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Broken mental-health system puts us at risk

Va. Tech & spate of other killings reveal danger of ignoring mental illness

By Arthur Caplan, Ph.D.

MSNBC contributor
Updated: 2:51 p.m. ET April 23, 2007

It isn't just guns. In all my life I never thought I'd write those words after a massacre involving a mass murder with a gun. But a week’s worth of intense media coverage of the heinous murders of students & faculty at Virginia Tech & analyses focusing on guns by innumerable experts has left me furious. 

I don’t think the expert wisdom is even close to understanding what must be done to try & prevent this type of tragedy in the future. It's not just guns. 

We need to fix a broken, abandoned & pathetic system of mental-health care.

In the same month that Seung-Hui Cho killed & injured scores of people at Virginia Tech, a researcher at the University of Washington was shot to death in her office by a former boyfriend, who then killed himself. Rebecca Griego had gotten a restraining order against Jonathan Rowan. When he showed up at her office he fired 5 shots into Rebecca. A colleague at the university said it was a “psycho from her past.”

In Mandeville, La., a man who had just had a restraining order issued against him by his estranged wife allegedly ambushed her & their 3 children. Police say James Magee chased his wife’s gray Toyota Scion for several blocks, ramming it repeatedly until the car crashed into a tree.

As Adrienne Magee tried to get out of the vehicle, James Magee allegedly stepped out of the truck & shot her in the head with a 12-gauge shotgun loaded with buckshot, killing her instantly. He then opened fire on his children as they tried to flee the vehicle, killing his 5-year-old son & striking his 7-year-old daughter in the chest, according to police.

Magee had never gotten any help for previous violent outbursts.

And in Queens, New York, a man killed his mother, a wheelchair-bound man & a home health care worker before shooting himself dead - just minutes after the mother called 911 pleading for help.

The mother's surviving sister blamed police for failing to protect her sister from the "mentally ill" son. "My sister was scared!" Annetta Taylor screamed. "She thought this might happen!"

Cops outside the house tried to calm her, but she continued. "I blame you!" she said. "She called & nobody would respond!"

The murdered mother, Sonia Taylor, had called police twice Monday during fights with her son Wade Dawkins.

The police had been called to the home 8 times since last May. During an incident this past October, Taylor told police her son, a drug abuser with no rap sheet, was throwing things around the house & acting violently.

The police brought him to a local hospital for an evaluation. He was quickly sent back to her house. 

All of these killings involved not just guns, all involved killers who might have benefited from mental-health treatment. None got the help they needed.

The Virginia Tech murderer was - to be blunt - totally crazy. He fit the dreary profile all too familiar from the shootings at Columbine High School near Denver & the Nickel Mines School in Amish country near Lancaster, Penn. Cho was an angry outcast, preoccupied with thoughts of violence against those whom he saw as bullying, victimizing or just plain ignoring him.

From the tapes he made of himself, it's obvious that he was in the grip of paranoia. He had profound social withdrawal, suicidal thinking, destructive fantasies & was a known stalker.

He scared people. But he fell thru the cracks of university bureaucracy & a hodgepodge mental-health system.

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Report after report over the past decade have warned that most public mental-health systems have, to quote one, “all but disintegrated.” Such systems, whether local, state or federal, are badly fragmented & ill-equipped to address our nation’s mental health in a comprehensive manner.

States have been balancing their budgets on the backs of the mentally ill for years. A recent example is North Carolina, where 33% cuts in the state budget have been proposed.  Advocates for the mentally ill there say that if the cuts hold, it means that in many towns the mental-health system will simply “collapse.” 

But you don’t really need to read the reports or look at the budgets.  Look out your window.  Most of the homeless people wandering around America’s cities are mentally ill. Try to get help for your anorexic daughter, alcoholic brother-in-law, suicidal spouse & see what happens.

See what happens if someone threatens or harasses you repeatedly in terms of a coordinated police & mental-health response.

Serving in Iraq or Afghanistan with post-traumatic stress disorder or another mental illness? Good luck. The military’s mental-health system is overwhelmed & understaffed. The services available to our soldiers’ families are just as bad.

I don’t buy the line that says "guns don’t kill people, people kill people." I think there are too many guns with too much firepower that are too readily available. When the damaged & the deranged amongst us go undiagnosed & untreated in a world of guns, then fatalities result. The guns aren't going anywhere. Politically, we lack the will to do anything about that problem. 

But that isn't the whole problem. It's time to start repairing a mental-health system that serves too few, costs too much, protects too little & can't even find the means to help those who clearly are in desperate need. Maybe after Virginia Tech we can at least find the will to do that much.

Arthur Caplan, Ph.D., is director of the Center for Bioethics at the University of Pennsylvania.

source: MSN Health

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A Path to Mental Health

By Bernadine Healy M.D.
Posted 4/29/07

A tortured young mind went on a deadly rampage two weeks ago, leaving families forever devastated, a campus weeping & a nation mourning. In the aftermath, it's only natural, if not obligatory, to seek explanations & look for ways we can prevent or mitigate such tragedy. The problem is complex. But at the center is a human being desperate for psychiatric intervention.

This catastrophic event, though rare, should be a wake-up call that we need to incorporate routine mental-health screening & prevention programs into adolescent medical care & school counseling. Such efforts could potentially thwart at least some of the psychopathy that underlies school shootings, since medicine now can help even the most severely ill. And they would also benefit the many young people struggling with far less extreme brain disorders.

