prevailing psychotherapeutic treatment at the time.

Where the Freudians maintained that a painstaking exploration of childhood experience was critical to understanding neurosis and curing it, Dr. Ellis believed in short-term therapy that called on patients to focus on what was happening in their lives at the moment and to take immediate action to change their behavior. “Neurosis,” he said, was “just a high-class word for whining.”

“The trouble with most therapy is that it helps you to feel better,” he said in a 2004 article in The New York Times. “But you don’t get better. You have to back it up with action, action, action.”

If his ideas broke with conventions, so did his manner of imparting them. Irreverent, charismatic, he was called the Lenny Bruce of psychotherapy. In popular Friday evening seminars that ran for decades, he counseled, prodded, provoked and entertained groups of 100 or more students, psychologists and others looking for answers, often lacing his comments with obscenities for effect.

His basic message was that all people are born with a talent “for crooked thinking,” or distortions of perception that sabotage their innate desire for happiness. But he recognized that people also had the capacity to change themselves. The role of therapists, Dr. Ellis argued, is to intervene directly, using strategies and homework exercises to help patients first learn to accept themselves as they are (unconditional self-acceptance, he called it) and then to retrain themselves to avoid destructive emotions — to “establish new ways of being and behaving,” as he put it.

His methods, along with those of Dr. Aaron T. Beck, a psychiatrist who was working independently, provided the basis for what is known as cognitive behavior therapy. A form of talk therapy, it has been shown to be at least as effective as drugs for many people in treating anxiety, depression, obsessive-compulsive disorder and other conditions.

His admirers credited Dr. Ellis with adapting the “talking cure,” the dominant therapy in extended Freudian sessions, to a pragmatic, stop-complaining-and-get-on-with-your-life form of guidance later popularized by television personalities like Dr. Phil.

Dr. Ellis had such an impact that in a 1982 survey, clinical psychologists ranked him ahead of Freud when asked to name the figure who had exerted the greatest influence on their field. (They placed him second behind Carl Rogers, the founder of humanistic psychology.) His reputation grew even more in the next two decades.

In 1955, however, when Dr. Ellis introduced his approach, most of the psychological and psychiatric establishment scorned it. His critics said he misunderstood the nature and force of emotions. Classical Freudians also took offense at Dr. Ellis’s critical observations about psychoanalysis and its founder. Dr. Ellis contended that Freud “really knew very little about sex” and that his view of the Oedipus complex, as suggesting a universal law of human disturbance, was “foolish.”

A sexual liberationist, Dr. Ellis collaborated with Dr. Alfred C. Kinsey in his taboo-breaking research on sexual behavior, and his writings about sex drew complaints from members of the American Psychological Association.

As a base for his work he established the Institute for Rational Living, now the Albert Ellis Institute, in a townhouse on East 65th Street in Manhattan. He lived there on the top floor.

The article in The Times described Dr. Ellis at 90, hard of hearing and recovering from abdominal surgery, coming downstairs one day in the spring of 2004 to lead one of his Friday sessions, just as he had for 30 years.

“Do you know why your family is trying to control you?” he asked a volunteer who had joined him in front of the audience. “Because they are out of their minds!” he said, inserting an unprintable adjective.

Another participant recalled the murder of her sister years ago by a drug dealer. “Why can’t you understand that some people are crazy and violent and do all kinds of terrible things?” Dr. Ellis declared. “Until you accept it, you’re going to be angry, angry, angry.”

Some critics complained that his seminars were more stand-up comedy than serious lecture. Still, despite his iconoclasm, or perhaps because of it, rational emotive behavior therapy became one of the most popular systems of psychotherapy in the 1970s and ’80s. In 1985, the American Psychological Association presented Dr. Ellis with its award for “distinguished professional contributions.”

Dr. Ellis was the author or co-author of more than 75 books, many of them best sellers. Among them were “A Guide to Successful Marriage,” “Overcoming Procrastination,” “How to Live With a Neurotic,” “The Art of Erotic Seduction,” “Sex Without Guilt,” “A Guide to Rational Living,” and “How to Stubbornly Refuse to Make Yourself Miserable About Anything — Yes, Anything.”

