History > 2013 > USA > Health (I)

Both Sides Rest

in Trial of a Philadelphia Abortion Doctor

Charged With Murder

April 29, 2013
The New York Times
By TRIP GABRIEL

PHILADELPHIA — They are known as Baby Boy A, Baby C, Baby D and Baby E, all of whom prosecutors call murdered children and the defense calls aborted fetuses — the very difference in language encapsulating why anti-abortion advocates are so passionate about drawing attention to the trial of Dr. Kermit Gosnell, which wrapped up here on Monday with summations by both sides.

In five weeks of testimony, jurors were told that Dr. Gosnell, 72, had performed late-term abortions by injecting a drug to stop the heart of the fetus, but that when one jerked an arm, cried or drew breath outside the womb, its spinal cord was cut with surgical scissors.

To anti-abortion leaders, the accounts have the power to break through decades of hardened positions in the abortion wars, not just because of the graphic details but because they raise the philosophical issue of why an abortion procedure performed in utero is legal, but a similar act a few minutes later, outside the womb, is considered homicide.

The distinction “is maybe a 15-minute or half-hour time frame and 10 inches of physical space,” said Michael Geer, the president of the Pennsylvania Family Institute, an anti-abortion group. “I think it’s going to resurrect a debate about the humanity of the unborn child.”

Abortion rights groups have a very different view. They say that Dr. Gosnell was a rogue practitioner, and that if abortion is further restricted, more women will be driven to clinics like his, which prosecutors called a “house of horrors.”

Jay Sekulow, the chief counsel of the American Center for Law and Justice, a conservative legal organization in Washington, said, “This case in the end is going to be viewed as monumental, no matter what the verdict is.”

Last week, Judge Jeffrey P. Minehart of the Court of Common Pleas threw out three of seven first-degree murder charges against Dr. Gosnell. The doctor’s defense lawyer, Jack J. McMahon, argued Monday that none of the remaining four cases had resulted in live births.

Because the women were given injections of the drug digoxin, which causes “fetal demise,” Mr. McMahon argued, any postdelivery movements were involuntary spasms.

“Every single piece of scientific evidence in this case has shown stillbirth,” he said.

But Edward Cameron, an assistant district attorney, countered that testimony showed Dr. Gosnell did not always use digoxin and that it did not always work as intended. He quoted a former clinic worker with medical school training but no doctor’s license who testified that the drug “wasn’t giving the desired effect, the heart was always beating.”

The prosecutor cited Pennsylvania law stating that if a baby delivered during an abortion “shows any sign of life, it’s considered alive — a heartbeat, breathing, a cry, movement.”

The jury will now make that determination in the cases, including that of Baby Boy A, whom clinic workers testified Dr. Gosnell joked was big enough “to walk me home.”

Baby D, a clinic worker testified, was delivered into a toilet by a woman waiting for Dr. Gosnell and it appeared to make swimming motions before one of the doctor’s assistants pulled it out and cut its neck.

Two workers said they heard Baby E crying before Dr. Gosnell cut its spine with scissors. The prosecutor quoted a worker: “It made noises, a whine like my baby.”

Mr. McMahon also cited the trial testimony, in which the clinic worker acknowledged she did not know for sure if Baby E was born alive. Eight workers from the clinic, the Women’s Medical Society in West Philadelphia, have pleaded guilty to lesser charges in the case, including Dr. Gosnell’s wife, Pearl, a cosmetologist who helped perform abortions.

If convicted, Dr. Gosnell could face the death penalty.

The case became a cause célèbre when anti-abortion activists complained that the mainstream news media were ignoring it for ideological reasons. It has since been widely covered, and every seat in the courtroom was taken on Monday.

Anti-abortion campaigners have seized on the trial because it highlights late-term abortions performed after fetal viability. The same public opinion polls that for decades have shown that a majority of Americans support abortion also show that most of them want it banned in certain cases.

Abortion opponents have leveraged these mixed feelings in recent years to lobby at the state level to restrict the procedure. Nine states have banned most abortions beyond 20 weeks of pregnancy. Last month, two states went further: Arkansas banned abortion after 12 weeks and North Dakota beyond about 6 weeks, when a fetal heartbeat is “detectable.” Abortion rights groups said both limits would be found unconstitutional in federal court.

Though late-term abortions are central to the Gosnell case, they are extremely rare. According to the Centers for Disease Control and Prevention, 92 percent of abortions are performed before 14 weeks, with 1.3 percent beyond 20 weeks.

“No woman carries their child to six, seven, eight months and then one day decides they don’t want to become a parent,” said Ilyse Hogue, the president of Naral Pro-Choice America. “These are terrible, tragic situations where families have to make difficult choices with their doctors. I think most Americans believe that’s where they belong.”

To abortion rights groups, if abortion is further restricted, desperate women will be forced to seek providers like Dr. Gosnell, who is also accused of performing 24 abortions beyond 24 weeks of pregnancy, the limit in Pennsylvania.

“Restrictions really work to hinder access to safe abortion,” said Dayle Steinberg, the president of Planned Parenthood Southeastern Pennsylvania. “It only increases the number of economically disadvantaged women who find themselves in extreme circumstances and they turn to unsafe options for care.”

Dr. Gosnell is also accused of third-degree murder in the death of a 41-year-old patient from Virginia, who visited his clinic after being turned away by three clinics closer to her home, according to testimony by a daughter of the woman.

Mr. McMahon said Dr. Gosnell’s staff members who pleaded guilty did so out of fear of the district attorney’s office, which he accused of creating “a tsunami of hype” in a grand jury report and in the news media about Dr. Gosnell’s practices. To counter that, he showed slides of a waiting room, hallway and procedure rooms at the defunct clinic that looked scrubbed and clean.

The prosecution, for its turn, rolled in a filthy procedure table and broken equipment removed from the clinic. Mr. Cameron, the assistant district attorney, brandished a stained ultrasound probe with unconcealed disgust.

The jury was expected to begin deliberations on Tuesday.

    Both Sides Rest in Trial of a Philadelphia Abortion Doctor Charged With Murder,
    NYT, 29.4.2013, http://www.nytimes.com/2013/04/30/us/trial-abortion-doctor-kermit-gosnell.html

Hilary Koprowski,

Who Developed

First Live-Virus Polio Vaccine,

Dies at 96

April 20, 2013
The New York Times
By MARGALIT FOX

It was a brew to rival any in “Macbeth.” The main ingredients were rat brain and a fearsome, carefully cultivated virus.

In his laboratory in Pearl River, N.Y., 20 miles north of Manhattan, Dr. Hilary Koprowski macerated the ingredients in an ordinary kitchen blender one January day in 1948. He poured the result — thick, cold, gray and greasy — into a beaker, lifted it to his lips and drank. It tasted, he later said, like cod liver oil.

With that sip, Dr. Koprowski, a virologist who died on April 11 at 96, inoculated himself against polio, years before the vaccines of Jonas Salk and Albert Sabin.

Dr. Koprowski was one of the world’s foremost biomedical researchers, helping usher in a spate of innovations, including a safer, less painful and more effective rabies vaccine that remains widely used.

But his most noteworthy innovation — developing the first viable vaccine against polio and testing it successfully on humans — is far less well known. It has long been eclipsed in public memory by the triumphs of Salk, whose injectable vaccine was introduced in 1955, and Sabin, whose oral vaccine was introduced in stages in the early 1960s.

“Koprowski’s was the first serious scientific attempt at a live-virus polio vaccine,” said the historian David M. Oshinsky, whose 2005 book, “Polio: An American Story,” chronicles the race to pre-empt the disease. “Jonas Salk is a god in America, Albert Sabin’s got a ton of publicity, and Hilary Koprowski, who really should be part of that trinity, is the forgotten man.”

From the beginning, a live-virus vaccine like Dr. Koprowski’s was the most coveted weapon in the war on polio. Such vaccines can be administered orally and are far cheaper than injections. And because they involve live viruses, which can spread within a community, they can also confer immunity on others. (The Salk vaccine, made from killed viruses, cannot.)

But there was a grave catch: for a live polio vaccine to be safe, the viruses would have to be sufficiently weakened — attenuated, in medical parlance — so they would produce antibodies without inducing polio’s neurological effects.

On the evidence, the Koprowski vaccine did precisely this. But though it was given to patients overseas with good results, it was never approved for use in the United States.

Dr. Koprowski was the last of the three great virologists who stalked polio at midcentury; Sabin died in 1993, Salk in 1995. His death raises a large retrospective question: Why, in an era when a polio vaccine was the most urgently sought grail in American public health, did his go unused?

The answer, gleaned from period news accounts, histories of the war on polio and interviews with Dr. Koprowski’s associates, illuminates the delicate balance of risk and reward — and the uneasy confluence of science, politics and personality — that can inform the development of a drug.

Dr. Koprowski, who spent more than 30 years as the director of the Wistar Institute, a biomedical research center in Philadelphia, was widely described as a titanic, sometimes polarizing figure: a refugee from Nazi-occupied Poland, he was a trained concert pianist, a fluent speaker of seven languages, a connoisseur of food and wine, and a collector of old master paintings.

“He was the single most forceful, dominant, charismatic person I have ever met in my life,” said Dr. Paul A. Offit, the chief of infectious diseases at Children’s Hospital of Philadelphia, who worked under Dr. Koprowski at Wistar in the 1980s.

That outsize personality, combined with Dr. Koprowski’s outsider status — he spent part of his career in industry at a time when academia had far more prestige — may have played a role in the fate of his vaccine, his biographer, Roger Vaughan, and Professor Oshinsky said in interviews.

Others, including Dr. Offit, say the outcome was based on science alone. But all agree that Dr. Koprowski, by demonstrating that a live-virus polio vaccine could be safe and effective, paved the way for the Sabin vaccine.

And it was Sabin’s vaccine, even more than Salk’s, that brought about the near-eradication of polio worldwide.

“Sometimes,” Dr. Koprowski says tellingly in Mr. Vaughan’s biography, “Listen to the Music: The Life of Hilary Koprowski” (2000), “I introduce myself as the developer of the Sabin poliomyelitis vaccine.”

Hilary Koprowski was born in Warsaw on Dec. 5, 1916. He attended the Warsaw Conservatory and Warsaw University simultaneously, earning a medical degree from the university in 1939.

Late that year, after the German invasion of Poland, Dr. Koprowski, who was partly of Jewish extraction, left the country with his family. He studied music in Rome before moving to Rio de Janeiro, where he worked for the Rockefeller Foundation’s Yellow Fever Research Service.

In 1944, Dr. Koprowski arrived in the United States and joined Lederle Laboratories, a pharmaceutical concern in Pearl River. It was there, in the late 1940s, that he began his work on polio.

By the mid-20th century, the United States was reporting 20,000 to 60,000 new cases of polio a year, most affecting children. In 1938, President Franklin D. Roosevelt, who had contracted polio as an adult, established what became the March of Dimes, which would finance the Salk and Sabin vaccines.

“What you have to understand about Koprowski was that he was the leading polio researcher from private industry,” Professor Oshinsky said. “Had he come out of the university and had he been funded by the March of Dimes, I think he would have been a favorite of the virology community.”

But he seemed, at least at times, to roil that community, already skittish about polio.

In the 1930s, researchers had tested two vaccines made from killed polio viruses, in principle safer than live ones. But as it transpired, the viruses had not been killed entirely, and the vaccines paralyzed some children.

As a result, the idea of testing a polio vaccine — much less a live one — on humans was almost beyond contemplation by midcentury.

The first successful live-virus vaccine of any kind was for yellow fever, developed in the late 1930s by the virologist Max Theiler; for his work, he received the 1951 Nobel Prize in Physiology or Medicine.

The method Theiler devised for attenuating the virus involved injecting it into a series of nonhuman embryo cells, including those of mice and chickens. In the late ’40s, Dr. Koprowski wondered whether a similar method could be used to attenuate polio.

Because the cotton rat, a genus found in the Americas, was susceptible to polio, Dr. Koprowski injected the virus into cotton rat brains.

“The thinking is this,” Dr. Offit explained: “As the virus gets better and better at growing in, in this case, a rodent, it would become less and less capable of growing or reproducing itself in people.”

The result was the grim gray cocktail Dr. Koprowski drank in the lab that day in 1948. He suffered no ill effects.

Two years later, Dr. Koprowski received a call from Letchworth Village, a home for mentally disabled children in Rockland County, N.Y. Fearing an outbreak of polio, the home asked him to vaccinate its children.

In February 1950, in the first human trial of a live polio vaccine, Dr. Koprowski vaccinated 20 children there. At the time, approval from the federal government was required to market drugs but not to test them.

Seventeen of the children developed antibodies against polio. (The other three turned out to have the antibodies already.) None of the children experienced complications.

Describing his trial at a scientific meeting the next year, Dr. Koprowski met with astonished displeasure. In an exchange recounted in Professor Oshinsky’s book, Sabin, who was present, accosted him, saying: “Why did you do it? Why? Why?”

Sabin’s objection was not to Dr. Koprowski’s testing the vaccine on cognitively disabled children — that was common practice then. It was to his having tested a live polio vaccine on any human being at all.

“Koprowski replied that someone had to take the next step,” Professor Oshinsky wrote, “so it might as well be him.”

In 1958, Dr. Koprowski administered his vaccine to nearly a quarter million patients in the Belgian Congo. “It appears to have been completely safe, almost 100 percent effective,” Time magazine reported.

(His work in the Congo came to renewed attention in the 1990s after two publications — Rolling Stone magazine and “The River,” a book by the British writer Edward Hooper — asserted that Dr. Koprowski had unwittingly spread H.I.V., the virus that causes AIDS, by injecting patients there with contaminated polio vaccines. The assertions have since been discredited.)

In 1960, after several live attenuated polio vaccines, including Sabin’s and Dr. Koprowski’s, had been studied, the United States surgeon general, Leroy E. Burney, announced the approval of Sabin’s. Tests on monkeys had shown it to be somewhat more attenuated, and therefore somewhat safer, than Dr. Koprowski’s.

“He believed they exaggerated the deficiencies and the dangers of his vaccine,” Professor Oshinsky said of Dr. Koprowski. “Hilary Koprowski’s rebuttal to Sabin would have been, ‘If you had started your vaccine when I started, in the late 1940s, there would be tens of thousands of kids who are not paralyzed now.’ ”

At Wistar, which he led from 1957 to 1991, Dr. Koprowski is credited with transforming the place from a moribund Victorian institution into a first-class research facility. Several important vaccines were created there under his stewardship, including one for rubella, developed in the 1960s by Stanley Plotkin.

Besides his own work on the improved rabies vaccine, which he helped develop in the ’60s, Dr. Koprowski was known for significant early work on the therapeutic use of monoclonal antibodies.

Occurring naturally in the body, these antibodies help the immune system attack particular kinds of cells. Made in quantity in the laboratory, they can be used to combat a range of infectious diseases, as well as certain cancers.

Dr. Koprowski, who held faculty positions at the University of Pennsylvania, with which Wistar is associated, was later affiliated with Thomas Jefferson University in Philadelphia.

Dr. Koprowski’s wife, the former Irena Grasberg, whom he married in 1938, died last year. He is survived by two sons, both of whom received his vaccine as children without complications — Christopher, who confirmed his father’s death, at his home in Wynnewood, Pa., and Claude — and by five grandchildren and three great-grandchildren.

Asked publicly about the lack of recognition for his polio vaccine, Dr. Koprowski was courtly, saying the corresponding lack of hoopla freed him to focus on pure research.

His private feelings differed.

“I think that there was a great deal of hurt and jealousy on his part that he never got credit for what he discovered, and for the path that he blazed for others to follow,” Professor Oshinsky said. “He pretty much told me that when I interviewed him.”

Dr. Koprowski received many laurels, including the French Legion of Honor. In 2007, his work was recognized with a signal honor, presented annually for distinguished contributions to vaccinology.

The award is known as the Albert B. Sabin Gold Medal.

    Hilary Koprowski, Who Developed First Live-Virus Polio Vaccine, Dies at 96, NYT, 20.4.2013,
    http://www.nytimes.com/2013/04/21/us/
    hilary-koprowski-developed-live-virus-polio-vaccine-dies-at-96.html

Mental Illness in California Prisons

April 10, 2013
The New York Times
By THE EDITORIAL BOARD

There are about 33,000 mentally ill prisoners in state prisons in California, close to 30 percent of the prison population. The number of suicides in state prisons has soared in recent years, to about 24 suicides per 100,000 inmates a year, a rate about 48 percent higher than the national average.

But 70 percent of the suicides might have been prevented with proper care, according to Judge Lawrence Karlton of Federal District Court in Sacramento. In a scathing ruling last week, Judge Karlton noted that the treatment of the seriously mentally ill in California prisons continues to violate prohibitions against cruel and unusual punishment — even though he has issued more than 100 court orders in the past 17 years to improve the care after this inmate class-action suit was filed in 1995.

He rejected a motion by the state to end his oversight. As he wrote, “Systemic failures persist in the form of inadequate suicide prevention measures, excessive administrative segregation of the mentally ill, lack of timely access to adequate care, insufficient treatment space and access to beds, and unmet staffing needs.”

The mental health care case is closely intertwined with the long-running litigation over unconstitutional overcrowding in California’s prisons. In 2011, the Supreme Court ordered the state to reduce overcrowding. To meet that directive, a three-judge panel, including Judge Karlton, in 2012 ordered the state to take “all steps necessary” to reach the population limit set by the Supreme Court. That requires reducing the state prison population to around 110,000 inmates from about 120,000 currently.

California has until December to comply with the overcrowding order, but in aggressively fighting it in court the state has repeatedly shown that it has no intention of meeting that deadline. The only way for California to satisfy Constitutional standards for its prisons is to reduce the number of inmates and improve the mental health care in those institutions without delay.

This article has been revised to reflect the following correction:

Correction: April 15, 2013

An editorial on Thursday about treatment of mental illness

in California prisons misstated how the state inmate suicide rate

compares with the national average.

It is about 48 percent higher, not nearly twice the national average.

    Mental Illness in California Prisons, NYT, 10.4.2013,
    http://www.nytimes.com/2013/04/11/opinion/mental-illness-in-california-prisons.html

Alabama Legislature Passes

New Limits on Abortion Clinics

April 3, 2013
The New York Times
By ERIK ECKHOLM

The Alabama Legislature late Tuesday adopted stringent new regulations for abortion clinics that supporters called a step to protect women but that others called medically unnecessary and a disguised effort to force the closing of the state’s five abortion clinics.

The bill, like measures passed last year in Mississippi and Tennessee and last month in North Dakota, would require that doctors performing abortions have admitting privileges at local hospitals. Several of Alabama’s clinics rely on doctors who fly in from out of state, and given the hostile political climate it appears unlikely that nearby hospitals would grant them such privileges, said Nikema Williams, vice president for public policy of Planned Parenthood Southeast, which runs two of the clinics.

A similar admissions requirement passed last year in Mississippi would shut down that state’s only abortion clinic, but enforcement is stayed while a federal court decides whether the law amounts to an unjustified infringement on access to abortion.

Another clause in the Alabama bill would require clinics to meet the building, equipment and staffing standards of ambulatory surgery centers, which would require some clinics to spend millions of dollars altering buildings, and buying beds and monitoring equipment, for what they say is no relevant medical purpose.

The bill will be sent to Gov. Robert Bentley, a Republican, who previously said he planned to sign it. The American Civil Liberties Union said that if the bill becomes law it is likely to sue to block it.

The Alabama measure is part of a spreading effort by anti-abortion groups to tighten the regulation of abortion clinics. Such laws seldom receive the attention of more sweeping bans on early abortions, like those recently adopted in Arkansas and North Dakota to protect the fetus once a heartbeat is detected, but are increasingly disruptive, said Carole Joffe, a sociologist at the University of California, San Francisco, who studies abortion laws and support abortion rights.

“Those other laws may sound more drastic,” she said of the bans on early abortions, “but one assumes the Supreme Court will not uphold them.”

“It’s the more reasonable-sounding things like hallway width, or requiring a doctor to have local admitting privileges, that some courts will possibly approve,” Dr. Joffe said. “These have the capacity to be much more devastating to the ability to provide abortion care.”

Dan McConchie, vice president for legislative affairs of Americans United for Life, said stricter regulations of doctors and facilities represented a genuine effort “to ensure that if clinics are going to operate, they operate to high standards that protect women’s health and safety.”

His organization, with headquarters in Washington, has offered sample regulatory laws to state legislators, including those in Alabama.

“If you’re genuinely concerned about women’s health, then you want the doctor to have the ability to care for complications,” he said of the proposed rules.

Abortion rights supporters said that the endangered clinics in Mississippi and elsewhere had arrangements with local doctors and hospitals to handle emergencies, and that requiring the visiting doctor to have admitting privileges offered no extra safety.

Mr. McConchie replied, “These are the doctors performing the procedure, they are the ones with greatest knowledge of what happened” in an emergency.

Admitting-privilege requirements have been adopted so far in Arizona, Kansas, Mississippi, Tennessee, Utah and North Dakota, according to Elizabeth Nash, state issues manager with the Guttmacher Institute, a research group in Washington that supports abortion rights. The rule in Tennessee forced the closing last year of one of Knoxville’s two clinics.

Mr. Bentley, as he praised the proposed clinic and physician regulations on March 5, spoke of more than medical safety, saying, “We need to remember we are dealing with human life and this is what God expects us to do,” according to The Associated Press.

Ms. Williams of Planned Parenthood said, in an interview on Wednesday, “If the politicians really cared about the health and welfare of women, they’d be working with us to address the poor health outcomes for women in Alabama.”

    Alabama Legislature Passes New Limits on Abortion Clinics, NYT, 3.4.2013,
    http://www.nytimes.com/2013/04/04/us/alabama-legislature-approves-abortion-clinic-limits.html

Dementia Cost, Already High,

Is Projected to Double by 2040

April 3, 2013
The New York Times
By PAM BELLUCK

The most rigorous study to date of how much it costs to care for Americans with dementia found that the financial burden is at least as high as that of heart disease or cancer, and is probably higher. And both the costs and the number of people with dementia will more than double within 30 years, skyrocketing at a rate that rarely occurs with a chronic disease.