The U.S. Secret Service, which studies "targeted violence," provides insight on the urgency of the need in its 2002 "Safe School Initiative" report: School attacks, instead of being the random impulsive acts of brawling rowdies, are well-planned events mostly carried out by a single student -who isn't evil but mentally ill.

Except for being male, the 41 attackers studied fit no profile of family background, race, ethnicity, or even academic performance. Many were A & B students. Few had a history of violent or criminal behavior. But their thoughts were of violence their behavior was often intimidating.

They frequently expressed violent themes in their writings, in one instance portraying homicide & suicide as solutions to feelings of despair. The perpetrators often had telegraphed to other students & teachers their depression or desperation & either talked about or had attempted suicide.

Feelings of persecution by others were common & led to festering resentment & anger.

Psychiatrists & psychologists recognize that these are red flags demanding medical intervention. Yet one of the most striking findings in the report was that the vast majority of these students never had a mental-health evaluation.

No wonder only 17% were diagnosed with a psychiatric illness - it wasn't looked for. That alone points to a huge mental health gap: If the distress of these students didn't trigger medical attention, it's unlikely that less severe struggles that are seen in as many as 15 to 20% of other students will do so. 

Still a chance. Yet the school years are a critical time in the development of minds & brains. In fact, the brain doesn't fully mature until late adolescence & early adulthood, when the prefrontal cortex undergoes the final stages of building & organization.

This area controls impulses, moral reasoning, judgment & rational thinking & accounts for that magical time parents yearn for when their emotion-driven teens morph into people capable of nuanced thinking.

This is also the time when two major brain illnesses emerge -schizophrenia, a disorder marked by irrational thought & bipolar or manic-depressive illness, a disorder of mood.

Henry Nasrallah, a schizophrenia researcher at the University of Cincinnati, notes that the experiences of a 20-year-old student struggling with messages from within or perceived signals from without & putting the wrong meaning on other people's actions (& behaving accordingly) are all signs of an emerging schizophrenia.

Rarely - & he stresses rarely - does it lead to violence. But when these illnesses erupt into psychoses, the patient loses touch with reality & displays bizarre & inexplicable behavior.

Only recently have we learned that these are neurodevelopmental disorders whose early signs might well be picked up in routine pediatric screening. For example, a classic behavior in a child that can precede psychosis later in life is speaking to almost no one, even family, says Nasrallah.

Genes are known to confer vulnerability, but equally important is the environment. Stress or great disappointment can exacerbate symptoms; connecting with an adult in an ongoing relationship can do the opposite.

Interventions like social-skills training combined with talk therapy & targeted medication can make a huge difference. Early treatment can lessen the frequency & intensity of psychotic episodes, leaving many patients with only the mildest of symptoms.

And the younger the brain, the more malleable it is. The ultimate goal is to not only modify evolution of disease but keep it from arising in the first place. This is achievable & the path to get there is becoming clear.

This story appears in the May 7, 2007 print edition of U.S. News & World Report.

source: US News & World Report

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Mental Demons
By William S. Cottringer, Ph.D.
We humans have been given something that can be seen as a gift or a curse - the ability or the affliction of self consciousness. This is our unique characteristic that separates us from the rest of the things in our world.
What are these mental demons which this self consciousness can create in us, that often get in our way of success when we come under their spells?
Here are 8 mental demons to watch out for & manage better.


The human brain decides truths & realities on authority & the best authority is personal experience. The trouble is that experience comes from the comparison & contrast of opposites such as pleasant or unpleasant, exciting or boring, rich or poor, yes or no, or any of the other infinite sets of dualistic pairs of opposites we've created in this life.
Everything is either this or that. As you'll see below though, the words we've given to these pairs of opposites have taken on an existence all their own, giving birth to all these other mental demons in our land of Babel. The duality demon is prince of demons though.


Along with this duality demon came the distinction between realness & illusion & truth & falseness. And then comes the discernment of which is which?
Illusions become very real & controlling of us especially when they start interacting with the next several demons.

Of course the biggest illusion is the one that lures us to favor one solution or side over the other in important issues, when all that can really occur is movement towards the middle where the truth that sets us free resides.
But that reality is hidden away with many layers of more convincing illusions. The one illusion that deserves most of our attention is the one when we sense a separation from life, when in fact all things are part of the inseparable, whole oneness of the universe, we can call God (no thing, just part of everything).


There's one reality we sense to be true but we ignore its demonic spell never-the-less. This important reality is that what we see depends mostly on where we're doing the looking from.
When we change physical or temporal vantage points, we see different realities. This is the practical proof of relative truth which just serves to keep the real truth further away from us.

When you fully understand the power of this perspective demon, that insight provides more solutions than there are problems - when you don’t like what you see, change vantage points.
It really is as simple as that, but you have to see past what you're looking at to notice what you've been failing to notice all along - how you're allowing yourself to be victim of all these powerful mental demons.


An important reality
to consider is that time itself came before time measurement. Time measurement is an artificial way to simplify & regulate the most elusive, slippery thing in our universe.
When we allow ourselves to come under the spell of a mechanical, sequential, orderly notion of time, we never have enough of it to get things done. Even nanosecond microchips can’t keep up.