He often went back to his own life experiences to help explain his positive frame of thinking. Albert Ellis was born on Sept. 27, 1913, in Pittsburgh, the oldest of three children. As a child, he wrote, he had a kidney disorder that turned him from sports to books. His parents moved to the Bronx and separated when he was 11. He once wrote that he had limited but amiable contacts with his father, a traveling salesman, and that his mother, an amateur actress, was not interested in domestic life.

He maintained that the experience had left no scars. “I took my father’s absence and my mother’s neglect in stride,” he wrote, “and even felt good about being allowed so much autonomy and independence.”

He did well in school, skipped grades, won writing contests and, he said, was pleased with his accomplishments.

But at 19 he was painfully shy and eager to change his behavior. In one exercise he staked out a bench in a park near his home, determined to talk to every woman who sat there alone. In one month, he said, he approached 130 women.

“Thirty walked away immediately,” he said in the Times article. “I talked with the other 100, for the first time in my life, no matter how anxious I was. Nobody vomited and ran away. Nobody called the cops.”

Though he got only one date as a result, his shyness disappeared, he said. He similarly overcame a fear of speaking in public by making himself do just that, over and over. He became an accomplished public speaker.

Dr. Ellis studied accounting at City College during the Depression and took up some entrepreneurial schemes after graduating. In one, he paired used men’s jackets and pants of similar colors and sold them as suits. He wrote fiction but found no publishers. He had read a good deal about sex and set up a bureau in which he counseled couples.

His first marriage, to Karyl Corper, an actress, in 1938, ended in annulment. His second, in 1956, to Rhoda Winter, a dancer, ended in divorce. For 37 years, from 1966 to 2003, he lived with a companion, Janet L. Wolfe, a psychologist who had been executive director of the institute. More recently he married Debbie Joffe-Ellis, a psychologist and former assistant, who survives him.

After receiving a doctorate in clinical psychology from Columbia in 1947, Dr. Ellis spent several years undergoing classical psychoanalysis while using its techniques in his job at a state mental hygiene clinic in New Jersey. He quit in 1950 to begin a private practice specializing in sex and marriage therapy and soon started drifting from Freudian orthodoxy, finding it, he said, a waste of time.

He turned to Greek, Roman and modern philosophers and considered his own experience. Out of this came rational emotive behavioral therapy, which he decided would focus not on excavating childhood but on confronting the irrational thoughts that lead to self-destructive feelings and behavior. He founded his Manhattan institute in 1959.

“I was hated by practically all psychologists and psychiatrists,” he recalled. They thought his approach was “superficial and stupid,” he said, and “they resented that I said therapy doesn’t have to take years.”

In 2005, Dr. Ellis sued the institute after it removed him from its board and canceled his Friday seminars. He and his supporters claimed that the institute had fallen into the hands of psychologists who were moving it away from his revolutionary therapy techniques.

The board said it had acted out of economic necessity, asserting that payouts to Dr. Ellis for medical and other expenses were jeopardizing the institute’s tax-exempt status. Dr. Ellis was by then hard of hearing and required daily nursing care. Some board members said they were uncomfortable with his confrontational style and eccentricities and saw him as a liability.

In January 2006, a State Supreme Court judge ruled that the board had been wrong in ousting Dr. Ellis without proper notice and reinstated him. But his friend Ms. Rosellini said Dr. Ellis’s relations with the board had remained strained afterward.

Despite his failing health, Dr. Ellis maintained a demanding schedule late into his life.

“I’ll retire when I’m dead,” he said at 90. “While I’m alive, I want to keep doing what I want to do. See people. Give workshops. Write and preach the gospel according to St. Albert.”

Albert Ellis, 93, Influential Psychotherapist, Dies,
NYT,
25.7.2007,
https://www.nytimes.com/2007/07/25/
nyregion/25ellis.html

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