The research, led by an economist at the RAND Corporation, financed by the federal government, and published Wednesday in The New England Journal of Medicine, provides the most reliable basis yet for measuring the scale of the problem. Until now, the most-cited estimates of the condition’s cost and prevalence came from an advocacy group, the Alzheimer’s Association.

Although some figures from the new research are lower than the association’s projections, they are nonetheless staggering and carry new gravity because they come from an academic research effort. Behind the numbers is a sense that the country, facing the aging of the baby boom generation, is unprepared for the coming surge in the cost and cases of dementia.

“It’s going to swamp the system,” said Dr. Ronald C. Petersen, who is chairman of the advisory panel to the federal government’s recently created National Alzheimer’s Plan and was not involved in the RAND study.

If anything, Dr. Petersen said of the study’s numbers, “they’re being somewhat conservative.” Dr. Petersen, the director of the Alzheimer’s Disease Research Center at the Mayo Clinic, is part of another team collecting data on dementia costs.

The RAND results show that nearly 15 percent of people aged 71 or older, about 3.8 million people, have dementia. By 2040, the authors said, that number will balloon to 9.1 million people.

“I don’t know of any other disease predicting such a huge increase,” said Dr. Richard J. Hodes, director of the National Institute on Aging, which financed the study. “And as we have the baby boomer group maturing, there are going to be more older people with fewer children to be informal caregivers for them, which is going to intensify the problem even more.”

The study found that direct health care expenses for dementia, including nursing home care, were $109 billion in 2010. For heart disease, those costs totaled $102 billion; for cancer, $77 billion.

The study also quantified the value of the sizable amount of informal care for dementia, usually provided by family members at home. That number ranged from $50 billion to $106 billion, depending on whether economists valued it by the income a family member was giving up or by what a family would have paid for a professional caregiver.

Michael D. Hurd, the lead author and a principal senior researcher at RAND, said the team could find no research quantifying such informal care for heart disease and cancer. But he and other experts agree that given the intensive nature and constant monitoring required to care for people with dementia, informal costs are probably much higher than those for most other diseases.

Dr. Petersen said, “Clearly, dementia is going to outstrip those dramatically.”

Without a way to prevent, cure or effectively treat these conditions yet, the bulk of the costs — 75 to 84 percent, the study found — involves helping patients in nursing homes or at home manage the most basic activities of life as they become increasingly impaired cognitively and then physically.

“The long-term care costs associated with people with dementia are particularly high because of the nature of the disease,” said Donald Moulds, acting assistant secretary for planning and evaluation at the federal Department of Health and Human Services. “People eventually become incapable of caring for themselves, and then in the vast majority of cases, their loved ones become incapable of caring for them.”

Each case of dementia costs $41,000 to $56,000 a year, the study said. Researchers project that the total costs of dementia care will more than double by 2040, to a range of $379 billion to $511 billion, from $159 billion to $215 billion in 2010. Because the population will also increase, Dr. Hurd said, the burden of cost per capita will not grow quite as fast, but will still be nearly 80 percent more in 2040.

The study used information collected over almost a decade on nearly 11,000 people from a large database called the Health and Retirement Study, considered a gold standard among researchers on aging issues. All of the people followed were given detailed cognitive tests, while a subset of them were more intensely evaluated for dementia and their results used as benchmarks to rate cognitive decline for the others, Dr. Hurd said.

Dr. Hurd noted that in addition to the estimates of people with actual dementia, earlier analyses of the same data estimated that 22 percent of people aged 71 and older — about 5.4 million people — have mild cognitive impairment that does not reach the threshold for dementia. In the study, about 12 percent of those people developed dementia each year, meaning that they experienced problems with memory, concentration and daily functioning that were severe enough to meet the medical definition.

The number of dementia cases calculated in the RAND study is smaller than that from the Alzheimer’s Association, which used a different database and tended to count people in earlier stages of memory loss. The association estimates that five million people aged 65 and older have Alzheimer’s, the most common dementia.

The RAND cost estimates for current dementia care are similar to the Alzheimer’s Association’s, but the association’s future cost projections are significantly higher: $1.2 trillion in 2050.

Robert Egge, the association’s vice president for public policy, said his group’s cost projections are based on the assumption that “more and more people will be in severe stages of dementia” in the future because they will be older. He said his group welcomed the RAND study, especially its comparison of dementia to other serious illnesses. It shows that groups using different methodologies reached the same conclusion about the high costs of dementia care, he said.

Dr. Petersen, whose team at the Mayo Clinic will be analyzing costs using a third distinct data set, said he suspected that “the reality is somewhere in the middle” of the RAND numbers and the Alzheimer’s Association’s projections.

When it comes to dementia, Dr. Hurd said, his team’s study could not capture the full toll of the disease. “One thing we haven’t talked about, and it’s not in the paper, is the tremendous emotional cost,” he said. “Economists are coldhearted, but they’re not that coldhearted.”

    Dementia Cost, Already High, Is Projected to Double by 2040, NYT, 3.4.2013,
    http://www.nytimes.com/2013/04/04/health/dementia-care-costs-are-soaring-study-finds.html

Diagnosis: Human

April 2, 2013
The New York Times
By TED GUP

THE news that 11 percent of school-age children now receive a diagnosis of attention deficit hyperactivity disorder — some 6.4 million — gave me a chill. My son David was one of those who received that diagnosis.

In his case, he was in the first grade. Indeed, there were psychiatrists who prescribed medication for him even before they met him. One psychiatrist said he would not even see him until he was medicated. For a year I refused to fill the prescription at the pharmacy. Finally, I relented. And so David went on Ritalin, then Adderall, and other drugs that were said to be helpful in combating the condition.

In another age, David might have been called “rambunctious.” His battery was a little too large for his body. And so he would leap over the couch, spring to reach the ceiling and show an exuberance for life that came in brilliant microbursts.

As a 21-year-old college senior, he was found on the floor of his room, dead from a fatal mix of alcohol and drugs. The date was Oct. 18, 2011.

No one made him take the heroin and alcohol, and yet I cannot help but hold myself and others to account. I had unknowingly colluded with a system that devalues talking therapy and rushes to medicate, inadvertently sending a message that self-medication, too, is perfectly acceptable.

My son was no angel (though he was to us) and he was known to trade in Adderall, to create a submarket in the drug among his classmates who were themselves all too eager to get their hands on it. What he did cannot be excused, but it should be understood. What he did was to create a market that perfectly mirrored the society in which he grew up, a culture where Big Pharma itself prospers from the off-label uses of drugs, often not tested in children and not approved for the many uses to which they are put.

And so a generation of students, raised in an environment that encourages medication, are emulating the professionals by using drugs in the classroom as performance enhancers.

And we wonder why it is that they use drugs with such abandon. As all parents learn — at times to their chagrin — our children go to school not only in the classroom but also at home, and the culture they construct for themselves as teenagers and young adults is but a tiny village imitating that to which they were introduced as children.

The issue of permissive drug use and over-diagnosis goes well beyond hyperactivity. In May, the American Psychiatric Association will publish its D.S.M. 5, the Diagnostic and Statistical Manual of Mental Disorders. It is called the bible of the profession. Its latest iteration, like those before, is not merely a window on the profession but on the culture it serves, both reflecting and shaping societal norms. (For instance, until the 1970s, it categorized homosexuality as a mental illness.)

One of the new, more controversial provisions expands depression to include some forms of grief. On its face it makes sense. The grieving often display all the common indicators of depression — loss of interest in life, loss of appetite, irregular sleep patterns, low functionality, etc. But as others have observed, those same symptoms are the very hallmarks of grief itself.

Ours is an age in which the airwaves and media are one large drug emporium that claims to fix everything from sleep to sex. I fear that being human is itself fast becoming a condition. It’s as if we are trying to contain grief, and the absolute pain of a loss like mine. We have become increasingly disassociated and estranged from the patterns of life and death, uncomfortable with the messiness of our own humanity, aging and, ultimately, mortality.

Challenge and hardship have become pathologized and monetized. Instead of enhancing our coping skills, we undermine them and seek shortcuts where there are none, eroding the resilience upon which each of us, at some point in our lives, must rely. Diagnosing grief as a part of depression runs the very real risk of delegitimizing that which is most human — the bonds of our love and attachment to one another. The new entry in the D.S.M. cannot tame grief by giving it a name or a subsection, nor render it less frightening or more manageable.

The D.S.M. would do well to recognize that a broken heart is not a medical condition, and that medication is ill-suited to repair some tears. Time does not heal all wounds, closure is a fiction, and so too is the notion that God never asks of us more than we can bear. Enduring the unbearable is sometimes exactly what life asks of us.

But there is a sweetness even to the intensity of this pain I feel. It is the thing that holds me still to my son. And yes, there is a balm even in the pain. I shall let it go when it is time, without reference to the D.S.M., and without the aid of a pill.

Ted Gup is an author and fellow of the Edmond J. Safra Center

for Ethics at Harvard University.

    Diagnosis: Human, NYT, 2.4.2013,
    http://www.nytimes.com/2013/04/03/opinion/diagnosis-human.html

The Immortal Life of Henrietta Lacks, the Sequel

March 23, 2013
The New York Times
By REBECCA SKLOOT

LAST week, scientists sequenced the genome of cells taken without consent from a woman named Henrietta Lacks. She was a black tobacco farmer and mother of five, and though she died in 1951, her cells, code-named HeLa, live on. They were used to help develop our most important vaccines and cancer medications, in vitro fertilization, gene mapping, cloning. Now they may finally help create laws to protect her family’s privacy — and yours.

The family has been through a lot with HeLa: they didn’t learn of the cells until 20 years after Lacks’s death, when scientists began using her children in research without their knowledge. Later their medical records were released to the press and published without consent. Because I wrote a book about Henrietta Lacks and her family, my in-box exploded when news of the genome broke. People wanted to know: did scientists get the family’s permission to publish her genetic information? The answer is no.

Imagine if someone secretly sent samples of your DNA to one of many companies that promise to tell you what your genes say about you. That report would list the good news (you’ll probably live to be 100) and the not-so-good news (you’ll most likely develop Alzheimer’s, bipolar disorder and maybe alcoholism). Now imagine they posted your genetic information online, with your name on it. Some people may not mind. But I assure you, many do: genetic information can be stigmatizing, and while it’s illegal for employers or health insurance providers to discriminate based on that information, this is not true for life insurance, disability coverage or long-term care.

“That is private family information,” said Jeri Lacks-Whye, Lacks’s granddaughter. “It shouldn’t have been published without our consent.”

Some scientists agree: Jonathan Eisen, a genomics researcher at the University of California, Davis, tweeted, “A bit stunned that the people publishing the HeLa genome appear to not have gotten consent from the family.” Another said this was going to further damage public trust in science. A few argued that the cells had changed so much over time, they couldn’t accurately tell us anything about Lacks (to which a geneticist replied, “Your claim is so wrong that I don’t know where to start”). Several noted that consent wasn’t required to publish the HeLa genome (true). But over all, the scientific community was surprisingly silent on the issue.

On its own, the HeLa genome doesn’t say anything specific about Lacks: it’s a string of billions of letters that detail the genetic information that makes up a HeLa cell, which is useful for science. A news release from the European Molecular Biology Laboratory, where the HeLa genome was sequenced, said, “We cannot infer anything about Henrietta Lacks’s genome, or of her descendants, from the data generated in this study.”

But that’s not true. And a few scientists decided to prove it. One uploaded HeLa’s genome to a public Web site called SNPedia, a Wikipedia-like site for translating genetic information. Minutes later, it produced a report full of personal information about Henrietta Lacks, and her family. (The scientist kept that report confidential, sharing it only with me.) Until recently, few people had the ability to process raw genome data like this. Now anyone who can send an e-mail can do it. No one knows what we may someday learn about Lacks’s great-grandchildren from her genome, but we know this: the view we have today of genomes is like a world map, but Google Street View is coming very soon.

Scientifically speaking, that’s good news. There’s a lot of hope for using technology like this for affordable “personalized medicine.” But legally and ethically speaking, we’re not ready for it.

As Francis S. Collins, director of the National Institutes of Health, says: “This latest HeLa situation really shows us that our policy is lagging years and maybe decades behind the science. It’s time to catch up.” The regulations governing this sort of research were written in the 1970s, long before anyone imagined what you could learn from a bit of DNA. They are largely based on the now outdated belief that if samples are “anonymized” (i.e., your name is removed), there’s no need to get consent before using them in research.

The problem, says Yaniv Erlich, a fellow at the Whitehead Institute for Biomedical Research, is that anonymity vanishes when it comes to DNA: “People don’t realize it’s impossible to hide genetic information once it’s out there.” He and his colleagues recently proved that it’s possible to use online public databases to find the identities of people whose anonymous DNA samples had been sequenced and published online. Yet researchers aren’t required to tell you that there is no guarantee that a genome, once sequenced, will stay private or anonymous.

More than a year and a half ago, the N.I.H. and several government organizations proposed changing current regulations to require consent for tissue research, genome sequencing and sharing private data. The proposal generated public comment but nothing changed, and science continues to move forward with speed, potential and outdated regulation.

The Lackses’ experiences over the last 60 years foretold nearly every major ethical issue raised by research on human tissues and genetic material. Now they’re raising a new round of ethical questions for science: though their consent is not (yet) required for publishing private genetic information from HeLa, should it be? Should we require consent before anyone’s genome is sequenced and published? And what control should gene-sharing family members have?

The Lacks family is proud of HeLa’s contributions to society, and they don’t want to stop HeLa research. But they do want to learn about the HeLa genome — how it can be used for the good of science while still protecting the family’s privacy — so they can decide whether to consent to its publication. And they want researchers to acknowledge that HeLa cells are not anonymous and should be treated accordingly.

After hearing from the Lacks family, the European team apologized, revised the news release and quietly took the data off-line. (At least 15 people had already downloaded it.) They also pointed to other databases that had published portions of Henrietta Lacks’s genetic data (also without consent). They hope to talk with the Lacks family to determine how to handle the HeLa genome while working toward creating international standards for handling these issues.

The publication of the HeLa genome without consent isn’t an example of a few researchers making a mistake. The whole system allowed it. Everyone involved followed standard practices. They presented their research at conferences and in a peer-reviewed journal. No one raised questions about consent.

In the three years since my book about HeLa was published, the Lacks family and I have spoken to audiences by the thousands about these issues. Public response is overwhelmingly consistent and in line with several studies: the public supports the science and wants to help it move forward. But that support is dependent on consent and trust.

Rebecca Skloot is the author of “The Immortal Life of Henrietta Lacks.”

    The Immortal Life of Henrietta Lacks, the Sequel, NYT, 23.3.2013,
    http://www.nytimes.com/2013/03/24/opinion/sunday/
    the-immortal-life-of-henrietta-lacks-the-sequel.html

Bill in North Dakota Bans Abortion

After Heartbeat Is Found

March 15, 2013
The New York Times
By ERIK ECKHOLM

Little more than a week after Arkansas adopted the country’s most stringent abortion limits, banning the procedure at 12 weeks of pregnancy, the North Dakota Legislature on Friday passed a more restrictive bill that would ban most abortions as early as 6 weeks into pregnancy.

The Legislature, which is dominated by Republicans, also passed a second measure that would ban abortions sought because of a genetic abnormality or to select the sex of the child.

Both bills must be signed by Gov. Jack Dalrymple, a Republican, to become law. As of Friday afternoon, the governor had not said whether he would do so.

No other state has barred abortions because of evidence that a fetus has a genetic defect like Down syndrome, which rises in incidence with maternal age, leading many pregnant women to seek tests for the disorder. Pennsylvania, Oklahoma and Arizona have all banned abortions for the purpose of gender selection.

National abortion rights groups, including the Center for Reproductive Rights, Planned Parenthood and the American Civil Liberties Union, condemned the measures that passed the North Dakota Senate on Friday, after previous approval by the House. These groups warned that if adopted, both measures would be declared unconstitutional by federal courts.

Under Supreme Court rulings, women have a right to an abortion until the fetus is viable outside the womb, generally around 24 weeks into pregnancy.

“We urge the governor to veto all of these bills to ensure that this personal and private decision can be made by a woman and her family, not politicians sitting in the Capitol,” said Jennifer Dalven, the director of the A.C.L.U.’s Reproductive Freedom Project.

One of the newly passed North Dakota bills outlaws abortions when a fetal heartbeat is “detectable” using “standard medical practice.” Heartbeats are often detectable at about 6 weeks, using an intrusive transvaginal ultrasound, or at about 10 to 12 weeks when using abdominal ultrasounds.

The bill does not specify a time threshold or whether doctors with a patient in the initial weeks of pregnancy must use the transvaginal probe. A proposed law in Virginia last year that would have required use of the transvaginal ultrasound caused a national outcry, and the bill was ultimately shelved. Arkansas declared a 12-week limit specifically to avoid that controversy.

But some experts said that doctors in North Dakota, which has only one clinic performing abortions, in Fargo, could face prosecution if they did not use the vaginal ultrasound when necessary to detect a heartbeat. Doctors who knowingly perform abortions in violation of the measure, if it is adopted, could be charged with a felony that carries a five-year prison sentence; the patients would not face criminal charges.

The law makes exceptions for abortion to save the life of the mother or for other severe medical emergencies, but not in cases of rape or incest.

In 2011, according to state data, 1,247 abortions were performed in North Dakota. If the ban becomes law, more than 75 percent of the procedures could be outlawed, according to Elizabeth Nash, a state issues manager with the Guttmacher Institute in Washington, a research group that supports abortion rights.

The early abortion ban was sponsored by Representative Bette Grande, a Republican from Fargo.

“A heartbeat is accepted by everyone as a sign of life,” she said in a blog posting on Tuesday as she argued that it was time for the Supreme Court to revisit the definition of viability.

This article has been revised to reflect the following correction:

Correction: March 15, 2013

Because of an editing error,

an earlier version of this article incorrectly stated

when a blog post by Rep. Bette Grande was published.

The post appeared Tuesday, not Wednesday.

    Bill in North Dakota Bans Abortion After Heartbeat Is Found, NYT, 15.3.2013,
    http://www.nytimes.com/2013/03/16/us/
    north-dakota-approves-bill-to-ban-abortions-after-heartbeat-is-found.html

Suicide, With No Warning

March 8, 2013
The New York Times
By ELISABETH ROSENTHAL

TO his large, loving family and many friends, Kerry Lewiecki was an optimist and problem-solver, with a big laugh and impressive hugs. Early in the summer of 2010, he graduated from the University of Oregon with dual degrees in law and conflict resolution; invitations went out for his August wedding to his longtime girlfriend.

Then, just a few weeks later, within the span of a few hours, he bought a gun and shot and killed himself, at age 27. His father, Mike, a doctor in Albuquerque, who still chokes up when he recalls that day, said: “We had no clue he was desperate. I don’t think he’d ever shot a gun before.”

Support for stricter gun laws is growing, impelled by a year of grisly mass murders — at a movie theater in Aurora, Colo., an elementary school in Newtown, Conn., and, most recently, by a vengeful former policeman in California. Last month, President Obama kicked off a continuing national debate by proposing an array of new policies, including an assault weapons ban, an expansion of background checks and restrictions on high-capacity magazines.

But more than 60 percent of gun-related deaths in the United States are suicides, like Mr. Lewiecki’s. Reducing that statistic will most likely take different interventions than are currently proposed — like waiting periods and safe storage requirements — and those are not even on the table.

While background checks might turn up people with severe mental illness who have been prone to violence, gun suicides are often committed by people whose history doesn’t suggest a serious problem. In studies, a quarter to a third of those who killed themselves were not in contact with a psychiatrist at the time of death, and the majority were not on psychiatric medicines. “The first time the family may know of the distress is when they kill themselves,” said Dr. David Gunnell, a suicide epidemiologist at the University of Bristol in England. There may be no red flags and little forethought. To carry out a campus killing rampage, perpetrators collect weapons, identify victims and select locations. In contrast, suicides are often solitary, impulsive acts, experts say.

That is why a cornerstone of suicide prevention is simple: “restricting access to common and particularly lethal means for everyone — we know that’s effective,” said Dan Reidenberg, executive director of SAVE (Suicide Awareness and Voices of Education), a national suicide prevention group.

That means different things in different places. In Britain, suicide prevention efforts in the late 1990s involved banning the sales of large bottles of paracetamol (known as Tylenol in the United States), which had been used in tens of thousands of suicide attempts each year. When I was reporting from China a decade ago, rural officials responded to an epidemic of suicide among women by restricting pesticide sales.

In the United States, we build barriers on bridges, but have fewer barriers to the quick access to guns: “In the U.S. one of the most straightforward things to do to prevent suicide is to make firearms less accessible,” Dr. Gunnell said. The Lewiecki family believes that Kerry might well be alive if there had been a waiting period before purchase in Oregon. Studies suggest that far fewer American teenagers would commit suicide if gun owners were required to use trigger locks. Seventy-five percent of the guns used in youth suicides and unintentional injuries were accessible in the home or the home of a friend.

Psychiatrists first started focusing on how much the ready availability of lethal means affected suicide rates after a fortuitous experiment in England. When the country switched its heating from coal to natural gas in the 1970s, suicide rates plummeted, because the fumes were not as deadly; gas has a far lower carbon monoxide content. Sri Lanka developed the highest suicide rate in the world in the 1980s, following the introduction of pesticides on a mass scale. Once the government removed the most toxic compounds, like Paraquat (lethal in 70 percent of cases) suicide rates dropped 50 percent, though the number of attempts dropped by less.

Studies show that once a convenient lethal method is removed, many do not seek other options. “If people go to the Golden Gate Bridge and encounter a barrier, they don’t go to the Bay Bridge and try there,” Dr. Reidenberg said.

INDEED, many people who commit suicide are more momentarily desperate than classically depressed, experts say. In Sri Lanka, “pesticide was often taken after an argument with a parent or a spouse,” said Dr. Gunnell, who studied that epidemic.