This limited perspective of time decreases our potential for success probably more than anything. The eternal now moment is much more fluid & psychological in nature & really infinite, not finite as the mechanical perspective & illusion insists.
Eternity is the best kept secret in the universe & those who escape the shadow of the time demon have all the abundance their hearts could ever desire. You can take this to the bank on any authority.


Somewhere along the process of splitting the world in half, into this & that, we added some moral flavoring to things that defined them much further in the way of being good or bad, true or false, worthwhile or worthless, etc.
The words & the things they stand for begin to take on realities way past their original intentions & create entirely different consequences that are very real.

When we come under this judgment demon’s spell, we've cut our chances for happiness & success & everything else we want in half or less, not to mention what we have done to other people’s lives.
Worse yet, we may be totally confusing what's good, worthwhile & productive with what isn’t. Ironically, you have to use correct judgment to escape the very large shadow this particular mental demon casts far & wide.


For some reason or another we seem to have to let the tail wag the dog & get the cart before the horse before we learn how to proceed with the right order of things. We try to change everything from outside-in first before we make the effort to try & fit in what we can change from the inside out.
We try to control our behavior before we learn to manage our thinking which causes the behavior & we study failure & disease before we see the merits of studying success & wellness.

We almost nail our own coffins shut when we then allow ourselves to come under the spell of this reversal demon, being convinced that this is the way it has to be & making that permanent judgment. Thank heavens for the perpetual perspective movement that finally jars us into a different judgment!

Actually all these other demons make our choices that much more difficult. Consider the choice that Adam & Eve had in the Garden of Eden - Eat from the Tree of Life & have perfection & bliss forever but give into your curiosity & eat from the Tree of Knowledge of Good & Evil & be dead forever.

Actually, as it turned out, this one choice may have resulted in all these other mental demons getting in our way of returning to the Garden of Eden. Now wouldn’t that be ironic? Part of the plan? Are all things well in spite of appearances? Is this a possible illusion worth exploring!


We originally invented words to represent real objects & things in our environments to conveniently talk about abstractly because they were becoming too heavy or difficult to carry around to show first hand. Can you imagine the u-haul that would be necessary to demonstrate Webster’s Dictionary firsthand?

The trouble is the more words we created to represent more things, the further away the words took us from really knowing the thing it was supposedly representing. The gap between all the words in the dictionary & the objects in the real world became so wide that the chance of good communication was confusing in the middle. And that doesn’t even include all the confusion & miscommunication brought on by various word connotations, interpretations & non-verbal spins.


There are a couple of sensible solutions to managing our mental demons better:

1. Don’t get too dismayed. Things are much better than they appear, just because of these mental demons. But guess what? There really is a happy ending to this play we call life. Too many people have found it for that reality to be an illusion. I guess failure may have to precede success?

2. Since you can really only see 180-degrees even with both eyes working together, it's probably a good idea not to automatically assume you're on the right side of life, especially if you haven’t experienced the other side. In other words, never take yourself or your viewpoint too seriously, unless you're absolutely sure about it.

3. Be careful in using the best words to accurately & completely represent the ideas, objects & things you want to talk or write about. Usually, the simpler the better & a little thought goes a long way.

4. Question the moral flavor you ascribe to things without ample evidence. How do you really know this is good, true & useful & that's bad, untrue & useless? Learn to ask more questions before you make automatic judgments that divide things into okay or not okay.

5. Learn to think, talk, write, read, feel & act in positive terms that we all enjoy such as honesty, politeness, humor, equality, spontaneity, acceptance, tentativeness, sensitivity & good listening.
Do whatever you can to avoid conveying things like negativity, control, judgment, rudeness, poor listening, dishonesty, superiority, manipulation & over-certainty.

6. Start intending to catch yourself coming under the spell of one or more of these mental demons & increase your awareness when that is happening so you aren't being held hostage any more than you need to be, to see what you need to see.

source: self growth.com

Medicating Aliah
News: When state mental health officials fall under the influence of Big Pharma, the burden falls on captive patients. Like this 13-year-old girl.

May/June 2005 Issue

ALIAH GLEASON IS A BIG, lively girl with a round face, a quick wit, and a sharp tongue. She's 13 and in 8th grade at Dessau Middle School in Pflugerville, Texas, an Austin suburb, but could pass for several years older. She is the 2nd of 4 daughters of Calvin and Anaka Gleason, an African American couple who run a struggling business taking people on casino bus trips.

In the early part of 7nth grade, Aliah was a B and C student who "got in trouble for running my mouth." Sometimes her antics went overboard - like the time she barked at a teacher she thought was ugly. "I was calling this teacher a man because she had a mustache," Aliah recalled over breakfast with her parents at an Austin restaurant.

School officials considered Aliah disruptive, deemed her to have an "oppositional disorder," and placed her in a special education track. Her parents viewed her as a spirited child who was bright but had a tendency to argue and clown. Then one day, psychologists from the University of Texas (UT) visited the school to conduct a mental health screening for 6th and 7nth grade girls, and Aliah's life took a dramatic turn.

A few weeks later, the Gleasons got a "Dear parents" form letter from the head of the screening program. "You will be glad to know your daughter did not report experiencing a significant level of distress," it said.

Not long after, they got a very different phone call from a UT psychologist, who told them Aliah had scored high on a suicide rating and needed further evaluation. The Gleasons reluctantly agreed to have Aliah see a UT consulting psychiatrist. She concluded Aliah was suicidal but did not hospitalize her, referring her instead to an emergency clinic for further evaluation.