Up to 50 percent of people who attempt suicide make the decision to do so within minutes to an hour before they act, studies have found. They may be depressed or have contemplated suicide, “but the final decision comes very quickly, and there’s often ambivalence up to the moment,” Dr. Reidenberg said.

Although SAVE has not taken a specific policy position on firearms, it maintains that guns, just like dangerous medicines, should be safely stored.

But putting time between a suicidal impulse and getting a loaded gun in hand may be hard to legislate in the United States. A 2008 Supreme Court decision struck down a Washington, D.C., law that required weapons to be stored disassembled or to have trigger locks on the grounds that the law interfered with the right to self-defense; a handful of states still mandate the safety features. While the 1993 Brady Violence Prevention Act required a five-day waiting period for a background check before firearms purchases, the provision expired in 1998 and checks are now done through the Internet-enabled National Instant Check System, in minutes.

Would a wait have deterred Kerry Lewiecki? In law school he had developed severe pain in his hands, arms and back that was not responding well to treatment. Despite that, he enjoyed weekends with his fiancée, and they spoke on the morning of his death. That same day he mailed books to his parents’ home, in preparation for a Father’s Day visit.

Said his father, “If it had not been so easy to buy a gun maybe he would have spoken with someone or woken up the next morning and heard the birds and felt better.”

Elisabeth Rosenthal is a reporter

on the environment and health for The New York Times.

    Suicide, With No Warning, NYT, 8.3.2013,
    http://www.nytimes.com/2013/03/10/sunday-review/suicide-with-no-warning.html

Stubbing Out Cigarettes for Good

March 3, 2013
The New York Times
By RICHARD A. DAYNARD

BOSTON

PERHAPS no public official was as synonymous with the antismoking movement as C. Everett Koop, who died last Monday at age 96. Dr. Koop, who worked tirelessly to turn America into “a smoke-free society,” did not live to see that goal reached. But the rest of us have the power to make it happen.

Fewer than one in five American adults smoke, a share that’s plunged by about half since the 1960s — an achievement due, in some measure, to Dr. Koop’s antismoking crusade as surgeon general, from 1981 to 1989. Revelations in the 1990s about tobacco companies’ cover-up of smoking’s dangers also played a role. So have a host of other strategies that have included consumer taxes, minimum ages for cigarette purchases, restrictions on smoking in public spaces and programs to help people quit. Continuing on the same path, with some luck, we might be able reduce the smoking rate a little more.

But that would still leave us with a profound public health tragedy: cigarettes continue to kill more than 400,000 Americans a year and cost untold billions in health care spending.

To its credit, the Food and Drug Administration has tried more aggressive approaches, including a recent effort to require hard-hitting graphic warnings on cigarette packages. That proposal, already the rule in dozens of countries, has been held up in United States federal courts over concerns that the ads might infringe on cigarette manufacturers’ First Amendment rights. But even if implemented, more scare tactics would not go far enough.

What we need is an all-out push to reduce smoking rates to well below 10 percent. The notion is nothing new to tobacco-control advocates, many of whom gathered last week in Cambridge, Mass., for a conference on the governance of tobacco, sponsored by Harvard with support from the World Health Organization.

But outside of such academic meetings and journals, little has been said about two possible approaches that could have an immediate impact.

One involves federal action; the other, state or local action. Both are made possible by the Family Smoking Prevention and Tobacco Control Act, which President Obama signed in June 2009.

Under the act, the F.D.A. has the power to establish tobacco product standards including “provisions, where appropriate, for nicotine yields of the product.” The only limitation on this power is that the F.D.A. may not require that nicotine yields be reduced to zero. The law calls on the F.D.A. to apply public health criteria — “the risks and benefits to the population as a whole” — in designing its regulations. It also encourages the F.D.A. to create tobacco standards that will help existing users stop smoking and decrease the risk that nonsmokers will start.

The F.D.A. would be well within its authority to require nicotine content to be below addictive levels — an idea that originated with a 1994 article in The New England Journal of Medicine urging a nonaddictive nicotine standard.

Cigarette makers would lobby hard to block such a standard. But if the F.D.A. insisted on the change, and cigarettes ceased to be addictive, ample evidence shows that most smokers would quit or switch to less toxic nicotine products. Current nonsmokers, moreover, would be far less likely to become addicted.

Another part of the act affirms the authority of states and municipal governments to prohibit the sale, distribution and possession of — and even access and exposure to — tobacco products by individuals of any age.

This provides an opportunity for states, counties and cities to adopt the Smokefree Generation, a proposal by A. J. Berrick, a mathematics professor in Singapore.

The idea is simple: no one born in or after 2000 can ever be sold cigarettes. Under such legislation, which jurisdictions like the Australian state of Tasmania are considering, the vast majority of this cohort — the oldest are now 13 — would never begin smoking. It’s hard to imagine too many parents objecting, and it would be easy for retailers to enforce. In the United States, it would provide a useful focus for state and local public health officials to do something game-changing, rather than sitting on the sidelines waiting for Washington to act.

Critics will say that, even if a state or city passed such a law, would-be smokers could go to an adjoining one to buy cigarettes. But evidence suggests that border-crossing and smuggling would be minimal. States that have sharply raised their cigarette taxes, after all, have not only increased tax revenue but also reduced rates of smoking prevalence, even among nicotine addicts. Young people, who are generally not addicted (yet) and who tend not to have peers who smoke, are even less likely to chase cigarettes across state or county lines.

Some antismoking advocates who support existing approaches (smoking-cessation programs, higher taxes) fear that pushing for an “end game” — a smoking rate below 10 percent — is too ambitious. But then, banning smoking in restaurants, workplaces and bars was once seen as crazy, too. Sometimes, a little crazy goes a long way.

Richard A. Daynard is a professor of law at Northeastern University

and president of its Public Health Advocacy Institute.

    Stubbing Out Cigarettes for Good, NYT, 3.3.2013,
    http://www.nytimes.com/2013/03/04/opinion/two-paths-to-the-gradual-abolition-of-smoking.html

In Medical First, a Baby With H.I.V. Is Deemed Cured

March 3, 2013
The New York Times
By ANDREW POLLACK and DONALD G. McNEIL Jr.

Doctors announced on Sunday that a baby had been cured of an H.I.V. infection for the first time, a startling development that could change how infected newborns are treated and sharply reduce the number of children living with the virus that causes AIDS.

The baby, born in rural Mississippi, was treated aggressively with antiretroviral drugs starting around 30 hours after birth, something that is not usually done. If further study shows this works in other babies, it will almost certainly be recommended globally. The United Nations estimates that 330,000 babies were newly infected in 2011, the most recent year for which there is data, and that more than three million children globally are living with H.I.V.

If the report is confirmed, the child born in Mississippi would be only the second well-documented case of a cure in the world. That could give a lift to research aimed at a cure, something that only a few years ago was thought to be virtually impossible, though some experts said the findings in the baby would probably not be relevant to adults.

The first person cured was Timothy Brown, known as the Berlin patient, a middle-aged man with leukemia who received a bone-marrow transplant from a donor genetically resistant to H.I.V. infection.

“For pediatrics, this is our Timothy Brown,” said Dr. Deborah Persaud, associate professor at the Johns Hopkins Children’s Center and lead author of the report on the baby. “It’s proof of principle that we can cure H.I.V. infection if we can replicate this case.”

Dr. Persaud and other researchers spoke in advance of a presentation of the findings on Monday at the Conference on Retroviruses and Opportunistic Infections in Atlanta. The results have not yet been published in a peer-reviewed medical journal.

Some outside experts, who have not yet heard all the details, said they needed convincing that the baby had truly been infected. If not, this would be a case of prevention, something already done for babies born to infected mothers.

“The one uncertainty is really definitive evidence that the child was indeed infected,” said Dr. Daniel R. Kuritzkes, chief of infectious diseases at Brigham and Women’s Hospital in Boston.

Dr. Persaud and some other outside scientists said they were certain the baby — whose name and gender were not disclosed — had been infected. There were five positive tests in the baby’s first month of life — four for viral RNA and one for DNA. And once the treatment started, the virus levels in the baby’s blood declined in the pattern characteristic of infected patients.

Dr. Persaud said there was also little doubt that the child experienced what she called a “functional cure.” Now 2 1/2, the child has been off drugs for a year with no sign of functioning virus.

The mother arrived at a rural hospital in the fall of 2010 already in labor and gave birth prematurely. She had not seen a doctor during the pregnancy and did not know she had H.I.V. When a test showed the mother might be infected, the hospital transferred the baby to the University of Mississippi Medical Center, where it arrived at about 30 hours old.

Dr. Hannah B. Gay, an associate professor of pediatrics, ordered two blood draws an hour apart to test for the presence of the virus’ RNA and DNA.

The tests found a level of virus at about 20,000 copies per milliliter, fairly low for a baby. But since tests so early in life were positive, it suggests the infection occurred in the womb rather than during delivery, Dr. Gay said.

Typically a newborn with an infected mother would be given one or two drugs as a prophylactic measure. But Dr. Gay said that based on her experience, she almost immediately used a three-drug regimen aimed at treatment, not prophylaxis, not even waiting for the test results confirming infection.

Virus levels rapidly declined with treatment and were undetectable by the time the baby was a month old. That remained the case until the baby was 18 months old, after which the mother stopped coming to the hospital and stopped giving the drugs.

When the mother and child returned five months later, Dr. Gay expected to see high viral loads in the baby. But the tests were negative.

Suspecting a laboratory error, she ordered more tests. “To my greater surprise, all of these came back negative,” Dr. Gay said.

Dr. Gay contacted Dr. Katherine Luzuriaga, an immunologist at the University of Massachusetts, who was working with Dr. Persaud and others on a project to document possible pediatric cures. The researchers, sponsored by amfAR, the Foundation for AIDS Research, put the baby through a battery of sophisticated tests. They found tiny amounts of some viral genetic material but no virus able to replicate, even lying dormant in so-called reservoirs in the body.

There have been scattered cases reported in the past, including one in The New England Journal of Medicine in 1995, of babies clearing the virus, even without treatment.

Those reports were greeted skeptically, particularly since testing methods were not very sophisticated back then. But those reports and this new one could suggest there is something different about babies’ immune systems, said Dr. Joseph McCune of the University of California, San Francisco.

One hypothesis is that the drugs killed off the virus before it could establish a hidden reservoir in the baby. One reason people cannot be cured now is that the virus hides in a dormant state, out of reach of existing drugs. When drug therapy is stopped, the virus can emerge from hiding.

“That goes along with the concept that, if you treat before the virus has had an opportunity to establish a large reservoir and before it can destroy the immune system, there’s a chance you can withdraw therapy and have no virus,” said Dr. Anthony S. Fauci, the director of the National Institute for Allergy and Infectious Diseases. Adults, however, typically do not know they are infected right as it happens, he said.

Dr. Steven Deeks, professor of medicine at the University of California, San Francisco, said if the reservoir never established itself, then he would not call it a true cure, though this was somewhat a matter of semantics. “Was there enough time for a latent reservoir, the true barrier to cure, to establish itself?” he said.

Still, he and others said, the results could lead to a new protocol for quickly testing and treating infants.

In the United States, transmission from mother to child is rare — several experts said there are only about 200 cases a year or even fewer — because infected mothers are generally treated during their pregnancies.

If the mother has been treated during pregnancy, babies are typically given six weeks of prophylactic treatment with one drug, AZT, while being tested for infection. In cases like the Mississippi one, where the mother was not treated during pregnancy, standards have been changing, but typically two drugs are used.

But women in many developing countries are less likely to be treated during pregnancy. And in South Africa and other African countries that lack sophisticated testing, babies born to infected mothers are often not tested until after six weeks, said Dr. Yvonne Bryson, chief of global pediatric infectious disease at the University of California, Los Angeles.

Dr. Bryson, who was not involved in the Mississippi work, said she was certain the baby had been infected and called the finding “one of the most exciting things I’ve heard in a long time.”

Studies are being planned to see if early testing and aggressive treatment can work for other babies. While the bone marrow transplant that cured Mr. Brown is an arduous and life-threatening procedure, the Mississippi treatment is not and could become a new standard of care.

While it might be difficult for some poorer countries to do, treating for only a year or two would be cost effective, “sparing the kid a lifetime of antiretroviral therapy,” said Rowena Johnston, director of research at amfAR.

    In Medical First, a Baby With H.I.V. Is Deemed Cured, NYT, 3.3.3013,
    http://www.nytimes.com/2013/03/04/health/for-first-time-baby-cured-of-hiv-doctors-say.html

Jane C. Wright, Pioneering Oncologist, Dies at 93

March 1, 2013
The New York Times
By BRUCE WEBER

Dr. Jane C. Wright, a pioneering oncologist who helped elevate chemotherapy from a last resort for cancer patients to an often viable treatment option, died on Feb. 19 at her home in Guttenberg, N.J. She was 93.

Her death was confirmed by her daughter Jane Jones, who said her mother had dementia.

Dr. Wright descended from a distinguished medical family that defied racial barriers in a profession long dominated by white men. Her father, Dr. Louis T. Wright, was among the first blacks to graduate from Harvard Medical School and was reported to be the first black doctor appointed to the staff of a New York City hospital. His father was an early graduate of what became the Meharry Medical College, the first medical school in the South for African-Americans, founded in Nashville in 1876.

Dr. Jane Wright began her career as a researcher working alongside her father at a cancer center he established at Harlem Hospital in New York.

Together, they and others studied the effects of a variety of drugs on tumors, experimented with chemotherapeutic agents on leukemia in mice and eventually treated patients, with some success, with new anticancer drugs, including triethylene melamine.

After her father died in 1952, Dr. Wright took over as director of the center, which was known as the Harlem Hospital Cancer Research Foundation. In 1955, she joined the faculty of the New York University Medical Center as director of cancer research, where her work focused on correlating the responses of tissue cultures to anticancer drugs with the responses of patients.

In 1964, working as part of a team at the N.Y.U. School of Medicine, Dr. Wright developed a nonsurgical method, using a catheter system, to deliver heavy doses of anticancer drugs to previously hard-to-reach tumor areas in the kidneys, spleen and elsewhere.

That same year, Dr. Wright was the only woman among seven physicians who, recognizing the unique needs of doctors caring for cancer patients, founded the American Society of Clinical Oncologists, known as ASCO. She was also appointed by President Lyndon B. Johnson to the President’s Commission on Heart Disease, Cancer and Stroke, led by the heart surgeon Dr. Michael E. DeBakey. Its recommendations emphasized better communication among doctors, hospitals and research institutions and resulted in a national network of treatment centers.

In 1967, Dr. Wright became head of the chemotherapy department and associate dean at New York Medical College. News reports at the time said it was the first time a black woman had held so high a post at an American medical school.

“Not only was her work scientific, but it was visionary for the whole science of oncology,” Dr. Sandra Swain, the current president of ASCO, said in a telephone interview. “She was part of the group that first realized we needed a separate organization to deal with the providers who care for cancer patients. But beyond that it’s amazing to me that a black woman, in her day and age, was able to do what she did.”

Jane Cooke Wright was born in Manhattan on Nov. 30, 1919. Her mother, the former Corinne Cooke, was a substitute teacher in the New York City schools.

Ms. Wright attended the Ethical Culture school in Manhattan and the Fieldston School in the Bronx (now collectively known Ethical Culture Fieldston School) and graduated from Smith College, where she studied art before turning to medicine. She received a full scholarship to New York Medical College, earning her medical degree in 1945. Before beginning research with her father, she worked as a doctor in the city schools.

Dr. Wright’s marriage, in 1947, to David D. Jones, a lawyer, ended with his death in 1976. She is survived by their two daughters, Jane and Alison Jones, and a sister, Barbara Wright Pierce, who is also a doctor.

As both a student and a doctor, Dr. Wright said in interviews, she was always aware that as a black woman she was an unusual presence in medical institutions. But she never felt she was a victim of racial prejudice, she said.

“I know I’m a member of two minority groups,” she said in an interview with The New York Post in 1967, “but I don’t think of myself that way. Sure, a woman has to try twice as hard. But — racial prejudice? I’ve met very little of it.”

She added, “It could be I met it — and wasn’t intelligent enough to recognize it.”

    Jane C. Wright, Pioneering Oncologist, Dies at 93, NYT, 1.3.2013,
    http://www.nytimes.com/2013/03/01/nyregion/jane-c-wright-pioneering-oncologist-dies-at-93.html

Same Genetic Basis Found

in 5 Types of Mental Disorders

February 28, 2013
The New York Times
By GINA KOLATA

The psychiatric illnesses seem very different — schizophrenia, bipolar disorder, autism, major depression and attention deficit hyperactivity disorder. Yet they share several genetic glitches that can nudge the brain along a path to mental illness, researchers report. Which disease, if any, develops is thought to depend on other genetic or environmental factors.

Their study, published online Wednesday in the Lancet, was based on an examination of genetic data from more than 60,000 people worldwide. Its authors say it is the largest genetic study yet of psychiatric disorders. The findings strengthen an emerging view of mental illness that aims to make diagnoses based on the genetic aberrations underlying diseases instead of on the disease symptoms.

Two of the aberrations discovered in the new study were in genes used in a major signaling system in the brain, giving clues to processes that might go awry and suggestions of how to treat the diseases.

“What we identified here is probably just the tip of an iceberg,” said Dr. Jordan Smoller, lead author of the paper and a professor of psychiatry at Harvard Medical School and Massachusetts General Hospital. “As these studies grow we expect to find additional genes that might overlap.”

The new study does not mean that the genetics of psychiatric disorders are simple. Researchers say there seem to be hundreds of genes involved and the gene variations discovered in the new study confer only a small risk of psychiatric disease.

Steven McCarroll, director of genetics for the Stanley Center for Psychiatric Research at the Broad Institute of Harvard and M.I.T., said it was significant that the researchers had found common genetic factors that pointed to a specific signaling system.

“It is very important that these were not just random hits on the dartboard of the genome,” said Dr. McCarroll, who was not involved in the new study.

The work began in 2007 when a large group of researchers began investigating genetic data generated by studies in 19 countries and including 33,332 people with psychiatric illnesses and 27,888 people free of the illnesses for comparison. The researchers studied scans of people’s DNA, looking for variations in any of several million places along the long stretch of genetic material containing three billion DNA letters. The question: Did people with psychiatric illnesses tend to have a distinctive DNA pattern in any of those locations?

Researchers had already seen some clues of overlapping genetic effects in identical twins. One twin might have schizophrenia while the other had bipolar disorder. About six years ago, around the time the new study began, researchers had examined the genes of a few rare families in which psychiatric disorders seemed especially prevalent. They found a few unusual disruptions of chromosomes that were linked to psychiatric illnesses. But what surprised them was that while one person with the aberration might get one disorder, a relative with the same mutation got a different one.

Jonathan Sebat, chief of the Beyster Center for Molecular Genomics of Neuropsychiatric Diseases at the University of California, San Diego, and one of the discoverers of this effect, said that work on these rare genetic aberrations had opened his eyes. “Two different diagnoses can have the same genetic risk factor,” he said.

In fact, the new paper reports, distinguishing psychiatric diseases by their symptoms has long been difficult. Autism, for example, was once called childhood schizophrenia. It was not until the 1970s that autism was distinguished as a separate disorder.

But Dr. Sebat, who did not work on the new study, said that until now it was not clear whether the rare families he and others had studied were an exception or whether they were pointing to a rule about multiple disorders arising from a single genetic glitch.

“No one had systematically looked at the common variations,” in DNA, he said. “We didn’t know if this was particularly true for rare mutations or if it would be true for all genetic risk.” The new study, he said, “shows all genetic risk is of this nature.”

The new study found four DNA regions that conferred a small risk of psychiatric disorders. For two of them, it is not clear what genes are involved or what they do, Dr. Smoller said. The other two, though, involve genes that are part of calcium channels, which are used when neurons send signals in the brain.

“The calcium channel findings suggest that perhaps — and this is a big if — treatments to affect calcium channel functioning might have effects across a range of disorders,” Dr. Smoller said.

There are drugs on the market that block calcium channels — they are used to treat high blood pressure — and researchers had already postulated that they might be useful for bipolar disorder even before the current findings.

One investigator, Dr. Roy Perlis of Massachusetts General Hospital, just completed a small study of a calcium channel blocker in 10 people with bipolar disorder and is about to expand it to a large randomized clinical trial. He also wants to study the drug in people with schizophrenia, in light of the new findings. He cautions, though, that people should not rush out to take a calcium channel blocker on their own.

“We need to be sure it is safe and we need to be sure it works,” Dr. Perlis said.

    Same Genetic Basis Found in 5 Types of Mental Disorders, NYT, 28.2.2013,
    http://www.nytimes.com/2013/03/01/health/
    study-finds-genetic-risk-factors-shared-by-5-psychiatric-disorders.html

C. Everett Koop,

Forceful U.S. Surgeon General,

Dies at 96

February 25, 2013
The New York Times
By HOLCOMB B. NOBLE

Dr. C. Everett Koop, who was widely regarded as the most influential surgeon general in American history and played a crucial role in changing public attitudes about smoking, died on Monday at his home in Hanover, N.H. He was 96.

His death was confirmed by Susan A. Wills, an assistant at the Geisel School of Medicine at Dartmouth College, which has an institute named after Dr. Koop.

Dr. Koop had never served in public office when President Ronald Reagan appointed him surgeon general of the United States in 1981. By the time he stepped down in 1989, he had become a household name, a rare distinction for a public health administrator.

Dr. Koop issued emphatic warnings about the dangers of smoking, he almost single-handedly pushed the government into taking a more aggressive stand against AIDS, and despite his moral opposition to abortion, he refused to use his office as a pulpit from which to preach against it.

These stands led many liberals who had opposed his nomination to praise him, and many conservatives who had supported his appointment to vilify him. Conservative politicians representing tobacco-growing states were among his harshest critics, and many Americans, for moral or religious reasons, were upset by his public programs to fight AIDS and felt betrayed by his relative silence on abortion.

As much as anyone, it was Dr. Koop who took the lead in trying to wean Americans off smoking, and he did so in imposing fashion. At a sturdy 6-foot-1, with his bushy gray biblical beard, Dr. Koop would appear before television cameras in the gold-braided dark-blue uniform of a vice admiral — the surgeon general’s official uniform, which he revived — and sternly warn of the terrible consequences of smoking.

“Smoking kills 300,000 Americans a year,” he said in one talk. “Smokers are 10 times more likely to develop lung cancer than nonsmokers, two times more likely to develop heart disease. Smoking a pack a day takes six years off a person’s life.”

When Dr. Koop took office, 33 percent of Americans smoked; when he left, the percentage had dropped to 26. By 1987, 40 states had restricted smoking in public places, 33 had prohibited it on public conveyances and 17 had banned it in offices and other work sites. More than 800 local antismoking ordinances had been passed, and the federal government had restricted smoking in 6,800 federal buildings. Antismoking campaigns by private groups like the American Lung Association and the American Heart Association had accelerated.

Dr. Koop also played a major role in educating Americans about AIDS. Though he believed that the nation had been slow in facing the crisis, he extolled its efforts once it did, particularly in identifying H.I.V., the virus that causes the disease, and in developing a blood test to detect it.

Where he failed, in his own view, was to interest either Reagan or his successor as president, George Bush, in making health care available to more Americans.

Dr. Koop was completing a successful career as a pioneer in pediatric surgery when he was nominated for surgeon general, having caught the attention of conservatives with a series of seminars, films and books in collaboration with the theologian Francis Schaeffer that expressed anti-abortion views.

At his confirmation hearings, Senate liberals mounted a fierce fight against him. Senator Edward M. Kennedy, Democrat of Massachusetts, said Dr. Koop, in denying a right to abortion, adhered to a “cruel, outdated and patronizing stereotype of women.” Women’s rights organizations, public health groups, medical associations and others lobbied against his appointment. An editorial in The New York Times called him “Dr. Unqualified.”

But after months of testimony and delay, he was confirmed by a vote of 68 to 24, garnering more support than many had expected. Some senators who had been hesitant to support him said he had convinced them of his integrity.

Dr. Koop himself said he had taken a principled approach to the nomination. As he and his wife, Elizabeth, had driven to Washington for the confirmation hearings, he recalled telling her, “If I ever have to say anything I don’t believe or feel shouldn’t be said, we’ll go home.”

An Only Child in Brooklyn

Charles Everett Koop was born on Oct. 14, 1916, in Brooklyn, and grew up in a three-story brick house in South Brooklyn surrounded by relatives; his paternal grandparents lived on the third floor, and his maternal grandparents as well as uncles, aunts and cousins lived on the same street. He was the only child of John Everett Koop, a banker and descendant of 17th-century Dutch settlers of New York, and the former Helen Apel.

Dr. Koop traced his interest in medicine to watching his family’s doctors at work as a child. To develop the manual dexterity of a surgeon, he practiced tying knots and cutting pictures out of magazines with each hand. At 14 he sneaked into an operating theater at Columbia University’s medical college. At home he operated on rabbits, rats and stray cats in the basement after his mother had administered anesthesia. By his account, not one of the animals died.

While attending high school at the private Flatbush School, he worked as a summer volunteer in hospitals near his family’s vacation home in Port Washington, on Long Island. He attended Dartmouth College and, after graduating, entered Cornell University Medical College in Manhattan and married Elizabeth Flanagan of New Britain, Conn., a Vassar student.

Dr. Koop completed his residency at the University of Pennsylvania Hospital, where he acquired a reputation for boldness. Afterward, his surgery professor, Dr. I. S. Ravdin, offered him a job as surgeon in chief of Children’s Hospital in Philadelphia, a rare offer for someone so young.

Dr. Koop held that position until the Reagan administration recruited him 35 years later. By then he had become renowned in medicine as an innovator in surgery on infants.

He and his colleagues performed thousands of operations to correct birth defects in premature babies or other newborns; 475 operations alone were on those with esophageal atresia, a condition, previously fatal, in which the esophagus and the stomach are not connected.

In one case, after cutting open the side of a baby’s chest to find an entire section of the esophagus missing, he built, on the spot, a new link out of tissue from the baby’s colon. It became standard procedure for repairing such a defect. He also did groundbreaking work in separating conjoined twins.

Faith and Principle

His experience in correcting birth defects compelled him to thrust himself into the middle of a controversy in the early 1980s over the rights of infants with congenital defects to receive medical care. In two cases involving infants, identified as Baby Doe and Baby Jane Doe, those who favored government intervention to save a disabled child were pitted against liberals, libertarians and medical groups who argued that parents had the right to withhold treatment from a child who was severely impaired.

Though courts sided with the parents, Dr. Koop spoke out against the parents’ decisions in both cases, saying that the medical and legal establishments had a duty to protect citizens against neglect and discrimination, no matter their age, and that a government’s authority to override the rights of parents had been established in truancy law and in child abuse and immunization laws. (Baby Doe died while the case was being appealed to the United States Supreme Court; Baby Jane Doe survived, though a delay in treatment was believed to have contributed to her severe retardation.)

Dr. Koop often said that his Presbyterian faith had helped him and his wife cope with the death of his 19-year-old son, David, who was killed in 1968 when a cliff gave way while he was climbing in New Hampshire. Dr. Koop and his wife wrote about the loss of a child in “Sometimes Mountains Move,” published in 1974.

Dr. Koop’s religion was also central to his opposition to abortion, which he considered a violation of divine principle. But once in public office, he said, he found it necessary to declare — to the disappointment of the White House — that evidence did not support the contention that abortions were essentially unsafe. In taking that position, he later said, he was being naïve. He had failed to realize that the Reagan administration expected him to oppose abortion zealously, he wrote in his 1991 autobiography, “Koop: The Memoirs of America’s Family Doctor.” And in an interview for this obituary in 1996, he said he had declined to speak out on abortion because he thought his job was to deal with factual health issues like the hazards of smoking, not to express opinions on moral issues.

Abortion presented little health hazard to women, he said, so it was a moral and religious matter, not a health issue.

Taking On Big Tobacco

Dr. Koop said he had begun campaigning against smoking after studying the research into its link to cancer, heart disease, stroke and other diseases. He was “dumbfounded,” he said, “and then plainly furious at the tobacco industry for attempting to obfuscate and trivialize this extraordinarily important public information.”

In taking on the tobacco lobby, he was also taking on powerful politicians from tobacco-growing states. After Dr. Koop accused the industry of directing advertising at children and threatening human lives, Gov. Jim Hunt of North Carolina, a Democrat, called for his impeachment, and Senator Jesse Helms, Republican of North Carolina, tried in vain to have Congress investigate him.

Dr. Koop came to believe that the Reagan administration itself offered only lukewarm support for the antismoking public-education campaign “A Smoke-Free Society by the Year 2000.” Feeling stymied, he said, he asked himself, “What if I called on America itself?” So he embarked on a national speaking tour in 1984, often wearing the uniform of his office. The uniform, he said, was intended to help restore his diminishing authority as the surgeon general and director of the Public Health Service.

In 1986, a surgeon general’s report expanded the alarm about smoking, stating that secondhand smoke had also been conclusively proved to cause cancer. Over the next year, federal, state and local governments and private businesses began to restrict smoking in public and quasi-public places like restaurants, airports and workplaces. (In 2004 he joined with three other former surgeons general to offer a plan to cut cigarette smoking in part with a $2-a-pack tax increase.)

AIDS had just been discovered when Dr. Koop was awaiting confirmation in 1981. But within weeks, with 108 cases reported in the United States and 43 deaths, “I knew we were in big trouble,” he said. He realized later, he said, that the Reagan administration had been slow to address the disease because the election had brought to power people who were antithetical to homosexuals, then thought to be its only victims.

As the epidemic worsened, reaching drug addicts infected with contaminated needles and hemophiliacs who had received a contaminated blood-clotting factor, Reagan, in 1986, asked Dr. Koop to prepare a special report. Dr. Koop proceeded cautiously, knowing the report would be unpopular with many in the administration, with conservatives in Congress and with church groups opposed to homosexuality. He wrote 17 drafts.

A Public Profile

With its release, he was attacked as advocating that third graders be taught about sodomy and that 8-year-olds be given condoms. What the report said was that the best protection against AIDS was abstinence and monogamy, but that for those who practiced neither, condoms were a necessary precaution.

White House aides tried to get him to delete the reference to condoms, but he refused to alter the report or make it more morally judgmental. He prevailed, and the government eventually printed more than 20 million copies of the report.

Dr. Koop later wrote that “political meddlers in the White House” had complicated his work on the disease, and that “at least a dozen times I pleaded with my critics in the White House to let me have a meeting with President Reagan” on AIDS in the mid-1980s. Too many people, he said, “placed conservative ideology far above saving human lives.”

He added: “Our first public health priority, to stop the further transmission of the AIDS virus, became needlessly mired in the homosexual politics of the early 1980s. We lost a great deal of precious time because of this, and I suspect we lost some lives as well.”

Dr. Koop had no success in pushing the Reagan administration to take action on delivering health care to Americans who could not afford it. He announced his resignation after Mr. Bush was elected president in 1988 and did not name him secretary of health and human services, as Dr. Koop had hoped.

Dr. Koop’s first wife died in 2007; he is survived by their three children, Allen, Norman and Elizabeth Thompson; eight grandchildren; and his second wife, Cora Hogue, whom he married in 2010.

In 1992 Dr. Koop founded the Koop Foundation in Hanover, N.H., to help strengthen humanitarian values among doctors. In 1995, nearing his 80th birthday, he became chief executive of a Time-Warner division, Time Life Medical, to produce videos for sale in pharmacies. Dr. Koop appeared in the videos, each tailored to patients with a newly diagnosed disease, to explain the ailment, alternative treatments and anticipated outcomes.

In 1997 he founded DrKoop.com, a popular medical information Web site whose critics said blurred the line between objective information and advertising and promotional content. The site was valued at more than $1 billion before it went bankrupt in the collapse of the Internet bubble.

Dr. Koop also came under criticism in 1999 when a panel of scientists he led investigated claims that certain chemicals used to make plastics more flexible — in hospital tubes and some children’s toys, for example — were dangerous. The panel determined that they were safe, a finding disputed by Health Care Without Harm, an international coalition of health workers, advocacy groups and environmentalists.

Dr. Koop maintained a public profile well into his later years. In January 2010, he appeared in an advertisement opposing the Democratic health care proposal then being negotiated in Congress, saying it threatened to ration health care for older people, an assertion that drew criticism as misleading.

When he stepped down as surgeon general, however, Dr. Koop had won over many of his original detractors.

“The skeptics and cynics, this page included, were wrong to fear that Surgeon General C. Everett Koop would use his office only as a pulpit for his anti-abortion views,” an editorial in The Times said in 1989, as he was leaving office. “Throughout he has put medical integrity above personal value judgments and has been, indeed, the nation’s First Doctor.”

Daniel E. Slotnik contributed reporting.

    C. Everett Koop, Forceful U.S. Surgeon General, Dies at 96, NYT, 25.2.2013,
    http://www.nytimes.com/2013/02/26/us/c-everett-koop-forceful-surgeon-general-dies-at-96.html

Drowned in a Stream of Prescriptions

February 2, 2013
The New York Times
By ALAN SCHWARZ

VIRGINIA BEACH — Every morning on her way to work, Kathy Fee holds her breath as she drives past the squat brick building that houses Dominion Psychiatric Associates.

It was there that her son, Richard, visited a doctor and received prescriptions for Adderall, an amphetamine-based medication for attention deficit hyperactivity disorder. It was in the parking lot that she insisted to Richard that he did not have A.D.H.D., not as a child and not now as a 24-year-old college graduate, and that he was getting dangerously addicted to the medication. It was inside the building that her husband, Rick, implored Richard’s doctor to stop prescribing him Adderall, warning, “You’re going to kill him.”

It was where, after becoming violently delusional and spending a week in a psychiatric hospital in 2011, Richard met with his doctor and received prescriptions for 90 more days of Adderall. He hanged himself in his bedroom closet two weeks after they expired.

The story of Richard Fee, an athletic, personable college class president and aspiring medical student, highlights widespread failings in the system through which five million Americans take medication for A.D.H.D., doctors and other experts said.

Medications like Adderall can markedly improve the lives of children and others with the disorder. But the tunnel-like focus the medicines provide has led growing numbers of teenagers and young adults to fake symptoms to obtain steady prescriptions for highly addictive medications that carry serious psychological dangers. These efforts are facilitated by a segment of doctors who skip established diagnostic procedures, renew prescriptions reflexively and spend too little time with patients to accurately monitor side effects.

Richard Fee’s experience included it all. Conversations with friends and family members and a review of detailed medical records depict an intelligent and articulate young man lying to doctor after doctor, physicians issuing hasty diagnoses, and psychiatrists continuing to prescribe medication — even increasing dosages — despite evidence of his growing addiction and psychiatric breakdown.

Very few people who misuse stimulants devolve into psychotic or suicidal addicts. But even one of Richard’s own physicians, Dr. Charles Parker, characterized his case as a virtual textbook for ways that A.D.H.D. practices can fail patients, particularly young adults. “We have a significant travesty being done in this country with how the diagnosis is being made and the meds are being administered,” said Dr. Parker, a psychiatrist in Virginia Beach. “I think it’s an abnegation of trust. The public needs to say this is totally unacceptable and walk out.”

Young adults are by far the fastest-growing segment of people taking A.D.H.D medications. Nearly 14 million monthly prescriptions for the condition were written for Americans ages 20 to 39 in 2011, two and a half times the 5.6 million just four years before, according to the data company I.M.S. Health. While this rise is generally attributed to the maturing of adolescents who have A.D.H.D. into young adults — combined with a greater recognition of adult A.D.H.D. in general — many experts caution that savvy college graduates, freed of parental oversight, can legally and easily obtain stimulant prescriptions from obliging doctors.

“Any step along the way, someone could have helped him — they were just handing out drugs,” said Richard’s father. Emphasizing that he had no intention of bringing legal action against any of the doctors involved, Mr. Fee said: “People have to know that kids are out there getting these drugs and getting addicted to them. And doctors are helping them do it.”

“...when he was in elementary school he fidgeted, daydreamed and got A’s. he has been an A-B student until mid college when he became scattered and he wandered while reading He never had to study. Presently without medication, his mind thinks most of the time, he procrastinated, he multitasks not finishing in a timely manner.”

Dr. Waldo M. Ellison

Richard Fee initial evaluation

Feb. 5, 2010

Richard began acting strangely soon after moving back home in late 2009, his parents said. He stayed up for days at a time, went from gregarious to grumpy and back, and scrawled compulsively in notebooks. His father, while trying to add Richard to his health insurance policy, learned that he was taking Vyvanse for A.D.H.D.

Richard explained to him that he had been having trouble concentrating while studying for medical school entrance exams the previous year and that he had seen a doctor and received a diagnosis. His father reacted with surprise. Richard had never shown any A.D.H.D. symptoms his entire life, from nursery school through high school, when he was awarded a full academic scholarship to Greensboro College in North Carolina. Mr. Fee also expressed concerns about the safety of his son’s taking daily amphetamines for a condition he might not have.

“The doctor wouldn’t give me anything that’s bad for me,” Mr. Fee recalled his son saying that day. “I’m not buying it on the street corner.”

Richard’s first experience with A.D.H.D. pills, like so many others’, had come in college. Friends said he was a typical undergraduate user — when he needed to finish a paper or cram for exams, one Adderall capsule would jolt him with focus and purpose for six to eight hours, repeat as necessary.

So many fellow students had prescriptions or stashes to share, friends of Richard recalled in interviews, that guessing where he got his was futile. He was popular enough on campus — he was sophomore class president and played first base on the baseball team — that they doubted he even had to pay the typical $5 or $10 per pill.

“He would just procrastinate, wait till the last minute and then take a pill to study for tests,” said Ryan Sykes, a friend. “It got to the point where he’d say he couldn’t get anything done if he didn’t have the Adderall.”

Various studies have estimated that 8 percent to 35 percent of college students take stimulant pills to enhance school performance. Few students realize that giving or accepting even one Adderall pill from a friend with a prescription is a federal crime. Adderall and its stimulant siblings are classified by the Drug Enforcement Administration as Schedule II drugs, in the same category as cocaine, because of their highly addictive properties.

“It’s incredibly nonchalant,” Chris Hewitt, a friend of Richard, said of students’ attitudes to the drug. “It’s: ‘Anyone have any Adderall? I want to study tonight,’ ” said Mr. Hewitt, now an elementary school teacher in Greensboro.

After graduating with honors in 2008 with a degree in biology, Richard planned to apply to medical schools and stayed in Greensboro to study for the entrance exams. He remembered how Adderall had helped him concentrate so well as an undergraduate, friends said, and he made an appointment at the nearby Triad Psychiatric and Counseling Center.

According to records obtained by Richard’s parents after his death, a nurse practitioner at Triad detailed his unremarkable medical and psychiatric history before recording his complaints about “organization, memory, attention to detail.” She characterized his speech as “clear,” his thought process “goal directed” and his concentration “attentive.”

Richard filled out an 18-question survey on which he rated various symptoms on a 0-to-3 scale. His total score of 29 led the nurse practitioner to make a diagnosis of “A.D.H.D., inattentive-type” — a type of A.D.H.D. without hyperactivity. She recommended Vyvanse, 30 milligrams a day, for three weeks.

Phone and fax requests to Triad officials for comment were not returned.

Some doctors worry that A.D.H.D. questionnaires, designed to assist and standardize the gathering of a patient’s symptoms, are being used as a shortcut to diagnosis. C. Keith Conners, a longtime child psychologist who developed a popular scale similar to the one used with Richard, said in an interview that scales like his “have reinforced this tendency for quick and dirty practice.”

Dr. Conners, an emeritus professor of psychiatry and behavioral sciences at Duke University Medical Center, emphasized that a detailed life history must be taken and other sources of information — such as a parent, teacher or friend — must be pursued to learn the nuances of a patient’s difficulties and to rule out other maladies before making a proper diagnosis of A.D.H.D. Other doctors interviewed said they would not prescribe medications on a patient’s first visit, specifically to deter the faking of symptoms.

According to his parents, Richard had no psychiatric history, or even suspicion of problems, through college. None of his dozen high school and college acquaintances interviewed for this article said he had ever shown or mentioned behaviors related to A.D.H.D. — certainly not the “losing things” and “difficulty awaiting turn” he reported on the Triad questionnaire — suggesting that he probably faked or at least exaggerated his symptoms to get his diagnosis.

That is neither uncommon nor difficult, said David Berry, a professor and researcher at the University of Kentucky. He is a co-author of a 2010 study that compared two groups of college students — those with diagnoses of A.D.H.D. and others who were asked to fake symptoms — to see whether standard symptom questionnaires could tell them apart. They were indistinguishable.

“With college students,” Dr. Berry said in an interview, “it’s clear that it doesn’t take much information for someone who wants to feign A.D.H.D. to do so.”

Richard Fee filled his prescription for Vyvanse within hours at a local Rite Aid. He returned to see the nurse three weeks later and reported excellent concentration: “reading books — read 10!” her notes indicate. She increased his dose to 50 milligrams a day. Three weeks later, after Richard left a message for her asking for the dose to go up to 60, which is on the high end of normal adult doses, she wrote on his chart, “Okay rewrite.”

Richard filled that prescription later that afternoon. It was his third month’s worth of medication in 43 days.

“The patient is a 23-year-old Caucasian male who presents for refill of vyvanse — recently started on this while in NC b/c of lack of motivation/ loss of drive. Has moved here and wants refill”

Dr. Robert M. Woodard

Notes on Richard Fee

Nov. 11, 2009

Richard scored too low on the MCAT in 2009 to qualify for a top medical school. Although he had started taking Vyvanse for its jolts of focus and purpose, their side effects began to take hold. His sleep patterns increasingly scrambled and his mood darkening, he moved back in with his parents in Virginia Beach and sought a local physician to renew his prescriptions.

A friend recommended a family physician, Dr. Robert M. Woodard. Dr. Woodard heard Richard describe how well Vyvanse was working for his A.D.H.D., made a diagnosis of “other malaise and fatigue” and renewed his prescription for one month. He suggested that Richard thereafter see a trained psychiatrist at Dominion Psychiatric Associates — only a five-minute walk from the Fees’ house.

With eight psychiatrists and almost 20 therapists on staff, Dominion Psychiatric is one of the better-known practices in Virginia Beach, residents said. One of its better-known doctors is Dr. Waldo M. Ellison, a practicing psychiatrist since 1974.

In interviews, some patients and parents of patients of Dr. Ellison’s described him as very quick to identify A.D.H.D. and prescribe medication for it. Sandy Paxson of nearby Norfolk said she took her 15-year-old son to see Dr. Ellison for anxiety in 2008; within a few minutes, Mrs. Paxson recalled, Dr. Ellison said her son had A.D.H.D. and prescribed him Adderall.

“My son said: ‘I love the way this makes me feel. It helps me focus for school, but it’s not getting rid of my anxiety, and that’s what I need,’ ” Mrs. Paxson recalled. “So we went back to Dr. Ellison and told him that it wasn’t working properly, what else could he give us, and he basically told me that I was wrong. He basically told me that I was incorrect.”

Dr. Ellison met with Richard in his office for the first time on Feb. 5, 2010. He took a medical history, heard Richard’s complaints regarding concentration, noted how he was drumming his fingers and made a diagnosis of A.D.H.D. with “moderate symptoms or difficulty functioning.” Dominion Psychiatric records of that visit do not mention the use of any A.D.H.D. symptom questionnaire to identify particular areas of difficulty or strategies for treatment.

As the 47-minute session ended, Dr. Ellison prescribed a common starting dose of Adderall: 30 milligrams daily for 21 days. Eight days later, while Richard still had 13 pills remaining, his prescription was renewed for 30 more days at 50 milligrams.

Through the remainder of 2010, in appointments with Dr. Ellison that usually lasted under five minutes, Richard returned for refills of Adderall. Records indicate that he received only what was consistently coded as “pharmacologic management” — the official term for quick appraisals of medication effects — and none of the more conventional talk-based therapy that experts generally consider an important component of A.D.H.D. treatment.