Six weeks later, in January 2004, a child-protection worker went to Aliah's school, interviewed her, then summoned Calvin Gleason to the school and told him to take Aliah to Austin State Hospital, a state mental facility. He refused, and after a heated conversation, she placed Aliah in emergency custody and had a police officer drive her to the hospital.

The Gleasons would not be allowed to see or even speak to their daughter for the next 5 months, and Aliah would spend a total of 9 months in a state psychiatric hospital and residential treatment facilities.

While in the hospital, she was placed in restraints more than 26 times and medicated - against her will and without her parents' consent - with at least 12 different psychiatric drugs, many of them simultaneously.

On her 2nd day at the state hospital, Aliah says she was told to take a pill to "help my mood swings." She refused and hid under her bed. She says staff members pulled her out by her legs, then told her if she took her medication, she'd be able to go home sooner. She took it. On another occasion, she "cheeked" a pill and later tossed it into the garbage.

She says that after staff members found it, 5 of them came to her room, one holding a needle. "I started struggling, and they held my head down and shot me in the butt," she says. "Then they left and I lay in my bed crying."

What, if anything, was wrong with Aliah remains cloudy. Court documents and medical records indicate that she would say she was suicidal or that her father beat her, and then she would recant. (Her attorney attributes such statements to the high dosages of psychotropic drugs she was forcibly put on.)

Her clinical diagnosis was just as changeable. During 2 months at Austin State Hospital, Aliah was diagnosed with "depressive disorder not otherwise specified," "mood disorder not otherwise specified with psychotic features," and "major depression with psychotic features."

In addition to the antidepressants Zoloft, Celexa, Lexapro, and Desyrel, as well as Ativan, an anti-anxiety drug, Aliah was given two newer drugs known as "atypical antipsychotics" - Geodon and Abilify - plus an older antipsychotic, Haldol.

She was also given the anti-convulsants Trileptal and Depakote - though she was not suffering from a seizure disorder -and Cogentin, an anti-Parkinson's drug also used to control the side effects of antipsychotic drugs. At the time of her transfer to a residential facility, she was on 5 different medications, and once there, she was put on still another atypical - Risperdal.

The case of Aliah Gleason raises troubling - and long-standing - questions about the coercive uses of psychiatric medications in Texas and elsewhere. But especially because Aliah lives in Texas, and because her commitment was involuntary, she became vulnerable to an even further hazard: aggressive drug regimens that feature new and controversial drugs - regimens that are promoted by drug companies, mandated by state governments, and imposed on captive patient populations with no say over what's prescribed to them.

In the past, drug companies sold their new products to doctors through ads and articles in medical journals or, in recent years, by wooing consumers directly through television and magazine advertising. Starting in the mid-1990s, though, the companies also began to focus on a powerful market force: the handful of state officials who govern prescribing for large public systems like state mental hospitals, prisons, and government-funded clinics.

One way drug companies have worked to influence prescribing practices of these public institutions is by funding the implementation of guidelines, or algorithms, that spell out which drugs should be used for different psychiatric conditions, much as other algorithms guide the treatment of diabetes or heart disease. The effort began in the mid-1990s with the creation of TMAP - the Texas Medication Algorithm Project.

Put simply, the algorithm called for the newest, most expensive medications to be used first in the treatment of schizophrenia, bipolar disorder, and major depression in adults.

Subsequently, the state began developing CMAP, a children's algorithm that is not yet codified by the state legislature. At least nine states have since adopted guidelines similar to TMAP. One such state, Pennsylvania, has been sued by two of its own investigators who claim they were fired after exposing industry's undue influence over state prescribing practices and the resulting inappropriate medicating of patients, particularly children.

Thanks in part to such marketing strategies, sales of the new atypical antipsychotics have soared. Unlike antidepressants - which have been marketed to huge audiences almost as lifestyle drugs - antipsychotics are aimed at a small but growing market: schizophrenics and people with bipolar disorder.

Atypicals are profitable because they are as much as 10 times more expensive than the old antipsychotics, such as Haldol. In 2004, atypical antipsychotics were the fourth-highest-grossing class of drugs in the United States, with sales totaling $8.8 billion - $2.4 billion of which was paid for by state Medicaid funds.

At a time when ethical questions are dogging the pharmaceutical industry and algorithm programs in Texas and Pennsylvania, President Bush's New Freedom Commission on Mental Health has lauded TMAP as a "model program" and called for the expanded use of screening programs like the one at Aliah Gleason's middle school. The question now is whose interests do these programs really serve?

THE TEXAS MEDICATION ALGORITHM PROJECT got under way in the mid-1990s just as the new generation of antipsychotic drugs was coming on the market. For some 40 years before, medications like Thorazine, Haldol, and Mellaril were given to patients with schizophrenia or psychosis to silence their voices and calm their agitation.

But they caused terrible side effects, including sedation, social withdrawal, and tardive dyskinesia, which causes muscle and facial tics and strange jerking movements like those in people with Parkinson's disease. Many patients would refuse to take them - when they had a choice. Some sued drug companies and doctors for failing to warn them about the side effects and won large awards.