His Adderall prescriptions were always for the fast-acting variety, rather than the extended-release formula that is less prone to abuse.

“PATIENT DOING WELL WITH THE MEDICATION, IS CALM, FOCUSED AND ON TASK, AND WILL RETURN TO OFFICE IN 3 MONTHS”

Dr. Waldo M. Ellison

Notes on Richard Fee

Dec. 11, 2010

Regardless of what he might have told his doctor, Richard Fee was anything but well or calm during his first year back home, his father said.

Blowing through a month’s worth of Adderall in a few weeks, Richard stayed up all night reading and scribbling in notebooks, occasionally climbing out of his bedroom window and on to the roof to converse with the moon and stars. When the pills ran out, he would sleep for 48 hours straight and not leave his room for 72. He got so hot during the day that he walked around the house with ice packs around his neck — and in frigid weather, he would cool off by jumping into the 52-degree backyard pool.

As Richard lost a series of jobs and tensions in the house ran higher — particularly when talk turned to his Adderall — Rick and Kathy Fee continued to research the side effects of A.D.H.D. medication. They learned that stimulants are exceptionally successful at mollifying the impulsivity and distractibility that characterize classic A.D.H.D., but that they can cause insomnia, increased blood pressure and elevated body temperature. Food and Drug Administration warnings on packaging also note “high potential for abuse,” as well as psychiatric side effects such as aggression, hallucinations and paranoia.

A 2006 study in the journal Drug and Alcohol Dependence claimed that about 10 percent of adolescents and young adults who misused A.D.H.D. stimulants became addicted to them. Even proper, doctor-supervised use of the medications can trigger psychotic behavior or suicidal thoughts in about 1 in 400 patients, according to a 2006 study in The American Journal of Psychiatry. So while a vast majority of stimulant users will not experience psychosis — and a doctor may never encounter it in decades of careful practice — the sheer volume of prescriptions leads to thousands of cases every year, experts acknowledged.

When Mrs. Fee noticed Richard putting tape over his computer’s camera, he told her that people were spying on him. (He put tape on his fingers, too, to avoid leaving fingerprints.) He cut himself out of family pictures, talked to the television and became increasingly violent when agitated.

In late December, Mr. Fee drove to Dominion Psychiatric and asked to see Dr. Ellison, who explained that federal privacy laws forbade any discussion of an adult patient, even with the patient’s father. Mr. Fee said he had tried unsuccessfully to detail Richard’s bizarre behavior, assuming that Richard had not shared such details with his doctor.

“I can’t talk to you,” Mr. Fee recalled Dr. Ellison telling him. “I did this one time with another family, sat down and talked with them, and I ended up getting sued. I can’t talk with you unless your son comes with you.”

Mr. Fee said he had turned to leave but distinctly recalls warning Dr. Ellison, “You keep giving Adderall to my son, you’re going to kill him.”

Dr. Ellison declined repeated requests for comment on Richard Fee’s case. His office records, like those of other doctors involved, were obtained by Mr. Fee under Virginia and federal law, which allow the legal representative of a deceased patient to obtain medical records as if he were the patient himself.

As 2011 began, the Fees persuaded Richard to see a psychologist, Scott W. Sautter, whose records note Richard’s delusions, paranoia and “severe and pervasive mental disorder.” Dr. Sautter recommended that Adderall either be stopped or be paired with a sleep aid “if not medically contraindicated.”

Mr. Fee did not trust his son to share this report with Dr. Ellison, so he drove back to Dominion Psychiatric and, he recalled, was told by a receptionist that he could leave the information with her. Mr. Fee said he had demanded to put it in Dr. Ellison’s hands himself and threatened to break down his door in order to do so.

Mr. Fee said that Dr. Ellison had then come out, read the report and, appreciating the gravity of the situation, spoken with him about Richard for 45 minutes. They scheduled an appointment for the entire family.

“meeting with parents — concern with ‘metaphoric’ speaking that appears to be outside the realm of appropriated one to one conversation. Richard says he does it on purpose — to me some of it sounds like pre-psychotic thinking.”

Dr. Waldo M. Ellison

Notes on Richard Fee

Feb. 23, 2011

Dr. Ellison stopped Richard Fee’s prescription — he wrote “no Adderall for now” on his chart and the next day refused Richard’s phone request for more. Instead he prescribed Abilify and Seroquel, antipsychotics for schizophrenia that do not provide the bursts of focus and purpose that stimulants do. Richard became enraged, his parents recalled. He tried to back up over his father in the Dominion Psychiatric parking lot and threatened to burn the house down. At home, he took a baseball bat from the garage, smashed flower pots and screamed, “You’re taking my medicine!”

Richard disappeared for a few weeks. He returned to the house when he learned of his grandmother’s death, the Fees said.

The morning after the funeral, Richard walked down Potters Road to what became a nine-minute visit with Dr. Ellison. He left with two prescriptions: one for Abilify, and another for 50 milligrams a day of Adderall.

According to Mr. Fee, Richard later told him that he had lied to Dr. Ellison — he told the doctor he was feeling great, life was back on track and he had found a job in Greensboro that he would lose without Adderall. Dr. Ellison’s notes do not say why he agreed to start Adderall again.

Richard’s delusions and mood swings only got worse, his parents said. They would lock their bedroom door when they went to sleep because of his unpredictable rages. “We were scared of our own son,” Mr. Fee said. Richard would blow through his monthly prescriptions in 10 to 15 days and then go through hideous withdrawals. A friend said that he would occasionally get Richard some extra pills during the worst of it, but that “it wasn’t enough because he would take four or five at a time.”

One night during an argument, after Richard became particularly threatening and pushed him over a chair, Mr. Fee called the police. They arrested Richard for domestic violence. The episode persuaded Richard to see another local psychiatrist, Dr. Charles Parker.

Mrs. Fee said she attended Richard’s initial consultation on June 3 with Dr. Parker’s clinician, Renee Strelitz, and emphasized his abuse of Adderall. Richard “kept giving me dirty looks,” Mrs. Fee recalled. She said she had later left a detailed message on Ms. Strelitz’s voice mail, urging her and Dr. Parker not to prescribe stimulants under any circumstances when Richard came in the next day.

Dr. Parker met with Richard alone. The doctor noted depression, anxiety and suicidal ideas. He wrote “no meds” with a box around it — an indication, he explained later, that he was aware of the parents’ concerns regarding A.D.H.D. stimulants.

Dr. Parker wrote three 30-day prescriptions: Clonidine (a sleep aid), Venlafaxine (an antidepressant) and Adderall, 60 milligrams a day.

In an interview last November, Dr. Parker said he did not recall the details of Richard’s case but reviewed his notes and tried to recreate his mind-set during that appointment. He said he must have trusted Richard’s assertions that medication was not an issue, and must have figured that his parents were just philosophically anti-medication. Dr. Parker recalled that he had been reassured by Richard’s intelligent discussions of the ins and outs of stimulants and his desire to pursue medicine himself.

“He was smart and he was quick and he had A’s and B’s and wanted to go to medical school — and he had all the deportment of a guy that had the potential to do that,” Dr. Parker said. “He didn’t seem like he was a drug person at all, but rather a person that was misunderstood, really desirous of becoming a physician. He was very slick and smooth. He convinced me there was a benefit.”

Mrs. Fee was outraged. Over the next several days, she recalled, she repeatedly spoke with Ms. Strelitz over the phone to detail Richard’s continued abuse of the medication (she found nine pills gone after 48 hours) and hand-delivered Dr. Sautter’s appraisal of his recent psychosis. Dr. Parker confirmed that he had received this information.

Richard next saw Dr. Parker on June 27. Mrs. Fee drove him to the clinic and waited in the parking lot. Soon afterward, Richard returned and asked to head to the pharmacy to fill a prescription. Dr. Parker had raised his Adderall to 80 milligrams a day.

Dr. Parker recalled that the appointment had been a 15-minute “med check” that left little time for careful assessment of any Adderall addiction. Once again, Dr. Parker said, he must have believed Richard’s assertions that he needed additional medicine more than the family’s pleas that it be stopped.

“He was pitching me very well — I was asking him very specific questions, and he was very good at telling me the answers in a very specific way,” Dr. Parker recalled. He added later, “I do feel partially responsible for what happened to this kid.”

“Paranoid and psychotic ... thinking that the computer is spying on him. He has also been receiving messages from stars at night and he is unable to be talked to in a reasonable fashion ... The patient denies any mental health problems ... fairly high risk for suicide.”

Dr. John Riedler

Admission note for Richard Fee

Virginia Beach Psychiatric Center

July 8, 2011

The 911 operator answered the call and heard a young man screaming on the other end. His parents would not give him his pills. With the man’s language scattered and increasingly threatening, the police were sent to the home of Rick and Kathy Fee.

The Fees told officers that Richard was addicted to Adderall, and that after he had received his most recent prescription, they allowed him to fill it through his mother’s insurance plan on the condition that they hold it and dispense it appropriately. Richard was now demanding his next day’s pills early.

Richard denied his addiction and threats. So the police, noting that Richard was an adult, instructed the Fees to give him the bottle. They said they would comply only if he left the house for good. Officers escorted Richard off the property.

A few hours later Richard called his parents, threatening to stab himself in the head with a knife. The police found him and took him to the Virginia Beach Psychiatric Center.

Described as “paranoid and psychotic” by the admitting physician, Dr. John Riedler, Richard spent one week in the hospital denying that he had any psychiatric or addiction issues. He was placed on two medications: Seroquel and the antidepressant Wellbutrin, no stimulants. In his discharge report, Dr. Riedler noted that Richard had stabilized but remained severely depressed and dependent on both amphetamines and marijuana, which he would smoke in part to counter the buzz of Adderall and the depression from withdrawal.

(Marijuana is known to increase the risk for schizophrenia, psychosis and memory problems, but Richard had smoked pot in high school and college with no such effects, several friends recalled. If that was the case, “in all likelihood the stimulants were the primary issue here,” said Dr. Wesley Boyd, a psychiatrist at Children’s Hospital Boston and Cambridge Health Alliance who specializes in adolescent substance abuse.)

Unwelcome at home after his discharge from the psychiatric hospital, Richard stayed in cheap motels for a few weeks. His Adderall prescription from Dr. Parker expired on July 26, leaving him eligible for a renewal. He phoned the office of Dr. Ellison, who had not seen him in four months.

“moved out of the house — doesn’t feel paranoid or delusional. Hasn’t been on meds for a while — working with a friend wiring houses rto 3 months — doesn’t feel he needs the abilify or seroquel for sleep.”

Dr. Waldo M. Ellison

Notes on Richard Fee

July 25, 2011

The 2:15 p.m. appointment went better than Richard could have hoped. He told Dr. Ellison that the pre-psychotic and metaphoric thinking back in March had receded, and that all that remained was his A.D.H.D. He said nothing of his visits to Dr. Parker, his recent prescriptions or his week in the psychiatric hospital.

At 2:21 p.m., according to Dr. Ellison’s records, he prescribed Richard 30 days’ worth of Adderall at 50 milligrams a day. He also gave him prescriptions postdated for Aug. 23 and Sept. 21, presumably to allow him to get pills into late October without the need for follow-up appointments. (Virginia state law forbids the dispensation of 90 days of a controlled substance at one time, but does allow doctors to write two 30-day prescriptions in advance.)

Virginia is one of 43 states with a formal Prescription Drug Monitoring Program, an online database that lets doctors check a patient’s one-year prescription history, partly to see if he or she is getting medication elsewhere. Although pharmacies are required to enter all prescriptions for controlled substances into the system, Virginia law does not require doctors to consult it.

Dr. Ellison’s notes suggest that he did not check the program before issuing the three prescriptions to Richard, who filled the first within hours.

The next morning, during a scheduled appointment at Dr. Parker’s clinic, Ms. Strelitz wrote in her notes: “Richard is progressing. He reported staying off of the Adderall and on no meds currently. Focusing on staying healthy, eating well and exercising.”

About a week later, Richard called his father with more good news: a job he had found overseeing storm cleanup crews was going well. He was feeling much better.

But Mr. Fee noticed that the more calm and measured speech that Richard had regained during his hospital stay was gone. He jumped from one subject to the next, sounding anxious and rushed. When the call ended, Mr. Fee recalled, he went straight to his wife.

“Call your insurance company,” he said, “and find out if they’ve filled any prescriptions for Adderall.”

“spoke to father — richard was in VBPC [Virginia Beach Psychiatric Center] and OD on adderall — NO STIMULANTS — HE WAS ALSO SEEING DR. PARKER”

Dr. Waldo M. Ellison

Interoffice e-mail

Aug. 5, 2011

An insurance representative confirmed that Richard had filled a prescription for Adderall on July 25. Mr. Fee confronted Dr. Ellison in the Dominion Psychiatric parking lot.

Mr. Fee told him that Richard had been in the psychiatric hospital, had been suicidal and had been taking Adderall through June and July. Dr. Ellison confirmed that he had written not only another prescription but two others for later in August and September.

“He told me it was normal procedure and not 90 days at one time,” Mr. Fee recalled. “I flipped out on him: ‘You gave my son 90 days of Adderall? You’re going to kill him!’ ”

Mr. Fee said he and Dr. Ellison had discussed voiding the two outstanding scripts. Mr. Fee said he had been told that it was possible, but that should Richard need emergency medical attention, it could keep him from getting what would otherwise be proper care or medication. Mr. Fee confirmed that with a pharmacist and decided to drive to Richard’s apartment and try to persuade him to rip up the prescriptions.

“I know that you’ve got these other prescriptions to get pills,” Mr. Fee recalled telling Richard. “You’re doing so good. You’ve got a job. You’re working. Things with us are better. If you get them filled, I’m worried about what will happen.”

“You’re right,” Mr. Fee said Richard had replied. “I tore them up and threw them away.”

Mr. Fee spent two more hours with Richard making relative small talk — increasingly gnawed, he recalled later, by the sense that this was no ordinary conversation. As he looked at Richard he saw two images flickering on top of each other — the boy he had raised to love school and baseball, and the desperate addict he feared that boy had become.

Before he left, Mr. Fee made as loving a demand as he could muster.

“Please. Give them to me,” Mr. Fee said.

Richard looked his father dead in the eye.

“I destroyed them,” he said. “I don’t have them. Don’t worry.”

“Richard said that he has stopped Adderall and wants to work on continuing to progress.”

Renee Strelitz

Session notes

Sept. 13, 2011

Richard generally filled his prescriptions at a CVS on Laskin Road, less than three miles from his parents’ home. But on Aug. 23, he went to a different CVS about 11 miles away, closer to Norfolk and farther from the locations that his father might have called to alert them to the situation. For his Sept. 21 prescription he traveled even farther, into Norfolk, to get his pills.

On Oct. 3, Richard visited Dr. Ellison for an appointment lasting 17 minutes. The doctor prescribed two weeks of Strattera, a medication for A.D.H.D. that contains no amphetamines and, therefore, is neither a controlled substance nor particularly prone to abuse. His records make no mention of the Adderall prescription Richard filled on Sept. 21; they do note, however, “Father says that he is crazy and abusive of the Adderall — has made directives with regard to giving Richard anymore stimulants — bringing up charges — I explained this to Richard.”

Prescription records indicate that Richard did not fill the Strattera prescription before returning to Dr. Ellison’s office two weeks later to ask for more stimulants.

“Patient took only a few days of Strattera 40 mg — it calmed him but not focusing,” the doctor’s notes read. “I had told him not to look for much initially — He would like a list of MD who could rx adderall.”

Dr. Ellison never saw Richard again. Given his patterns of abuse, friends said, Richard probably took his last Adderall pill in early October. Because he abruptly stopped without the slow and delicate reduction of medication that is recommended to minimize major psychological risks, especially for instant-release stimulants, he crashed harder than ever.

Richard’s lifelong friend Ryan Sykes was one of the few people in contact with him during his final weeks. He said that despite Richard’s addiction to Adderall and the ease with which it could be obtained on college campuses nearby, he had never pursued it outside the doctors’ prescriptions.

“He had it in his mind that because it came from a doctor, it was O.K.,” Mr. Sykes recalled.

On Nov. 7, after arriving home from a weekend away, Mrs. Fee heard a message on the family answering machine from Richard, asking his parents to call him. She phoned back at 10 that night and left a message herself.

Not hearing back by the next afternoon, Mrs. Fee checked Richard’s cellphone records — he was on her plan — and saw no calls or texts. At 9 p.m. the Fees drove to Richard’s apartment in Norfolk to check on him. The lights were on; his car was in the driveway. He did not answer. Beginning to panic, Mr. Fee found the kitchen window ajar and climbed in through it.

He searched the apartment and found nothing amiss.

“He isn’t here,” Mr. Fee said he had told his wife.

“Oh, thank God,” she replied. “Maybe he’s walking on the beach or something.”

They got ready to leave before Mr. Fee stopped.

“Wait a minute,” he said. “I didn’t check the closet.”

“Spoke with Richard’s mother, Kathy Fee, today. She reported that Richard took his life last November. Family is devasted and having a difficult time. Offerred assistance for family.”

Renee Strelitz

Last page of Richard Fee file

June 21, 2012

Friends and former baseball teammates flocked to Richard Fee’s memorial service in Virginia Beach. Most remembered only the funny and gregarious guy they knew in high school and college; many knew absolutely nothing of his last two years. He left no note explaining his suicide.

At a gathering at the Fees’ house afterward, Mr. Fee told them about Richard’s addiction to Adderall. Many recalled how they, too, had blithely abused the drug in college — to cram, just as Richard had — and could not help but wonder if they had played the same game of Russian roulette.

“I guarantee you a good number of them had used it for studying — that shock was definitely there in that room,” said a Greensboro baseball teammate, Danny Michael, adding that he was among the few who had not. “It’s so prevalent and widely used. People had no idea it could be abused to the point of no return.”

Almost every one of more than 40 A.D.H.D. experts interviewed for this article said that worst-case scenarios like Richard Fee’s can occur with any medication — and that people who do have A.D.H.D., or parents of children with the disorder, should not be dissuaded from considering the proven benefits of stimulant medication when supervised by a responsible physician.

Other experts, however, cautioned that Richard Fee’s experience is instructive less in its ending than its evolution — that it underscores aspects of A.D.H.D. treatment that are mishandled every day with countless patients, many of them children.

“You don’t have everything that happened with this kid, but his experience is not that unusual,” said DeAnsin Parker, a clinical neuropsychologist in New York who specializes in young adults. “Diagnoses are made just this quickly, and medication is filled just this quickly. And the lack of therapy is really sad. Doctors are saying, ‘Just take the meds to see if they help,’ and if they help, ‘You must have A.D.H.D.’ ”

Dr. Parker added: “Stimulants will help anyone focus better. And a lot of young people like or value that feeling, especially those who are driven and have ambitions. We have to realize that these are potential addicts — drug addicts don’t look like they used to.”

Documentary screening and panel discussion on ADHD, “ADD and Loving It?!”

Listing, The Virginian-Pilot

Oct. 10, 2012

The Fees decided to go. The event was sponsored by the local chapter of Children and Adults with Attention Deficit Disorder (Chadd), the nation’s primary advocacy group for A.D.H.D. patients. They wanted to attend the question-and-answer session afterward with local doctors and community college officials.

The evening opened with the local Chadd coordinator thanking the drug company Shire — the manufacturer of several A.D.H.D. drugs, including Vyvanse and extended-release Adderall — for partly underwriting the event. An hourlong film directed and narrated by two men with A.D.H.D. closed by examining some “myths” about stimulant medications, with several doctors praising their efficacy and safety. One said they were “safer than aspirin,” while another added, “It’s O.K. — there’s nothing that’s going to happen.”

Sitting in the fourth row, Mr. Fee raised his hand to pose a question to the panel, which was moderated by Jeffrey Katz, a local clinical psychologist and a national board member of Chadd. “What are some of the drawbacks or some of the dangers of a misdiagnosis in somebody,” Mr. Fee asked, “and then the subsequent medication that goes along with that?”

Dr. Katz looked straight at the Fees as he answered, “Not much.”

Adding that “the medication itself is pretty innocuous,” Dr. Katz continued that someone without A.D.H.D. might feel more awake with stimulants but would not consider it “something that they need.”

“If you misdiagnose it and you give somebody medication, it’s not going to do anything for them,” Dr. Katz concluded. “Why would they continue to take it?”

Mr. Fee slowly sat down, trembling. Mrs. Fee placed her hand on his knee as the panel continued.

    Drowned in a Stream of Prescriptions, NYT, 2.2.2013,
    http://www.nytimes.com/2013/02/03/us/
    concerns-about-adhd-practices-and-amphetamine-addiction.html

As Suicides Rise in U.S., Veterans Are Less of Total

February 1, 2013
The New York Times
By JAMES DAO

Suicides among military veterans, though up slightly in recent years, account for a shrinking percentage of the nation’s total number of suicides — a result of steadily rising numbers of suicides in the general population, according to a report released on Friday by the Department of Veterans Affairs.

The report, based on the most extensive data the department has ever collected on suicide, found that the number of suicides among veterans reached 22 a day in 2010, the most recent year available.

That was up by 22 percent from 2007, when the daily number was 18. But it is only 10 percent higher than in 1999, according to the report. Department officials described the numbers as “relatively stable” over the decade.

In the same 12-year period, the total number of suicides in the country rose steadily to an estimated 105 a day in 2010, up from 80 in 1999, a 31 percent increase.

As a result, the percentage of the nation’s daily suicides committed by veterans declined to 21 percent in 2010, from 25 percent in 1999.

“What’s happening with veterans is a reflection of what’s happening to America,” Jan Kemp, the national mental health director for suicide prevention at the Department of Veterans Affairs, said in an interview. “The suicide rate in America has been creeping up.”

Dr. Kemp said the fact that veterans accounted for a smaller percentage of the nation’s suicides suggested that improved outreach and suicide prevention programs might have had an effect.

But other experts said that for a variety of reasons — including the fact that many veterans have access to health care through the department — the suicide rate for veterans should be much lower than it is.

“This remains a crisis,” said Paul Sullivan, a founder of Veterans for Common Sense.