Into that environment, drug companies brought out the new atypical antipsychotics and began describing them in almost miraculous terms. The drugs - including Janssen Pharmaceutica's Risperdal, Eli Lilly's Zyprexa, Pfizer's Geodon, AstraZeneca's Seroquel, and Bristol-Myers Squibb's Abilify, as well as a slightly older drug, Clozapine by Sandoz - were said to be more effective than the first-generation antipsychotics and less likely to cause motor problems and other side effects. "A potential breakthrough of tremendous magnitude," Stanford University psychiatrist Alan Schatzberg gushed to the New York Times. Laurie Flynn, executive director of the National Alliance for the Mentally Ill, added that now "the long-term disability of schizophrenia can come to an end."

Despite the hoopla, not all doctors immediately embraced the new drugs, and many patients bounced haphazardly between the old and new antipsychotics. "They complained that whenever they got new doctors, their whole medication regimen usually changed," says Dr. Steven Shon, the medical director for behavioral health for the Texas Department of State Health Services (DSHS).

In 1995, Shon began talking with researchers at the UT-Southwestern Medical Center in Dallas about the use of algorithms to address these random prescribing practices. From the start, the process of creating the algorithms reflected the extensive ties between academic psychiatrists and the pharmaceutical industry. UT-Southwestern was a major research center stocked with investigators conducting drug trials paid for by pharmaceutical companies.

One of Shon's key collaborators was Dr. John Rush, a nationally known psychopharmacologist who has extensive ties to industry. Rush declined to speak for this article, but according to a disclosure statement appended to one of his published articles, he has received grant and research support from 14 pharmaceutical companies, has served as a consultant to 11, and has been a member of 10 drug company speakers' bureaus.

Together, Shon, Rush, and the then-chair of UT-Southwestern's psychiatry department convened panels of experts who drew up "consensus guidelines" for schizophrenia, bipolar disorder, and major depression - blueprints on which drugs to give patients in what order and combination. Of the 46 members of the three panels, 27 have conducted research on behalf of pharmaceutical companies, served on drug company speakers' bureaus, or served as consultants to a drug company, according to a review conducted for Mother Jones by the Center for Science in the Public Interest, a watchdog group that maintains a database on the financial links of researchers.

For the drug companies, TMAP represented an opportunity. Their products were given a high priority in the algorithm, and if the algorithm was widely followed, it could mean thousands of prescriptions and millions of dollars in revenue. The industry didn't miss the chance. "We went to the pharmaceutical companies or, actually, they approached us because they are always dropping by," Shon told Mother Jones. "Once we created the algorithms, they said, 'Could you use any financial help for any materials?' And we said, 'Yeah,' because we have to publish manuals. We have to create training videotapes."

Shon says the initial creation of the TMAP guidelines was underwritten by state funds, along with $3 million in grants from foundations, including $2.4 million from the Robert Wood Johnson Foundation, a charity set up by the estate of a former chief executive of Johnson & Johnson, the parent of Janssen. Shon insists that no industry money went into the creation of the guidelines, though a 1999 paper he coauthored outlining the "development and implementation" of TMAP acknowledged grant support from seven pharmaceutical companies.

Shon also told Mother Jones that his department received only $285,000 from drug companies for TMAP's training materials in the program's "feasibility testing stage." But Nanci Wilson, an investigative reporter for KEYE-TV in Austin, reviewed the DSHS accounts, and her analysis indicates that gifts from pharmaceutical companies totaled $1.3 million from 1997 to July 2004, at least $834,000 of which was earmarked for TMAP. For example:

  • Janssen Pharmaceutica, the maker of Risperdal, gave $191,183 "to help support further developmental activities of TMAP" or in general support of TMAP.
  • Eli Lilly, the maker of Prozac and Zyprexa, gave $47,000 to "help fund the collaborative effort to develop medication best practices for the treatment of major depression, schizophrenia and bipolar disorders." All together Lilly contributed $103,000 to support TMAP.
  • Pfizer, the maker of the antidepressant Zoloft and the new antipsychotic Geodon, contributed at least $146,500 for TMAP.
  • While not refuting Shon's statement, DSHS spokesman Doug McBride says he is "aware" that industry donated $1.3 million. Representatives of pharmaceutical companies contacted by Mother Jones denied that their contributions were intended to shape TMAP. "We didn't participate in the development or influence the content," said Janssen spokesman Doug Arbesfeld. "It was an arm's-length contribution." Heather Lusk, an Eli Lilly representative, said contributions to TMAP were "educational" grants made by a company grants office that "is completely independent of any kind of sales and marketing function."

    Pfizer's Jack Cox pointed out that nonprofit mental health advocacy groups also raise and spend money to influence policy. "There's an assumption that our money is dirty and corrupt," he said. "I beg to differ."

    AS THE TMAP PANEL MEMBERS worked on the protocols, drug companies aggressively promoted the new antipsychotics across the psychiatric landscape. Their key selling point: that they were more effective and caused fewer serious side effects than the older antipsychotics, especially Haldol, the most widely used. Though it did approve six atypicals, the FDA was dubious of some of these claims. "We would consider any advertisement or promotional labeling for Risperdal false, misleading or lacking fair balance… if there is a presentation of data that conveys the impression that [Risperdal] is superior to [Haldol] or any other marketed antipsychotic drug product with regard to safety or effectiveness," an FDA official wrote in a 1993 letter to Janssen Pharmaceutica. But the letter was only made public years later, when journalist Robert Whitaker quoted it in his 2002 book, Mad in America. Most prescribing doctors were left in the dark. (For more on how drug companies manipulated clinical trials for atypicals see motherjones.com/spinningdoctors.)