The new report does not provide a suicide rate for veterans, because the department is still refining that number, Dr. Kemp said. But she acknowledged that the rate was higher than for the general population, which is 12.4 suicides per 100,000 people.

Dr. Kemp said veterans tend to fall into higher-risk groups, which include: being male; living in a rural area, particularly in the West; and having access to firearms.

Past reports on suicide among veterans have been based on data collected by the federal government from only about a third of the states. But because of growing concerns about veteran suicide, the department asked every state to provide data on veterans.

The new report — which was previously described in The Washington Post — is based on a database built from information on more than 147,000 suicides in 21 states — a large enough number to develop accurate estimates for the entire veteran population, department officials said. Dr. Kemp added that the department now had data from 40 states and tentative agreements to receive information from the remaining 10.

Among the report’s other important findings was that male veterans who commit suicide tend to be older than nonveteran male suicides, with the largest number of veterans’ suicides occurring among men between 50 and 59. Dr. Kemp said the department intended to increase outreach to that age group.

At the same time, the new data suggested that veterans under 30 are committing suicide in smaller numbers than their nonveteran peers. That would seem to contradict theories that the recent wars have contributed to increased suicide among new veterans.

Somewhat surprisingly, the study confirmed an estimate first reported in 2008 that 18 veterans commit suicide each day. That figure had been viewed skeptically by many experts because it was not based on detailed data. But the new, more comprehensive data resulted in the same estimate.

    As Suicides Rise in U.S., Veterans Are Less of Total, NYT, 1.2.2013,
    http://www.nytimes.com/2013/02/02/us/veterans-make-up-shrinking-percentage-of-suicides.html

Birth Control Rule Altered

to Allay Religious Objections

February 1, 2013
The New York Times
By ROBERT PEAR

WASHINGTON — The Obama administration on Friday proposed yet another compromise to address strenuous objections from religious organizations about a policy requiring health insurance plans to provide free contraceptives, but the change did not end the political furor or legal fight over the issue.

The proposal could expand the number of groups that do not need to pay directly for birth control coverage, encompassing not only churches and other religious organizations, but also some religiously affiliated hospitals, universities and social service agencies. Health insurance companies would pay for the coverage.

The latest proposed change is the third in the last 15 months, all announced on Fridays, as President Obama has struggled to balance women’s rights, health care and religious liberty. Legal experts said the fight could end up in the Supreme Court.

Kathleen Sebelius, the secretary of health and human services, said the proposal would guarantee free coverage of birth control “while respecting religious concerns.”

But Kyle Duncan, the general counsel of the Becket Fund for Religious Liberty in Washington, which is representing employers in eight lawsuits, said the litigation would continue. “Today’s proposed rule does nothing to protect the religious freedom of millions of Americans,” Mr. Duncan said.

Religious groups dissatisfied with the new proposal want a broader, more explicit exemption for religious organizations and protection for secular businesses owned by people with religious objections to contraceptive coverage.

The tortured history of the rule has played out in several chapters. The Obama administration first issued standards requiring insurers to cover contraceptives for women in August 2011, less than a month after receiving recommendations to that effect from the National Academy of Sciences. In January 2012, the administration rejected a broad exemption sought by the Roman Catholic Church for insurance provided by Catholic hospitals, colleges and charities. After a firestorm of criticism from Catholic bishops and Republican lawmakers, the administration offered a possible compromise that February. But it left many questions unanswered and did not say how coverage would be provided for self-insured religious organizations.

Under the new proposal, churches and nonprofit religious organizations that object to providing birth control coverage on religious grounds would not have to pay for it.

Female employees could get free contraceptive coverage through a separate plan that would be provided by a health insurer. Institutions objecting to the coverage would not pay for the contraceptives.

Insurance companies would bear the cost of providing the separate coverage, with the possibility of recouping the costs through lower health care expenses resulting in part from fewer births.

Chiquita Brooks-LaSure, who helped develop the proposal as deputy director of the federal office that regulates health insurance, said: “Under the proposed rule, insurance companies — not churches or other religious organizations — will cover contraceptive services. No nonprofit religious institution will be forced to pay for or provide contraceptive coverage, and churches and houses of worship are specifically exempt.”

Moreover, she said, “Nonprofit religious organizations like universities, hospitals or charities with religious objections won’t have to arrange, contract or pay for coverage of these services for their employees or students.”

But some of the lawsuits objecting to the plan have been filed by businesses owned by people who say they have religious reasons for not wanting to provide contraceptive coverage. Under the proposed rule, “for-profit secular employers” would have to provide birth control coverage to employees, even if the business owners had a religious objection to the idea.

Insurers said they were studying the proposal, but had questions about how it would work. Many insurers asked where they would get the money to pay for birth control pills if — as the proposed rule says — they cannot “impose any premium, fee or other charge” for the coverage. The 2010 health care law generally requires employers to provide women with coverage at no cost for “preventive care and screenings,” which the administration says must include contraceptives for women under most health plans.

The administration says employers must cover sterilization and the full range of contraceptive methods approved by the Food and Drug Administration, including emergency contraceptive pills, like those known as ella and Plan B One-Step. Employers that do not provide such coverage will be subject to financial penalties.

On Friday, the administration proposed a complicated arrangement to finance contraceptive coverage for employees of religious organizations that serve as their own insurers. The federal government would require health insurance companies to help defray the cost. In return, the insurers would get a credit against the fees they pay for the privilege of selling health insurance to millions of Americans in new online markets run by the federal government.

The government was already planning to charge user fees to the insurers to pay for the operation of those marketplaces, known as insurance exchanges.

Ms. Brooks-LaSure said the user fees were “not a cost to the federal government or to taxpayers.” Rather, she said, the fees are “private dollars paid by private insurers that choose to operate in the exchanges.”

Insurers said, however, that the cost of user fees, like other expenses, would often be passed on to consumers.

The proposal also said insurers could not impose any annual or lifetime limits on the dollar value of contraceptive benefits. But the administration added that “the cost of the contraceptive coverage could include a reasonable margin,” or profit, for insurers.

Administration officials tried to address some objections on Friday by proposing a new definition of “religious employers” that could be exempted from the requirement to provide contraceptive coverage.

The administration affirmed that the exemption would apply to churches and other houses of worship and that it would also be available to certain affiliated nonprofit groups that certify, in writing, that they have religious objections to such coverage.

Now, under the proposal, the administration said, “a house of worship would not be excluded from the exemption because, for example, it provides charitable social services to persons of different religious faiths or employs persons of different religious faiths.”

The administration had previously agreed to allow exemptions for some religious employers. But church groups said the exemption was so narrow that it was almost meaningless. Previously, a religious employer could not have qualified for the exemption if it employed or served large numbers of people of a different faith, as many Catholic hospitals, universities and social service agencies do.

Stephen F. Schneck, the director of the Institute for Policy Research and Catholic Studies at the Catholic University of America in Washington, said, “The revised definition is an important win for religious institutions because it clarifies conscience protections for entities like Catholic hospitals, charities and universities.” Mr. Schneck was a leader of Catholics for Obama last year.

The administration said that the new definition, though simpler, “would not expand the universe of employer plans that would qualify for the exemption beyond that which was intended” in final rules issued last year.

Reaction was wide ranging. Cecile Richards, the president of the Planned Parenthood Federation of America, said the policy affirmed that “your boss does not get to decide whether you can have birth control.”

But Representative Christopher H. Smith, Republican of New Jersey and co-chairman of the Pro-Life Caucus in Congress, said the proposal represented “neither an accommodation nor a compromise” and provided “no relief for small businesses run by people of faith.”

    Birth Control Rule Altered to Allay Religious Objections, NYT, 1.2.2013,
    http://www.nytimes.com/2013/02/02/us/politics/
    white-house-proposes-compromise-on-contraception-coverage.html

Contraception Compromise

February 1, 2013
6:07 pm
The New York Times
Taking Note - The Editorial Page Editor's Blog
By DAVID FIRESTONE

The Obama administration has tried everything it can think of to accommodate religious groups that don't want to pay for their employees' birth control.

First, it eliminated the requirement for churches. Then church-affiliated groups like universities and hospitals said they didn't want to pay for birth control either, so last year the administration said insurance companies would have to foot the bill. Next the groups said they didn't want even a dollar of their insurance premiums to go toward contraception, so on Friday the administration announced a new plan to make sure that won't happen.

The plan is based around the idea that insurance companies benefit from increased use of contraception, because they don't have to pay for as many births or the complications of pregnancy. Several studies have found that there is virtually no cost to an insurance company of paying for birth control because of those offsetting reductions.

Under the plan, insurance companies must offer separate policies, covering only birth control, directly to employees of religious non-profits, free of charge.

In the case of religious affiliates that self-insure, a third-party administrator will arrange for the birth-control-only policies. Insurance companies that participate will get a break on the fees they have to pay to sell their policies in national health insurance exchanges.

The danger in the third-party scenario is that taxpayers or others paying insurance premiums might wind up subsidizing a few religious employers who want to impose their own doctrines on their employees, whether or not the employees agree. That's not an issue of religious freedom; if anything, some groups want to restrict the freedoms of their employees, who may be of a different religion.

What's clear, though, is that the administration has gone far enough in its accommodations. Now the test will be put to the religious groups: was their objection really about who pays a few extra dollars to insurance companies? Or did they simply object to the administration's demand for widespread, free access to birth control? Their response to today's plan will provide the answer.

    Contraception Compromise, NYT, 1.2.2013,
    http://takingnote.blogs.nytimes.com/2013/02/01/contraception-compromise/

Focus on Mental Health Laws

to Curb Violence Is Unfair,

Some Say

January 31, 2013
The New York Times
By ERICA GOODE and JACK HEALY

In their fervor to take action against gun violence after the shooting in Newtown, Conn., a growing number of state and national politicians are promoting a focus on mental illness as a way to help prevent further killings.

Legislation to revise existing mental health laws is under consideration in at least a half-dozen states, including Colorado, Oregon and Ohio. A New York bill requiring mental health practitioners to warn the authorities about potentially dangerous patients was signed into law on Jan. 15. In Washington, President Obama has ordered “a national dialogue” on mental health, and a variety of bills addressing mental health issues are percolating on Capitol Hill.

But critics say that this focus unfairly singles out people with serious mental illness, who studies indicate are involved in only about 4 percent of violent crimes and are 11 or more times as likely than the general population to be the victims of violent crime.

And many proposals — they include strengthening mental health services, lowering the threshold for involuntary commitment and increasing requirements for reporting worrisome patients to the authorities — are rushed in execution and unlikely to repair a broken mental health system, some experts say.

“Good intentions without thought make for bad laws, and I think we have a risk of that,” said J. Reid Meloy, a forensic psychologist and clinical professor at the University of California, San Diego, who has studied rampage killers.

Moreover, the push for additional mental health laws is often driven by political expediency, some critics say. Mental health proposals draw support from both Democrats and Republicans, in part because, unlike bans on semiautomatic weapons or high-capacity magazines — like the one proposed in the Senate last week — they do not involve confrontation with gun rights groups like the National Rifle Association.

“The N.R.A. is far more formidable as a political foe than the advocacy groups for the mentally ill,” said Dr. Jeffrey A. Lieberman, chairman of psychiatry at Columbia University and president-elect of the American Psychiatric Association.

Indeed, the N.R.A. itself, in response to the massacre in Newtown, argued that mental illness, and not the guns themselves, was at the root of recent shooting sprees. The group called for a national registry of people with mental illness — an alternative that legal experts agree would raise at least as many constitutional alarms as the banning of gun ownership.

For mental health groups, the proposals under consideration are tantalizing: By increasing services for those with mental illness, they raise the possibility of restoring some of the billions of dollars cut from mental health programs in recent years as budgets tightened in the financial downturn. The measures also hold out hope for improvement of a mental health system that many experts say is fragmented and drastically inadequate. And some proposals — those to revise commitment laws, for example — have the support of some mental health organizations.

But some mental health and legal experts say that politicians’ efforts might be better spent making the process of involuntary psychiatric commitment — and the criteria for restricting firearms access once someone has been forcibly committed — consistent from state to state. And some proposals have caused concern, raising questions about doctor-patient confidentiality, the rights of people with psychiatric disabilities and the integrity of clinical judgment.

Especially troublesome to some mental health advocates are provisions like New York’s, which expand the duty of practitioners to report worrisome patients — a model likely to be emulated by other states. New York’s law, part of a comprehensive package to address gun violence, requires reporting to the local authorities any patient “likely to engage in conduct that would result in serious harm to self or others.” Law enforcement officials would then be authorized to confiscate any firearm owned by such a patient.

John Monahan, a psychologist and professor of law at the University of Virginia, said that such laws are often superfluous.

Although many mental health practitioners mistakenly believe that federal laws like the Health Insurance Portability and Accountability Act forbid them to disclose information about patients, such statutes already include exceptions that permit clinicians to give information to the authorities when a patient presents a threat to others, Dr. Monahan said.

Most states also have laws requiring mental health professionals to notify the authorities and any intended victim when a patient makes a direct threat.

New York’s provision, Dr. Monahan said, differs from virtually every other state’s laws in allowing guns to be taken not only from those committed against their will but also from patients who enter treatment voluntarily.

“The devil is in the details,” he said of New York’s new law. “The two fears are that people will be deterred from seeking treatment that they need or that, once they are in treatment, they will clam up and not talk about violence.”

Most mental health experts agree that the link between mental illness and violence is not imaginary. Studies suggest that people with an untreated severe mental illness are more likely to be violent, especially when drug or alcohol abuse is involved. And many rampage killers have some type of serious mental disorder: James E. Holmes, accused of opening fire in a movie theater in Colorado in July, was seeing a psychiatrist who became alarmed about his behavior; Jared L. Loughner, who killed 6 people and injured 13 others in Arizona, including former Representative Gabrielle Giffords, was severely mentally ill.

But such killings account for only a tiny fraction of gun homicides in the United States, mental health experts point out. Besides the research indicating that little violent crime can be linked to perpetrators who are mentally ill, studies show that those crimes are far more likely to involve battery — punching another person, for example — than weapons, which account for only 2 percent of violent crimes committed by the mentally ill.

Because of this, some criminal justice experts say it makes more sense to pass laws addressing behavior, rather than a diagnosis of mental illness. In Indiana, for example, firearms can be confiscated from people deemed a potential threat, whether or not they have a mental illness.

Proposals in a number of states seek to redefine the threshold for involuntary commitment to psychiatric treatment. But in doing so, they have reignited a longstanding debate about the role of forced treatment.

In Ohio, lawmakers are expected to consider a proposal to increase access to outpatient commitment instead of hospitalization, while also doing away with language requiring people with mental illness to show a “grave and imminent risk to substantial rights” of themselves or others before they can be committed.

In Colorado, where legislators are undertaking a broad overhaul of the state’s mental health system proposed by Gov. John W. Hickenlooper, a Democrat, the proposal also includes changing the criteria for involuntary commitment.

Under the state’s current laws, caregivers can place patients on 72-hour mental health holds only if they are believed to pose an “imminent danger” to themselves or others. The governor’s plan would allow caregivers to commit people if they believe there is a “substantial probability” of harm. Virginia and some other states already have standards based on “substantial probability.”

But some mental health advocates are wary about lowering the threshold. “The evidence that we have tells us that that’s not an appropriate solution, it’s not an effective solution to this problem,” said Jennifer Mathis, deputy legal director at the Bazelon Center for Mental Health Law, an advocacy group for people with psychiatric disabilities.

But Cheryl Miller — whose 21-year-old son, Kyle, was shot by the police last June after he pointed a toy gun at them — believes that a revised law might have saved her child.

Two weeks before Kyle was killed she took him to an emergency mental health clinic to get him hospitalized. But the staff refused to commit him.

“I said, ‘I don’t want to take him home; he needs to go to the hospital,’ ” Ms. Miller said. “They didn’t think so. It goes back to, was he an imminent danger to himself? And it was ‘No.’ ”

    Focus on Mental Health Laws to Curb Violence Is Unfair, Some Say, NYT, 31.1.2013,
    http://www.nytimes.com/2013/02/01/us/
    focus-on-mental-health-laws-to-curb-violence-is-unfair-some-say.html

Invitation to a Dialogue: Forcing Treatment

January 29, 2013
The New York Times

To the Editor:

Recent tragic events have linked mental illness and violence. Some people — I, for one — consider this link dangerously stigmatizing. People with mental illness are far more likely to be victims of violence than perpetrators. Moreover, psychiatrists have limited capacity to reliably predict violence. Nonetheless, these events increase pressure to identify people who might conceivably commit violent acts, and to mandate treatment with antipsychotic medications.

For a tiny minority of patients who have committed serious crimes, mandated treatment can be effective, particularly as an alternative to incarceration. But for most patients experiencing psychotic states, mandated treatment may create more problems than it solves.

For many medical conditions, better outcomes occur when patients share in treatment design and disease management. Imposed treatments tend to engender resistance and resentment. This is also true for psychiatric conditions.

Patients with psychotic symptoms often feel that their own experience is dismissed as meaningless, like the ravings of an intoxicated or delirious person. Decisions to decline antipsychotic medications are often regarded mainly as a manifestation of illness — an illness the person is too sick to recognize — even though many people might reject antipsychotics because of metabolic and other toxicities.

When a clearly troubled person firmly believes that he or she needs no help, there are no simple answers. These situations are particularly agonizing for families. Safety is paramount — and at times can be elusive. Still, if psychiatrists humbly try to understand the person on his or her own terms, do not dismiss the person’s experience as meaningless and truly respect the person’s choices about treatment, sometimes this opens the way to an effective treatment relationship. For some suffering and alienated people — certainly not all — feeling respectfully understood can be a critical step toward recovery.

Mandated treatment is a blunt instrument that may drive more people away from seeking care than it compels into care.

CHRISTOPHER GORDON
Framingham, Mass., Jan. 28, 2013

The writer is a psychiatrist and an associate clinical professor of psychiatry

at Harvard Medical School.

    Invitation to a Dialogue: Forcing Treatment, NYT, 29.1.2013,
    http://www.nytimes.com/2013/01/30/opinion/invitation-to-a-dialogue-forcing-treatment.html

An Oil Boom Takes a Toll on Health Care

January 27, 2013
The New York Times
By JOHN ELIGON

WATFORD CITY, N.D. — The patients come with burns from hot water, with hands and fingers crushed by steel tongs, with injuries from chains that have whipsawed them off their feet. Ambulances carry mangled, bloodied bodies from accidents on roads packed with trucks and heavy-footed drivers.

The furious pace of oil exploration that has made North Dakota one of the healthiest economies in the country has had the opposite effect on the region’s health care providers. Swamped by uninsured laborers flocking to dangerous jobs, medical facilities in the area are sinking under skyrocketing debt, a flood of gruesome injuries and bloated business costs from the inflated economy.

The problems have been acute at McKenzie County Hospital here. Largely because of unpaid bills, the hospital’s debt has climbed more than 2,000 percent over the past four years to $1.2 million, according to Daniel Kelly, the hospital’s chief executive. Just three years ago, Mr. Kelly added, the hospital averaged 100 emergency room visits per month; last year, that average shot up to 400.

Over all, ambulance calls in the region increased by about 59 percent from 2006 to 2011, according to Thomas R. Nehring, the director of emergency medical services for the North Dakota Health Department. The number of traumatic injuries reported in the oil patch increased 200 percent from 2007 through the first half of last year, he said.

The 12 medical facilities in western North Dakota saw their combined debt rise by 46 percent over the course of the 2011 and 2012 fiscal years, according to Darrold Bertsch, the president of the state’s Rural Health Association.

Hospitals cannot simply refuse to treat people or raise their rates. Expenses at those 12 facilities increased by 15 percent, Mr. Bertsch added, and nine of them experienced operating losses. Costs are rising to hire and retain service staff members, as hospitals compete with fast food restaurants that pay wages of about $20 an hour.

“Plain and simple, those kinds of things are not sustainable,” he said.

Many of the new patients are transient men without health insurance or a permanent address in the area. In one of the biggest drivers of the hospital debt, patients give inaccurate contact information; when the time comes to collect payment, the patients cannot be found. McKenzie County Hospital has invested in new software that will help verify the information patients give on the spot.

Mr. Kelly has pushed for the state, which has a surplus of more than $1 billion, to allocate money intended for the oil region specifically to health care facilities in the area. He has also asked for the state to grant low-interest loans so hospitals can borrow money for facility improvements and for the governor to convene a task force to study health care issues in the oil patch.

Aides to Gov. Jack Dalrymple say he is taking steps to bolster medical training in the state, proposing to spend $68 million on a new medical school building at the University of North Dakota and $6 million to expand the nursing program at Lake Region State College. Mr. Dalrymple, a Republican, has also increased Medicaid financing for the state’s rural hospitals.

“Health care is certainly one of those areas that was targeted early on as we’ve seen growth out west,” said Jeffrey L. Zent, a spokesman for the governor.

Public utility numbers suggest that the population of Watford City has more than quadrupled to 6,500 over the past two years, Mr. Kelly said. In nearby Williston, considered the heart of the oil boom, the population, including temporary workers, has swelled to 25,000 to 33,000 from fewer than 15,000 in 2010, according to a study by North Dakota State University.

The huge population growth has produced new communities virtually overnight, creating logistical problems that affect the quality of medical care.

After a recent emergency call, Kelly Weathers, who has worked as a paramedic in the region for nearly 25 years, drove in circles with his team for about 15 minutes, searching for the address where they had been sent to treat a man who had hurt his back falling off a piece of equipment. But they could not find the street because a sign had not yet been erected. Eventually, a colleague of the injured man met the ambulance at the highway and escorted them to the site.

Mr. Weathers, who works for the Mountrail County Health Center in Stanley, said that in the past, “all the volunteers, they didn’t go by street signs.”

“It was like, ‘The corner store, third house to the north of that,’ ” he said. “So now, if you give them ‘62nd Avenue,’ they go, ‘Where’s that at?’ ”

Charles Quinn, 43, of Mississippi, has been working in the region for eight months repairing 18-wheelers. He said his job has its dangers because he often works under the trucks while they are running.

“It’s all kind of dangerous,” he said of the jobs in the oil patch. “There’s a lot more accidents around you because you got more people around you working.”

The cramped housing camps where many oil workers live can add to health issues. On a recent afternoon at McKenzie County Hospital, a man limped into the emergency room complaining about a dry, red patch of skin on his leg. Dr. Gary Ramage, the hospital’s sole full-time physician, said it was a bite from a brown recluse spider, which had most likely nested under the trailer where the man lives.

Since the oil industry started growing rapidly in the region, Dr. Ramage said, he has had to treat many more sexually transmitted diseases. Chlamydia rates in McKenzie County roughly doubled from 2010 to 2011.

With little money to spend, hospitals are struggling to finance sorely needed improvements and hire additional medical providers. McKenzie, which is six decades old, is a one-story brick building and has one room for emergencies. (A makeshift second emergency room was created from one of the inpatient rooms.) In a building across the street that houses a clinic, a narrow hallway with dark carpet is crowded with file drawers lining the walls.

Hospital executives are hoping to get the local government to approve a 1-cent sales tax increase so they can build a $55 million medical facility that would triple the size of the clinic, expand the emergency room, maintain the 24-bed hospital and increase space for other outpatient services like physical therapy. They have also spent the past year trying to hire two new doctors. Recruiting medical professionals to the area has long been a problem.

“Let’s be honest,” Mr. Kelly said. “People think they have to move to Siberia if they move to North Dakota.”

But for now, Dr. Ramage, a gregarious Canadian who has worked here for 18 years, is left shouldering much of the load. Before the oil boom started a few years back, Dr. Ramage covered both the clinic and the emergency room. Now he mostly works at the clinic, while the hospital hires roving physicians to cover the emergency room. He is well known in the community, and people call him at home when they are sick. But now, he does not know many of the patients he sees.

“My work is no longer small-town work,” he said. “My work has now been transformed from that of a small family practitioner to basically an E.R. doc.”

    An Oil Boom Takes a Toll on Health Care, NYT, 27.1.2013,
    http://www.nytimes.com/2013/01/28/us/boom-in-north-dakota-weighs-heavily-on-health-care.html

A Flood of Suits Fights Coverage of Birth Control

January 26, 2013
The New York Times
By ETHAN BRONNER

In a flood of lawsuits, Roman Catholics, evangelicals and Mennonites are challenging a provision in the new health care law that requires employers to cover birth control in employee health plans — a high-stakes clash between religious freedom and health care access that appears headed to the Supreme Court.

In recent months, federal courts have seen dozens of lawsuits brought not only by religious institutions like Catholic dioceses but also by private employers ranging from a pizza mogul to produce transporters who say the government is forcing them to violate core tenets of their faith. Some have been turned away by judges convinced that access to contraception is a vital health need and a compelling state interest. Others have been told that their beliefs appear to outweigh any state interest and that they may hold off complying with the law until their cases have been judged. New suits are filed nearly weekly.

“This is highly likely to end up at the Supreme Court,” said Douglas Laycock, a law professor at the University of Virginia and one of the country’s top scholars on church-state conflicts. “There are so many cases, and we are already getting strong disagreements among the circuit courts.”

President Obama’s health care law, known as the Affordable Care Act, was the most fought-over piece of legislation in his first term and was the focus of a highly contentious Supreme Court decision last year that found it to be constitutional.

But a provision requiring the full coverage of contraception remains a matter of fierce controversy. The law says that companies must fully cover all “contraceptive methods and sterilization procedures” approved by the Food and Drug Administration, including “morning-after pills” and intrauterine devices whose effects some contend are akin to abortion.

As applied by the Health and Human Services Department, the law offers an exemption for “religious employers,” meaning those who meet a four-part test: that their purpose is to inculcate religious values, that they primarily employ and serve people who share their religious tenets, and that they are nonprofit groups under federal tax law.

But many institutions, including religious schools and colleges, do not meet those criteria because they employ and teach members of other religions and have a broader purpose than inculcating religious values.

“We represent a Catholic college founded by Benedictine monks,” said Kyle Duncan, general counsel of the Becket Fund for Religious Liberty, which has brought a number of the cases to court. “They don’t qualify as a house of worship and don’t turn away people in hiring or as students because they are not Catholic.”

In that case, involving Belmont Abbey College in North Carolina, a federal appeals court panel in Washington told the college last month that it could hold off on complying with the law while the federal government works on a promised exemption for religiously-affiliated institutions. The court told the government that it wanted an update by mid-February.

Defenders of the provision say employers may not be permitted to impose their views on employees, especially when something so central as health care is concerned.

“Ninety-nine percent of women use contraceptives at some time in their lives,” said Judy Waxman, a vice president of the National Women’s Law Center, which filed a brief supporting the government in one of the cases. “There is a strong and legitimate government interest because it affects the health of women and babies.”

She added, referring to the Centers for Disease Control and Prevention, “Contraception was declared by the C.D.C. to be one of the 10 greatest public health achievements of the 20th century.”

Officials at the Justice Department and the Health and Human Services Department declined to comment, saying the cases were pending.

A compromise for religious institutions may be worked out. The government hopes that by placing the burden on insurance companies rather than on the organizations, the objections will be overcome. Even more challenging cases involve private companies run by people who reject all or many forms of contraception.

The Alliance Defending Freedom — like Becket, a conservative group — has brought a case on behalf of Hercules Industries, a company in Denver that makes sheet metal products. It was granted an injunction by a judge in Colorado who said the religious values of the family owners were infringed by the law.

“Two-thirds of the cases have had injunctions against Obamacare, and most are headed to courts of appeals,” said Matt Bowman, senior legal counsel for the alliance. “It is clear that a substantial number of these cases will vindicate religious freedom over Obamacare. But it seems likely that the Supreme Court will ultimately resolve the dispute.”

The timing of these cases remains in flux. Half a dozen will probably be argued by this summer, perhaps in time for inclusion on the Supreme Court’s docket next term. So far, two- and three-judge panels on four federal appeals courts have weighed in, granting some injunctions while denying others.

One of the biggest cases involves Hobby Lobby, which started as a picture framing shop in an Oklahoma City garage with $600 and is now one of the country’s largest arts and crafts retailers, with more than 500 stores in 41 states.

David Green, the company’s founder, is an evangelical Christian who says he runs his company on biblical principles, including closing on Sunday so employees can be with their families, paying nearly double the minimum wage and providing employees with comprehensive health insurance.

Mr. Green does not object to covering contraception but considers morning-after pills to be abortion-inducing and therefore wrong.

“Our family is now being forced to choose between following the laws of the land that we love or maintaining the religious beliefs that have made our business successful and have supported our family and thousands of our employees and their families,” Mr. Green said in a statement. “We simply cannot abandon our religious beliefs to comply with this mandate.”

The United States Court of Appeals for the 10th Circuit last month turned down his family’s request for a preliminary injunction, but the company has found a legal way to delay compliance for some months.

These cases pit the First Amendment and a religious liberty law against the central domestic policy of the Obama administration, likely affecting many tens of thousands of employees. The First Amendment says that “Congress shall make no law respecting an establishment of religion, or prohibiting the free exercise thereof,” and much attention has been focused in the past two decades on the issue of “free exercise,” meaning preventing governmental interference with religious practices.

Free-exercise cases in recent years have been about the practices of small groups — the use of a hallucinogen by a religious group, for example — rather than something as central as the Affordable Care Act.

The cases also test the contours of a 1993 law known as the Religious Freedom Restoration Act. The law prohibits the federal government from imposing a “substantial burden” on any religious practice without a “compelling state interest.” The burden must also be the least restrictive possible.

Professor Laycock of the University of Virginia said: “The burden is clear especially for religious organizations, which ought to be able to run themselves in accordance with their religious teachings. They are being asked to pay for medications they view as evil.” He added that because the health care law had many exceptions, including for very small companies, the government might find it hard to convince the courts that contraception coverage is, in fact, a compelling interest.

But William Marshall, a First Amendment scholar at the University of North Carolina Law School, said the Supreme Court asserted in a 1990 opinion by Justice Antonin Scalia that religious groups had a big burden in overcoming “a valid and neutral law of general applicability.”

“You could have an objection of conscience to anything the government wants you to do — pay taxes because they will go to war or to capital punishment, or having your picture on your driver’s license,” Mr. Marshall said. “The court has made clear that religious groups have no broad right for such exceptions.”

Mr. Laycock said that while judges are supposed to be neutral, they too can get caught up in the culture wars. Judges sympathetic to women’s sexual autonomy would probably come down on one side of the dispute, and those more concerned with religious liberty on the other, he said.

“There is a lot of political freight on this issue,” he said.

    A Flood of Suits Fights Coverage of Birth Control, NYT, 26.1.2013,
    http://www.nytimes.com/2013/01/27/health/
    religious-groups-and-employers-battle-contraception-mandate.html

The Last Calendar

January 22, 2013
The New York Times
By OLIVIA JUDSON

BY the time he was 76, my father was frail. His balance was poor and he had trouble walking. He lived alone in Baltimore in a big house full of stairs, and watching him come tottering down those stairs was terrifying. Each time, I thought he might fall. He refused to make the house safer — no stair lifts, no grab rails (they would disfigure the house, he said) — and would not consider living anywhere else. When my brother and his wife invited my father to move in, the invitation was vigorously declined. And we lived in three different cities, far apart.

To try to cope better with this situation, my brother and I created a shared Google calendar — an online calendar in which we could both make entries from wherever we happened to be. Each time either of us spoke to our father, we marked it in the calendar — what time of day it was, how he sounded, what we spoke about. (If one of us called and he did not answer, we marked that, too. Yes, we both have an obsessive streak.)

For example, on Oct. 13, 2009, at 1:30, I telephoned home, spoke to my father and wrote in the calendar that he was “just off to see the new doctor, writing a list of his medications. Nothing else to report; leaves starting to turn and it’s starting to get cold.” Later that afternoon, he called my brother and said that he liked the new doctor (she was “slim, tall, pretty, and seemed very nice”), and that he had indeed discussed his medications with her.

The upshot was that we had an excellent record of how he was — whether he was getting out, if he was cheerful or feeling low, changes to his medicines, any falls he said he had had. The calendar also allowed us to make sure that one of us spoke to him just about every day. And if I couldn’t reach him, I didn’t have to wonder if he was lying hurt and helpless at the bottom of the stairs for days — I could look at the calendar and see that my brother had spoken to him a few hours ago.

We never told my father we did this — he probably would have been furious. There is, after all, something weird about the idea that people are taking notes on you, however loving their motives. It was our imperfect solution to an imperfect setup. And it helped us.

Just before his 79th birthday, my father started collapsing. First, he fell in the street. He thought he had tripped, but he wasn’t sure. Then he fell several times in the house (fortunately, not while on the stairs). The calendar provided a full record of it — and we could both see that there was something new, something abnormal. It turned out that his heart was stopping. My brother flew down and took him to a hospital, where he had a pacemaker put in.

But the calendar had other, more subtle effects, too. It was, in essence, a journal kept by two people who read each other’s entries, and so it gradually became a conversation between the two of us as well as a straight-up record of events. One day, he’s infuriating my brother with speculations about two friends’ having an inappropriate affair: “I said I thought he was being outrageous and that it was none of his business, even if his wild speculations were true. I hope he has the sense not to say anything to anyone else about his unfounded, wild, no evidence claims.” Another day, I’m remarking, “I’m worried by the extent to which he does not seem to cook for himself anymore.”

As you might expect, there are times when reading someone else’s journal entries is disquieting and revealing. I discovered aspects of my brother’s relationship with our father that I hadn’t appreciated. One of his entries said: “Asked about my accident (first time).” This was more than a year after my brother had been hit by a car and badly hurt. My heart cracked: I had not realized how inattentive my father had been.

Going back through the calendar now, more than 18 months after my father died, the entries chart a relentless physical decline — profound fatigue, sore hips and knees, aching wrists, swollen legs, inflamed teeth, increasing forgetfulness, the savage indignities of old age. One day, he took a bath but couldn’t get out of the tub. Luckily, the housekeeper arrived; she couldn’t get him out either, so she recruited the postman to help. My father thought this was hilarious: I admired his ability to laugh.

For through it all, there’s such courage. Yes, he’s just had a pacemaker installed and he’s feeling rotten, but he’s making strawberry jam. One day, “He sounded very low — lonely, old, and scared.” But another, he’s reading a history of some sinister French aristocrats and planning to install a wood stove in the fireplace. A beloved friend is coming to stay. He’s just learned a new poem.

At the time, I was glad we kept the calendar because it helped us to cope with a difficult situation. Now I’m glad for a different reason: it helps me remember small details about him, the little things that slip out of memory, that fade with time. Laughs, tears, worries, frustrations, joy and love — it’s all in the calendar.

Olivia Judson is a writer and an evolutionary biologist.

    The Last Calendar, NYT, 22.1.2013,
    http://www.nytimes.com/2013/01/23/opinion/the-last-calendar.html

Please Take Away My Right to a Gun

January 18, 2013
The New York Times
By WENDY BUTTON

A FEW years ago, I awoke at 2:30 a.m. to more than a “rapping, rapping at my chamber door.” It was a full-force pounding of a body trying to break into my little house in Washington, D.C. It was the sound and scenario that, as a single woman living alone, I feared more than spiders in the house.

Because I was writing political speeches at the time, my BlackBerry slept on the pillow beside me. I grabbed it and looked out my bedroom window at the stoop below. There he was: tall, dark clothes, big. He backed up and then raced to the door, pounding his body against it. Then he kicked at it the way actors take boots to the heads of bad guys in the movies.

I dialed 911 and ran downstairs, my 100-pound Newfoundland with me.

I gave the dispatcher my address, let her know that I lived around the corner from a police station and said, “Please hurry.” She heard the loud noise and remained on the line with me.

I put the BlackBerry on speaker and pushed a heavy armchair toward the door. I watched as the wood expanded with each pound. The white paint splintered some. The deadbolt held at the top, but the bottom half of the door popped open, letting in the steam heat from the summer night. I took that chair and slammed it so the side pushed the door back in line with the frame. I held that chair with everything my 5 foot 3 inches had. My dog sat right by me on the rug, ready.

“The police are outside,” the dispatcher said.

I let go of the chair’s arms and thanked the woman for staying on the phone with me. I answered the questions from the police and looked at the drunk man in the back of the patrol car, kicking at the seats. When they left, I pushed the couch, chair, coffee table and even a lamp in front of the locked door. I did that every night for a week until a steel-gated security door was installed.

And then, I did more.

I considered buying a gun. The threat of violence rattles you like that. What rolled round my head after that dark morning was: what if I hadn’t heard the noise, what if it’s different next time? While I held that chair with all of my strength, I wished that I had had a gun because if he had gotten in, then I could have pointed it at him, maybe deterred him and if necessary pulled the trigger.

So I looked at guns. Some had mother-of-pearl handles and looked like something Mae West would use in a movie. Others were Glocks, shotguns and rifles. I had gone as far as to dial the number of the Metropolitan Police Department’s firearms registration division and begin the process. Then I stopped and put my BlackBerry down.

I remembered who I am.

I am one of the millions of people in this country who live with depression. I knew that in the gun registration form there would be a version of this question: Have you ever voluntarily or involuntarily been committed to a hospital? The answer is yes — voluntarily. But because my hospitalization was years earlier and I wasn’t in treatment at the time, I could have gotten a gun.

My depression appeared for the first time in the late ’90s, right before I began writing for politicians. It comes and goes like fog. Medicine can help. I have my tricks to manage and get through it. Sometimes it sticks around for a day or a week, and sometimes it stays away for a couple of years. But it never leads me to sleep all day, cry and wear sweat pants like the people in the commercials. You’d look at me and never know that sometimes my fight against the urge to die is so tough the only way I get through it is second by second; I live by the second hand.

According to the Centers for Disease Control and Prevention, 38,364 Americans lost that fight in 2010 and committed suicide; 19,392 used a gun. No one ever attempted to break down my door in the early morning again, but I had an episode when my depression did come back in full force in the early winter of 2009, after I made a career-ending decision and isolated myself too much; on a January night in 2010; and again in May 2012, after testifying in the federal criminal trial of John Edwards, my former boss. If I had purchased that gun and it had been in my possession, I’m not sure I would have been able to resist and would be here typing these words.

The other day, the president and the vice president announced their plans to curb gun violence in the wake of the shooting in Newtown, Conn. I agree with all of their measures. But I believe they should be bolder and stop walking on eggshells about what to do with people like me and those not even close to being like me but still labeled with the crazy term “mentally ill.” The executive actions the president signed to increase access and treatment are all good, although the experts will struggle with confidentiality and privacy issues.

But since most people like me are more likely to harm ourselves than to turn into mass-murdering monsters, our leaders should do more to keep us safe from ourselves.

Please take away my Second Amendment right. Do more to help us protect ourselves because what’s most likely to wake me in the early hours isn’t a man’s body slamming at my door but depression, that raven, tapping, rapping, banging for relief.

I have a better chance of surviving if I never have the option of being able to pull the trigger.

Wendy Button is a former political speechwriter.

    Please Take Away My Right to a Gun, NYT, 18.1.2013,
    http://www.nytimes.com/2013/01/19/opinion/please-take-away-my-right-to-a-gun.html

Warning Signs of Violent Acts Often Unclear

January 15, 2013
The New York Times
By BENEDICT CAREY and ANEMONA HARTOCOLLIS

No one but a deeply disturbed individual marches into an elementary school or a movie theater and guns down random, innocent people.

That hard fact drives the public longing for a mental health system that produces clear warning signals and can somehow stop the violence. And it is now fueling a surge in legislative activity, in Washington and New York.

But these proposed changes and others like them may backfire and only reveal how broken the system is, experts said.

“Anytime you have one of these tragic cases like Newtown, it’s going to expose deficiencies in the mental health system, and provide some opportunity for reform,” said Richard J. Bonnie, a professor of public policy at the University of Virginia’s law school who led a state commission that overhauled policies after the 2007 Virginia Tech shootings that left 33 people dead. “But you have to be very careful not to overreact.”

New York State legislators on Tuesday passed a gun bill that would require therapists to report to the authorities any client thought to be “likely to engage in” violent behavior; under the law, the police would confiscate any weapons the person had.

And in Washington, lawmakers said that President Obama was considering a range of actions as part of a plan to reduce gun violence, including more sharing of records between mental health and law enforcement agencies.

The White House plan to make use of mental health data was still taking shape late Tuesday. But several ideas being discussed — including the reporting provision in the New York gun law — are deeply contentious and transcend political differences.

Some advocates favored the reporting provision as having the potential to prevent a massacre. Among them was D. J. Jaffe, founder of the Mental Illness Policy Org., which pushes for more aggressive treatment policies. Some mass killers “were seen by mental health professionals who did not have to report their illness or that they were becoming dangerous and they went on to kill,” he said.

Yet many patient advocates and therapists strongly disagreed, saying it would intrude into the doctor-patient relationship in a way that could dissuade troubled people from speaking their minds, and complicate the many judgment calls therapists already have to make.

The New York statute requires doctors and other mental health professionals to report any person who “is likely to engage in conduct that would result in serious harm to self or others.”

Under current ethical guidelines, only involuntary hospitalizations (and direct threats made by patients) are reported to the authorities. These reports then appear on a federal background-check database. The new laws would go further.

“The way I read the new law, it means I have to report voluntary as well as involuntary hospitalizations, as well as many people being treated for suicidal thinking, for instance, as outpatients,” said Dr. Paul S. Appelbaum, director of the Division of Law, Ethics, and Psychiatry at Columbia University’s medical school. “That is a much larger group of people than before, and most of whom will never be a serious threat to anyone.”

One fundamental problem with looking for “warning signs” is that it is more art than science. People with serious mental disorders, while more likely to commit aggressive acts than the average person, account for only about 4 percent of violent crimes over all.

The rate is higher when it comes to rampage or serial killings, closer to 20 percent, according to Dr. Michael Stone, a New York forensic psychiatrist who has a database of about 200 mass and serial killers. He has concluded from the records that about 40 were likely to have had paranoid schizophrenia or severe depression or were psychopathic, meaning they were impulsive and remorseless.

“But most mass murders are done by working-class men who’ve been jilted, fired, or otherwise humiliated — and who then undergo a crisis of rage and get out one of the 300 million guns in our country and do their thing,” Dr. Stone said.

The sort of young, troubled males who seem to psychiatrists most likely to commit school shootings — identified because they have made credible threats — often do not qualify for any diagnosis, experts said. They might have elements of paranoia, of deep resentment, or of narcissism, a grandiose self-regard, that are noticeable but do not add up to any specific “disorder” according to strict criteria.

“The really scary ones, you have a gut feeling right away when you talk to them,” said Dr. Deborah Weisbrot, director of the outpatient clinic of child and adolescent psychiatry at Stony Brook University, who has interviewed about 200 young people, mostly teenage boys, who have made threats. “What they have in common is a kind of magical thinking, odd beliefs like they can read other people’s minds, or see the future, or that things happening in their dreams come true.”

Even if such instincts could be relied on, the mental health system is so fragmented in the country that it is hard to know whether the information would get to the right person in time. According to Dr. Bonnie, the Virginia law professor, the Virginia Tech gunman was ordered to outpatient treatment by a judge more than a year before his rampage but was never hospitalized, which would have shown up on a background check.

The state database now includes such cases, after the reforms. “But we’re a state that has a centralized database like that; in many states there’s no one place to get it all; it’s all kept locally, community by community,” Dr. Bonnie said.

The federal background check database, which is supposed to have updated information from states, has only a patchwork, because of the wide variety of state laws on reporting, experts said. Even if it were entirely up to date, it would not catch the many millions who never see a mental health professional despite deep distress.

Some experts, like Dr. Appelbaum, say the Connecticut school shooting offers the kind of opportunity that only comes once every generation or two: to rethink the entire mental health system. It might include appointing a presidential commission; re-envisioning community mental health care; focusing more on vigilance for problems in young people, and reducing stigma.

“It seems to me an opportunity to step back and rethink what the entire system should look like,” Dr. Appelbaum said.