    The largest study to date, a review of 52 clinical trials including more than 12,000 patients published in the British Medical Journal in 2000, found "no clear evidence that atypical antipsychotics are more effective or better tolerated than conventional antipsychotics." A 2003 study comparing Zyprexa, the top-selling atypical antipsychotic, and Haldol, published in the Journal of the American Medical Association, found the new drug "does not demonstrate advantages compared with [Haldol]… in compliance, symptoms… or overall quality of life."

    The new drugs now appear to be associated with higher suicide rates and to cause tardive dyskinesia, too, though perhaps at lower rates than the first-generation drugs. They can cause rapid weight gain and thus an increased risk of diabetes. In September 2003, the FDA required the makers of all atypicals to add to their labels a warning that the drugs can cause hyperglycemia, diabetes, and even death. Janssen was also made to send doctors a letter conceding it had misled them when it said that Risperdal does not increase the risk of diabetes. In fact, the company had to admit, it probably does.

    When TMAP's schizophrenia algorithm was finalized in 1997, however, it did exactly what industry representatives must have hoped for: It called for the newest, most expensive drugs—five atypicals—to be used first. If a patient does not respond well to one of those drugs, a second member of this group should be tried. If that drug also fails, a third drug should be tried, this time either another atypical or an older antipsychotic. The guidelines for major depression and bipolar disorder similarly favor new drugs.

    "When [the drug companies] saw the newer medications were there, they liked that, of course," says Shon. "I know that has raised questions in people's minds: 'Why are the newest, most expensive first?' Well, the newest, most expensive are either the most efficacious and/or the safest."

    But that assertion is increasingly disputed. "When atypicals came out, they looked a little better in effectiveness and a lot better in terms of side effects," says Mike Hogan, Ohio's mental health director and former chairman of President Bush's New Freedom Commission on Mental Health. "These days, they look perhaps a tiny bit better in terms of effectiveness, but increasingly it's not clear whether the side-effect profile is better or just different."

    Ohio adopted a TMAP-like algorithm in 2001 but with a critical difference. According to Hogan, it's merely a guideline for prescribing doctors to consider. But in Texas, state officials put far more pressure on its physicians to follow the protocols. Under regulations codified by the legislature in 1999, doctors in state-owned and state-funded mental health entities must follow the algorithm, or justify a different course with a note in a patient's file—a hurdle that sends the message that such deviation should be the rare exception.

    As the TMAP guidelines began to be adopted in 1997, Texas Medicaid spending on the five atypical antipsychotics skyrocketed from $28 million to $177 million in 2004.

    MANY DOSES OF THESE DRUGS went to patients like Aliah Gleason. She was one of 19,404 Texas teenagers prescribed an antipsychotic in July or August of 2004 through a publicly funded program, according to ACS-Heritage, a medical consulting firm hired by Texas to investigate the use of psychotropic drugs on children. Nearly 98 percent were atypical antipsychotics—unapproved for children and prescribed "off-label," a controversial practice in which doctors legally prescribe FDA-cleared drugs to patients, such as children, or for conditions, such as depression, for which they are not approved. The report found that more than half of the doses for antipsychotics appeared inappropriately high, that almost half did not appear to have valid diagnoses warranting their use, and that one-third of child patients were on two or more medications.

    When she was transferred from Austin State Hospital to a residential facility on March 18, 2004, Aliah was on five different medications, putting her on the extreme end of a growing practice known as polypharmacy that worries many doctors. "This is a complicated regimen using powerful psychotropic medications in a barely adolescent girl, so I would be quite concerned about it," says Dr. Joseph Woolston, a Yale University professor and chief of child psychiatry at Yale-New Haven Hospital. "It isn't grossly, acutely dangerous, but it is sedating and would make it difficult for a child to experience the world in a normal way. If you or I were on that regimen we would have a lot of trouble attending to work or school. We don't have any idea what that combination of medications does to a developing child. It may have a number of long-term side effects." He also suspects that the drugs may have been used as much to control the angry reactions of a girl who was hospitalized against her will as to treat any mental and emotional problems.

    Dr. Clifford Moy, clinical director of Austin State Hospital, says that while the hospital's philosophy is to avoid using more than one member of any particular class of psychiatric medication, using multiple drugs from different classes is often the best way to treat a patient with multiple symptoms. While declining, for privacy reasons, to discuss Aliah's treatment, he said medication and restraint would never be used for punitive purposes or merely to promote compliance with hospital rules, but only in the case of a "significant emergency behavioral situation." He added that forced injection of an antipsychotic—which happened to Aliah several times—might be used "if there were a legal consent for an oral antipsychotic medication, which the patient refused." Such consent was apparently provided, in Aliah's case, by the Department of Protective and Regulatory Services.

    The 46-bed child and adolescent wing where Aliah stayed was not, like the rest of Austin State Hospital, obligated to follow TMAP. Its treatment regimens were influenced more by CMAP, the children's algorithm not yet mandated by the legislature. CMAP steers clear of providing protocols for schizophrenia and bipolar disorder—the disorders that atypicals were designed to address—in part, says DSHS's Doug McBride, because there's "little scientific evidence" as to what the appropriate regimen for kids would be. CMAP does, however, call for combining atypicals with antidepressants for children diagnosed—as Aliah was—as suffering from depression "with psychotic features." McBride defends such off-label use of prescription drugs, saying that the FDA approval process "is not the end of clinical and other scientific evidence on the use of that medication."

    Beyond their technical dictates, the algorithms established a culture that affected which medications were prescribed. Steven Shon, who, along with his colleagues, had led training sessions for the staff of Austin State Hospital, argues that the algorithms were designed to prevent irrational and excessive medication. Yale's Woolston agrees with the goal, though not necessarily the reality. "Algorithms are supposed to cut down on people using medications inappropriately and to take into account medication interaction," he says. "Where they become a problem is when people use them as a mandate, forget their own clinical judgment, and believe that when you're in doubt, you're supposed to move forward in the algorithm and add more medication."

    Medications can be invaluable, and some patients say their lives have been transformed by atypicals. But algorithms reinforce the perception in both psychiatry and popular culture that mental problems always require drug treatment. "An algorithm may put blinders on a psychiatrist and create the presumption that the only clinical approach to problems is to use medications," Woolston says. If a patient doesn't respond to a particular medication, a doctor relying on an algorithm may think they need to use or add a different medication, he says. "But sometimes, the best approach is to say, 'Medication isn't working; let's try something else.'"

    ONCE THE DEVELOPMENT of the algorithms was largely complete, Shon began hitting the road, making about one trip a month—often at the expense of drug companies—to spread the TMAP gospel to officials in other states. This close relationship between TMAP and the pharmaceutical industry raises disturbing questions about whether the drug companies were wielding undue influence or profiting at the expense of patients. But no one raised these questions until 2002, when Allen Jones, an investigator for the state of Pennsylvania's Office of Inspector General (OIG) began to look into a complaint that mental health officials had set up an unorthodox bank account to collect money from drug companies.

    Jones, a lanky, 50-year-old chain-smoker, had spent several years with the OIG in the late '80s and early '90s, but left to pursue real estate investing to pay for his daughters' college tuition. He had only just rejoined the agency in the summer of 2002 when he began investigating this case. Over several months, he interviewed state officials, traveled to New York and New Jersey to question pharmaceutical company executives, and learned all he could about TMAP. He soon felt that something inappropriate, and possibly illegal, was going on. "It just did not pass the smell test," he says.

    Jones learned that in early 2000, Dr. Steven Karp, who was then medical director of the state's Office of Mental Health, had become interested in implementing a Pennsylvania version of TMAP. Karp discussed his interest with executives of Janssen Pharmaceutica, Jones found, and the company paid for Shon to come to Pennsylvania in late 2000 to meet with Karp and Steven Fiorello, the state's chief pharmacist. Shon returned in March 2001 to train state medical personnel, according to records Jones obtained and provided to Mother Jones. To cover Shon's travel expenses, Janssen made an "educational grant" of $1,765.75. A Janssen funding request form notes that the grant was to support the "TMAP initiative to expand atypical usage and drive Steve Shon's expenses." A box marked "Risperdal" is checked on the form. Janssen's check was sent to Fiorello and placed in the account where other donations from pharmaceutical companies were deposited.

    Two months later, Janssen provided $4,000 for Fiorello and a state psychiatrist to travel to New Orleans for meetings with Dr. Madhukar Trivedi, a UT-Southwestern psychiatrist and TMAP project team director. The funding request form for this payment listed the "deliverable" as the "successful implementation of PennMAP." A Janssen representative also attended and paid for $80-per-person dinners for the Pennsylvania and Texas officials. Fiorello and the psychiatrist made another trip to New Orleans later that year, also paid for by Janssen, according to Jones. Such perks, while of no great consequence to a company the size of Janssen, did forge a friendly relationship with Pennsylvania officials whose decisions carried enormous financial stakes for the company.

    Fiorello told Jones he was the state's "point man" for selecting drugs for the state formulary—those used in state hospitals—and that industry representatives visit him often "to ensure access of their drugs to the state system," Jones wrote in a file memo as he pursued his investigation. In April 2002, Fiorello and Dr. Frederick Maue, clinical director for the state's Department of Corrections, spoke at a Janssen-sponsored symposium for prison doctors and nurses on treating mentally ill offenders. They were paid $2,000 by Comprehensive NeuroScience, a marketing firm working for Janssen that helped shape their presentation. Another marketing company hired by Janssen appointed Karp to its advisory board, flying him to meetings in Seattle and Tampa. Pfizer put Fiorello on an advisory council and twice paid his expenses to come to New York.

    Jones became convinced that, as he puts it, "the pharmaceutical companies were buying influence with key decision makers in state government, trying to turn their drugs into blockbusters." But as he brought these findings to his boss, Daniel Sattele, he was told to stop pushing so hard. After he was barred from investigating whether state officials had received inappropriate payments from drug companies, Jones sued in federal court, alleging that "major public corruption investigations were being delayed, obstructed, or otherwise hindered by officials in the OIG." Sattele subsequently conceded in a deposition taken in 2003 that he asked Jones if he were "a salmon," telling him, "go with the flow, don't swim against the current." Sattele also said that after Jones came to him with his concerns for the fourth or fifth time, he reminded Jones of the industry's power and influence. "I said, 'Allen, pharmaceutical companies are very aggressive in their marketing…. They probably donate to both sides of the aisle,'" he recalled in the deposition.