    Warning Signs of Violent Acts Often Unclear, NYT, 15.1.2013,
    http://www.nytimes.com/2013/01/16/health/breaking-link-of-violence-and-mental-illness.html

New York Has Gun Deal, With Focus on Mental Ills

January 14, 2013
The New York Times
By THOMAS KAPLAN and DANNY HAKIM

ALBANY — Gov. Andrew M. Cuomo and lawmakers agreed on Monday to a broad package of changes to gun laws that would expand the state’s ban on assault weapons and would include new measures to keep guns away from the mentally ill.

The state Senate, controlled by a coalition of Republicans and a handful of Democrats, approved the legislative package just after 11 p.m. by a lopsided vote of 43 to 18. The Assembly, where Democrats who have been strongly supportive of gun control have an overwhelming majority, planned to vote on the measure Tuesday.

Approval of the legislation would make New York the first state to act in response to the mass shooting at an elementary school in Newtown, Conn., last month.

Mr. Cuomo, a Democrat, had pressed lawmakers to move quickly in response to Newtown, saying, “the people of this state are crying out for help.” And the Legislature proceeded with unusual haste: Monday was the first full day of this year’s legislative session.

“We don’t need another tragedy to point out the problems in the system,” Mr. Cuomo said at a news conference.

“Enough people have lost their lives,” he added. “Let’s act.”

The expanded ban on assault weapons would broaden the definition of such weapons, banning semiautomatic pistols and rifles with detachable magazines and one military-style feature, as well as semiautomatic shotguns with one military-style feature. New Yorkers who already own such guns could keep them but would be required to register them with the state.

“The message out there is so clear after Newtown,” said the Assembly speaker, Sheldon Silver, a Democrat from Manhattan. “To basically eradicate assault weapons from our streets in New York as quickly as possible is something the people of this state want.”

In an acknowledgment that many people have suggested that part of the solution to gun violence is a better government response to mental illness, the legislation includes not only new restrictions on gun ownership, but also efforts to limit access to guns by the mentally ill.

The most significant new proposal would require mental health professionals to report to local mental health officials when they believe that patients are likely to harm themselves or others. Law enforcement would then be authorized to confiscate any firearm owned by a dangerous patient; therapists would not be sanctioned for a failure to report such patients if they acted “in good faith.”

“People who have mental health issues should not have guns,” Mr. Cuomo told reporters. “They could hurt themselves, they could hurt other people.”

But such a requirement “represents a major change in the presumption of confidentiality that has been inherent in mental health treatment,” said Dr. Paul S. Appelbaum, the director of the Division of Law, Ethics, and Psychiatry at the Columbia University College of Physicians and Surgeons, who said the Legislature should hold hearings on possible consequences of the proposal.

“The prospect of being reported to the local authorities, even if they do not have weapons, may be enough to discourage patients with suicidal or homicidal thoughts from seeking treatment or from being honest about their impulses,” he said.

The legislation would extend and expand Kendra’s Law, which empowers judges to order mentally ill patients to receive outpatient treatment.

And it would require gun owners to keep weapons inaccessible in homes where a resident has been involuntarily committed, convicted of a crime or is the subject of an order of protection.

The legislative package, which Mr. Cuomo said he believed would be “the most comprehensive package in the nation,” would ban any gun magazine that can hold over 7 rounds of ammunition — the current limit is 10 rounds. It would also require background checks of ammunition buyers and automated alerts to law enforcement of high-volume purchases.

The legislation would increase penalties for multiple crimes committed with guns, would require background checks for most private gun sales, and create a statewide gun-registration database.

Senator Jeffrey D. Klein of the Bronx, the leader of an independent faction of Democrats who have allied with the Republicans to control the Senate, said the measure met the goals of many lawmakers.

“Republicans, it’s very clear, wanted harsher criminal penalties for illegal guns, which is something I agree with,” Mr. Klein added, “but on the other hand we’re also going to ban assault weapons and limit the number of rounds in a magazine. So I think putting those two things together makes it a better bill.”

Among the other elements of the proposed legislation were a so-called Webster provision, named for the shooting deaths of two firefighters in Webster, near Rochester, just before Christmas. The provision would mandate a life sentence without parole for anyone who murders a first responder.

And, in response to a controversy that erupted after The Journal News, a daily newspaper, published the names and addresses of handgun permit holders in Westchester and Rockland Counties, the legislation would prohibit disclosure of the names in the new statewide gun-registration database, and would allow individuals to exempt their own names and addresses from being disclosed by counties that have such databases.

The guns package was negotiated privately by the governor and legislative leaders over the last several weeks, but was only completed late Monday; rank-and-file Senators had only a few minutes to read the legislation before voting on it. Mr. Cuomo, saying, “If there is an issue that fits the definition of necessity, I believe it’s gun violence,” waived the normal three-day waiting period between introduction of new legislation and a vote.

The minority leader in the Assembly, Brian M. Kolb, a Republican from Canandaigua, objected to the move to expedite the process, saying, “I don’t think we should be rushing things just for the sake of headlines.”

By the time the Senate began to discuss the bill late Monday night, the galleries that overlook the chamber were mostly empty of spectators. A parade of Democrats, who have long pressed for new gun laws, rose to praise the bill as they explained their votes.

Senator Malcolm A. Smith, an independent Democrat from Queens, said provisions of the measure could be dedicated to the family members of New Yorkers who had been victims of gun violence.

“I think today we are setting the mark for the rest of the country,” he said.

Most of the senators who voted against the bill did not speak. One who did, Senator Kathleen A. Marchione, a Republican from Saratoga County, praised some parts of the measure, like the expansion of Kendra’s Law. But she said the new restrictions on guns would not get at the problem of gun violence.

“I truly believe that the Second Amendment constitutional freedoms of every New Yorker tonight has been weakened,” she said, adding, “Law-abiding citizens who own guns are not our problem. Law-abiding citizens understand and know how to take care of their guns, not to be a danger to others.”

    New York Has Gun Deal, With Focus on Mental Ills, NYT, 14.1.2013,
    http://www.nytimes.com/2013/01/15/nyregion/
    new-york-legislators-hope-for-speedy-vote-on-gun-laws.html

Susan Nolen-Hoeksema,

Psychologist Who Studied Depression in Women,

Dies at 53

January 13, 2013
The New York Times
By BENEDICT CAREY

Susan Nolen-Hoeksema, a psychologist and writer whose work helped explain why women are twice as prone to depression as men and why such low moods can be so hard to shake, died on Jan. 2 in New Haven. She was 53.

Her death followed heart surgery to correct a congenitally weak valve, said her husband, Richard Nolen-Hoeksema.

Dr. Nolen-Hoeksema, a professor at Yale University, began studying depression in the 1980s, a time of great excitement in psychiatry and psychology. New drugs like Prozac were entering the market; novel talking therapies were proving effective, too, particularly cognitive behavior therapy, in which people learn to defuse upsetting thoughts by questioning their basis.

Her studies, first in children and later in adults, exposed one of the most deceptively upsetting of these patterns: rumination, the natural instinct to dwell on the sources of problems rather than their possible solutions. Women were more prone to ruminate than men, the studies found, and in a landmark 1987 paper she argued that this difference accounted for the two-to-one ratio of depressed women to depressed men.

She later linked rumination to a variety of mood and behavior problems, including anxiety, eating disorders and substance abuse.

“The way I think she’d put it is that, when bad things happen, women brood — they’re cerebral, which can feed into the depression,” said Martin Seligman, a professor of psychology at the University of Pennsylvania, who oversaw her doctoral work. “Men are more inclined to act, to do something, plan, beat someone up, play basketball.”

Dr. Seligman added, “She was the leading figure in sex differences in depression of her generation.”

Dr. Nolen-Hoeksema wrote several books about her research for general readers, including “Women Who Think Too Much: How to Break Free of Overthinking and Reclaim Your Life.” These books described why rumination could be so corrosive — it is deeply distracting; it tends to highlight negative memories — and how such thoughts could be alleviated.

Susan Kay Nolen was born on May 22, 1959, in Springfield, Ill., to John and Catherine Nolen. Her father ran a construction business, where her mother was the office manager; Susan was the eldest of three children.

She entered Illinois State University before transferring to Yale. She graduated summa cum laude in 1982 with a degree in psychology.

After earning a Ph.D. in psychology at the University of Pennsylvania, she joined the faculty at Stanford. She later moved to the University of Michigan, before returning to Yale in 2004.

Along the way she published scores of studies and a popular textbook. In 2003 she became the editor of the Annual Review of Clinical Psychology, an influential journal.

Dr. Nolen-Hoeksema moved smoothly between academic work and articles and books for the general reader.

“I think part of what allowed her to move so easily between those two worlds was that she was an extremely clear thinker, and an extremely clear writer,” said Marcia K. Johnson, a psychology professor and colleague at Yale.

Dr. Nolen-Hoeksema lived in Bethany, Conn. In addition to her husband, a science writer, she is survived by a son, Michael; her brothers, Jeff and Steve; and her father, John.

“Over the past four decades women have experienced unprecedented growth in independence and opportunities,” Dr. Nolen-Hoeksema wrote in 2003, adding, “We have many reasons to be happy and confident.”

“Yet when there is any pause in our daily activities,” she continued, “many of us are flooded with worries, thoughts and emotions that swirl out of control, sucking our emotions and energy down, down, down. We are suffering from an epidemic of overthinking.”

    Susan Nolen-Hoeksema, Psychologist Who Studied Depression in Women, Dies at 53,
    NYT,13.1.2013, http://www.nytimes.com/2013/01/14/us/
    susan-nolen-hoeksema-psychologist-who-studied-depression-in-women-dies-at-53.html

The Woes of Roe

January 9, 2013
The New York Times
By GAIL COLLINS

Forty years ago this month, the Supreme Court handed down the great abortion rights decision Roe v. Wade. To be honest, you’re not going to be seeing a whole lot of cake and Champagne. Time magazine recognized the occasion with a downbeat cover story. (“They’ve Been Losing Ever Since.”) Gallup polls suggest support for abortion rights is fading, particularly among young Americans, and that more people now regard themselves as “pro-life” than “pro-choice.”

On the other hand — I know you had faith that eventually we’d get to the other hand — the polls depend on the question. According to the Quinnipiac poll, if you ask Americans whether they agree with the Roe decision, nearly two-thirds say yes.

It’s always been this way. Americans are permanently uncomfortable with the abortion issue, and they respond most positively to questions that suggest it isn’t up to them to decide anything. “Should be a matter between a woman and her doctor” is usually a popular option.

Whatever recent changes there are in public opinion may be less about abortion than about the term “pro-choice.” This week, Planned Parenthood unveiled a pile of new research, some of which suggests that younger women don’t like labels. Or at least not that one. “We’ve been discussing changing our name for the past year or so,” said Kelsey Warrick, a Georgetown University student who’s president of Hoyas for Choice.

Maybe it’s like feminism, a word with a glorious history that’s rejected by many young people who are staunchly in favor of women’s rights. Maybe, as Dawn Laguens, the executive vice president of Planned Parenthood, suggested at a press conference this week, it’s just that young women feel as though they’re up to their ears in choices already.

We may never know, although if pro-choice activists want to rebrand themselves the Movement for Leaving Women Alone, it’s likely nobody under the age of 50 would object.

One way or another, the abortion rights cause needs all the help it can get. Abortion clinics around the country are reeling under crazy new rules that make it impossible for them to operate. In Virginia, the state board of health is demanding that clinics follow the same architectural standards as hospitals, including 5-foot-wide hallways. In Texas, the Legislature is considering a law that would require that all abortions be performed in ambulatory surgical centers. When the state passed that requirement for pregnancies beyond 16 weeks in 2004, every single clinic doing that procedure was forced to shut down. Only a handful managed to reopen — in a state that encompasses more than 261,000 square miles.

In Mississippi, the state’s one and only abortion clinic, the Jackson Women’s Health Organization, is in danger of closing because of a new law requiring that any doctor who does abortions have admitting privileges at a local hospital. This would be less of a problem if the local hospitals were not all terrified of giving privileges to anybody who performs abortions. When the clinic tried to advertise for a doctor who already had the requisite affiliation, the state medical journal refused to take the ad.

“We’re just doing business as usual. Trying to be there for the women of Mississippi,” said Betty Thompson, the former director who stayed on after she retired and is now working as a counselor.

Over the last 40 years, women seeking abortions have been put through a lot of unnecessary trauma. Trips of hundreds of miles to the nearest clinic. Requirements that they have ultrasounds, or have ultrasounds and listen to the physician describe the ultrasound, or have ultrasounds and then wait 24 hours before the procedure. (In Texas, the doctor who does the abortion also has to conduct the ultrasound, creating a scheduling nightmare.)

They’re caught in the middle of a political fight over a deeply personal issue that leaves most Americans feeling uneasy. If you want to rack up a real positive response on a poll, ask people whether the women or the politicians should make decisions about their pregnancies. One of the surveys commissioned by Planned Parenthood showed 83 percent of likely voters picked the women, including 64 percent of those who called themselves pro-life.

If there’s been any permanent message in this long battle, that’s been it. No matter how conservative the state, sooner or later you will hit the point where the people object to politicians messing with a woman’s private business. Mississippi voters rejected a statewide referendum to give any fetus the right of “personhood.” Voters in South Dakota, another state with a single, struggling, abortion clinic, have twice rejected total abortion bans.

Every time the anti-abortion movement pushes too far, it reminds people that its cause, no matter how filled with moral fervor, is basically about imposing one particular theology on the rest of the country. Over the long run, the nervous, ambivalent, uncomfortable public won’t let that happen.

    The Woes of Roe, NYT, 9.1.2013,
    http://www.nytimes.com/2013/01/10/opinion/collins-the-woes-of-roe.html

Study Questions Effectiveness

of Therapy for Suicidal Teenagers

January 8, 2013
The New York Times
By BENEDICT CAREY

Most adolescents who plan or attempt suicide have already received at least some mental health treatment, raising questions about the effectiveness of current approaches to helping troubled youths, according to the largest in-depth analysis to date of suicidal behaviors in American teenagers.

The study, in the journal JAMA Psychiatry, found that 55 percent of suicidal teenagers had received some therapy before they thought about suicide, planned it or tried to kill themselves, contradicting the widely held belief that suicide is due in part to a lack of access to treatment.

The findings, based on interviews with a nationwide sample of more than 6,000 teenagers and at least one parent of each, linked suicidal behavior to complex combinations of mood disorders like depression and behavior problems like attention-deficit and eating disorders, as well as alcohol and drug abuse.

The study found that about one in eight teenagers had persistent suicidal thoughts at some point, and that about a third of those who had suicidal thoughts had made an attempt, usually within a year of having the idea.

Previous studies have had similar findings, based on smaller, regional samples. But the new study is the first to suggest, in a large nationwide sample, that access to treatment does not make a big difference.

The study suggests that effective treatment for severely suicidal teenagers must address not just mood disorders, but also behavior problems that can lead to impulsive acts, experts said. According to the Centers for Disease Control and Prevention, 1,386 people between the ages of 13 and 18 committed suicide in 2010, the latest year for which numbers are available.

“I think one of the take-aways here is that treatment for depression may be necessary but not sufficient to prevent kids from attempting suicide,” said Dr. David Brent, a professor of psychiatry at the University of Pittsburgh, who was not involved in the study. “We simply do not have empirically validated treatments for recurrent suicidal behavior.”

The report said nothing about whether the therapies given were state of the art or carefully done, said Matt Nock, a professor of psychology at Harvard and the lead author, and it is possible that some of the treatments prevented suicide attempts. “But it’s telling us we’ve got a long way to go to do this right,” Dr. Nock said. His co-authors included Ronald C. Kessler of Harvard and researchers from Boston University and Children’s Hospital Boston.

Margaret McConnell, a consultant in Alexandria, Va., said her daughter Alice, who killed herself in 2006 at the age of 17, was getting treatment at the time. “I think there might have been some carelessness in the way the treatment was done,” Ms. McConnell said, “and I was trusting a 17-year-old to manage her own medication. We found out after we lost her that she wasn’t taking it regularly.”

In the study, researchers surveyed 6,483 adolescents from the ages of 13 to 18 and found that 9 percent of male teenagers and 15 percent of female teenagers experienced some stretch of having persistent suicidal thoughts. Among girls, 5 percent made suicide plans and 6 percent made at least one attempt (some were unplanned).

Among boys, 3 percent made plans and 2 percent carried out attempts, which tended to be more lethal than girls’ attempts.

(Suicidal thinking or behavior was virtually unheard-of before age 10.)

Over all, about one-third of teenagers with persistent suicidal thoughts went on to make an attempt to take their own lives.

Almost all of the suicidal adolescents in the study qualified for some psychiatric diagnosis, whether depression, phobias or generalized anxiety disorder. Those with an added behavior problem — attention-deficit disorder, substance abuse, explosive anger — were more likely to act on thoughts of self-harm, the study found.

Doctors have tested a range of therapies to prevent or reduce recurrent suicidal behaviors, with mixed success. Medications can ease depression, but in some cases they can increase suicidal thinking. Talk therapy can contain some behavior problems, but not all.

One approach, called dialectical behavior therapy, has proved effective in reducing hospitalizations and suicide attempts in, among others, people with borderline personality disorder, who are highly prone to self-harm.

But suicidal teenagers who have a mixture of mood and behavior issues are difficult to reach. In one 2011 study, researchers at George Mason University reduced suicide attempts, hospitalizations, drinking and drug use among suicidal adolescent substance abusers. The study found that a combination of intensive treatments — talk therapy for mood problems, family-based therapy for behavior issues and patient-led reduction in drug use — was more effective than regular therapies.

“But that’s just one study, and it’s small,” said Dr. Brent of the University of Pittsburgh. “We can treat components of the overall problem, but that’s about all.”

Ms. McConnell said that her daughter’s depression had seemed mild and that there was no warning that she would take her life. “I think therapy does help a lot of people, if it’s handled right,” she said.

    Study Questions Effectiveness of Therapy for Suicidal Teenagers, NYT, 8.1.2013,
    http://www.nytimes.com/2013/01/09/health/gaps-seen-in-therapy-for-suicidal-teenagers.html

Growth of Health Spending Stays Low

January 7, 2013
The New York Times
By ROBERT PEAR

WASHINGTON — National health spending climbed to $2.7 trillion in 2011, or an average of $8,700 for every person in the country, but as a share of the economy, it remained stable for the third consecutive year, the Obama administration said Monday.

The rate of increase in health spending, 3.9 percent in 2011, was the same as in 2009 and 2010 — the lowest annual rates recorded in the 52 years the government has been collecting such data.

Federal officials could not say for sure whether the low growth in health spending represented the start of a trend or reflected the continuing effects of the recession, which crimped the economy from December 2007 to June 2009.

Kathleen Sebelius, the secretary of health and human services, said that “the statistics show how the Affordable Care Act is already making a difference,” saving money for consumers. But a report issued by the Centers for Medicare and Medicaid Services, in her department, said that the law had so far had “no discernible impact” on overall health spending.

Although some provisions of the law have taken effect, the report said, “their influence on overall health spending through 2011 was minimal.”

The recession increased unemployment, reduced the number of people with private health insurance, lowered household income and assets and therefore tended to slow health spending, said Micah B. Hartman, a statistician at the Centers for Medicare and Medicaid Services.

In the report, federal officials said that total national spending on prescription drugs and doctors’ services grew faster in 2011 than in the year before, but that spending on hospital care grew more slowly.

Medicaid spending likewise grew less quickly in 2011 than in the prior year, as states struggled with budget problems. But Medicare spending grew more rapidly, because of an increase in “the volume and intensity” of doctors’ services and a one-time increase in Medicare payments to skilled nursing homes, said the report, published in the journal Health Affairs.

National health spending grew at roughly the same pace as the overall economy, without adjusting for inflation, so its share of the economy stayed the same, at 17.9 percent in 2011, where it has been since 2009. By contrast, health spending accounted for just 13.8 percent of the economy in 2000.

Health spending grew more than 5 percent each year from 1961 to 2007. It rose at double-digit rates in some years, including every year from 1966 to 1984 and from 1988 to 1990.

The report did not forecast the effects of the new health care law on future spending. Some provisions of the law, including subsidized insurance for millions of Americans, could increase spending, officials said. But the law also trims Medicare payments to many health care providers and authorizes experiments to slow the growth of health spending.

“The jury is still out whether all the innovations we’re testing will have much impact,” said Richard S. Foster, who supervised the preparation of the report as chief actuary of the Medicare agency. “I am optimistic. There’s a lot of potential. More and more health care providers understand that the future cannot be like the past, in which health spending almost always grew faster than the gross domestic product.”

Evidence of the new emphasis can be seen in a series of articles published in The Archives of Internal Medicine, now known as JAMA Internal Medicine, under the title “Less Is More.” The series highlights cases in which “the overuse of medical care may result in harm and in which less care is likely to result in better health.”

Total spending for doctors’ services rose 3.6 percent in 2011, to $436 billion, while spending for hospital care increased 4.3 percent, to $850.6 billion.

Spending on prescription drugs at retail stores reached $263 billion in 2011, up 2.9 percent from 2010, when growth was just four-tenths of 1 percent. The latest increase was still well below the average increase of 7.8 percent a year from 2000 to 2010.

Federal officials said the increase in 2011 resulted partly from rapid growth in prices for brand-name drugs.

Prices for specialty drugs, typically prescribed by medical specialists for chronic conditions, have increased at double-digit rates in recent years, the government said. In addition, spending on new brand-name drugs — those brought to market in the previous two years — more than doubled from 2010 to 2011, driven by an increase in the number of new medicines.

“In 2011,” the report said, “spending for private health insurance premiums increased 3.8 percent, as did spending for benefits. Out-of-pocket spending by consumers increased 2.8 percent in 2011, accelerating from 2.1 percent in 2010 but still slower than the average annual growth rate of 4.7 percent” from 2002 to 2008.

Growth of Health Spending Stays Low,
NYT,
7.1.2013,
http://www.nytimes.com/2013/01/08/
us/health-spending-growth-stays-low-for-third-straight-year.html