    When Jones continued to pursue the case he was removed as lead investigator, then pulled off altogether, he says. Nonetheless, over the coming months, he quietly copied documents and, on his own time, gathered more information.

    In February 2004, Jones laid out his charges for the New York Times and the British Medical Journal. In April he was suspended. In May he again sued in federal court, charging that his superiors were harassing him to "cover up, discourage, and limit any investigations or oversight into the corrupt practices of large drug companies and corrupt public officials who have acted with them." He was then fired. He is now working as a bricklayer; both his actions are pending.

    A spokeswoman for the Pennsylvania Office of Inspector General declined to comment on Jones' allegations or his termination. A representative of the Department of Corrections told Mother Jones that Maue donated the honorarium he was given by Comprehensive NeuroScience to the state's general fund. And Stacey Ward, a spokeswoman for the Department of Public Welfare, said that the state "did not receive contributions of any kind from any pharmaceutical company to study or support the implementation of PennMAP." [Ed note: After the print edition of this story went to press, the Pennsylvania State Ethics Commission fined Steven Fiorello, the state’s chief pharmacist, $27,000 for using his position to earn extra income from sources that included Pfizer.]

    Meanwhile, another Pennsylvania official was becoming increasingly alarmed with how drugs being pushed by the pharmaceutical industry were actually affecting patients. Dr. Stefan Kruszewski, a Harvard-trained psychiatrist working for the state's Department of Public Welfare, was charged with reviewing psychiatric care provided by state-funded agencies to identify cases of waste, fraud, and abuse. In the summer of 2001, he began documenting examples of what he calls "insane polypharmacy" and widespread use of drugs for reasons not approved by the FDA. Most shocking to him were the cases of children placed in state-funded residential treatment facilities, sometimes for years, and heavily drugged on the new antipsychotics and anticonvulsants, including some of the same medications given, off-label, to Aliah Gleason.

    "These kids were on multiple medications without the clinical diagnoses to support the medications," Kruszewski says. One drug, Neurontin, approved for controlling seizures, "was being massively prescribed for anxiety, social phobia, PTSD, social anxiety, mood instability, sleep, oppositional defiant behavior, attention deficit disorder. Yet there's almost no evidence to support these uses in adults and no evidence for kids whatsoever."

    Last year a Pfizer subsidiary pleaded guilty to criminal fraud and agreed to pay $430 million in fines for promoting off-label prescribing of Neurontin, which racked up $2.8 billion in U.S. sales in 2004. Officials estimate that off-label uses account for some 90 percent of its sales. New York attorney Andrew Finkelstein says he's been enlisted by the relatives of 425 people who committed suicide while on Neurontin, and thus far has filed 46 lawsuits against Pfizer.

    Kruszewski sent memos to his bosses about dangerous off-label uses of these medications but says they were ignored. He also looked into the deaths of four children in residential programs and submitted a report on an Oklahoma facility, where Pennsylvania children were sometimes sent. He found that many of the kids "were severely overmedicated" with atypical antipsychotics, antidepressants, and anticonvulsants, and he theorized that the death of at least one child could be attributed to a culture that combined polypharmacy and neglect.

    His report earned him no plaudits. The day after submitting it, he says, he was yelled at for "trying to dig up dirt." The next day he was fired and escorted to the street. He has since filed suit in federal court against the state officials who fired him, along with several drug companies that, he charges, have "distorted statistics, violated regulations… and misrepresented the effects of the use of their psychotropic drugs… simply to make money." (The Pennsylvania Department of Public Welfare declined to comment on Kruszewski's charges because of his pending lawsuit.) Months after he was fired, Kruszewski alternates between anger and sorrow as he thumbs through documents piled in the dining room of his Harrisburg home. "I get very emotional about these reports," he says. "The people who were paid to protect consumers did exactly the wrong thing."

    UNLIKE SOME OTHER HEAVILY medicated children, Aliah Gleason survived. In June 2004, more than five months after she was taken from school, Calvin and Anaka Gleason saw their daughter for the first time—in a courtroom. "I was so excited," Aliah recalls. "I hid under the table so I could surprise them. I started crying when I saw them. I thought I would never see them again."

    It would take another four months of legal wrangling with the state before a district court judge ordered Aliah released into her parents' custody. Finally, the Gleasons were allowed to choose the people who would treat their daughter. They selected Austin psychologist John Breeding, a well-known critic of the overuse of psychiatric medications, and soon the whole family began meeting with him.

    The first priority, Breeding said, "was to get her off the medication." Working with the family's doctor, he helped design a program for tapering her off her final drugs, Risperdal and Depakote, a process that was completed by the end of last year. He says the goal now is to help her recover from the emotional wounds she suffered as a result of her time under the state's care. She also needs to lose all the weight she gained while on the atypicals.

    The good news, he says, is that "the family is reunited, she's doing well in school, and is even participating in extracurricular activities." Like her sisters, Aliah plays in the school band and also takes part in a drill team. "She's coming back, starting to get that gleam in her eye," Breeding says.

    Aliah found herself at the intersection of a capricious child-protection system and a health care system that's all too ready to medicate. As doctors dispense ever-greater quantities of potent psychiatric drugs, and the industry spends ever-greater amounts of money promoting them, how can consumers be confident that decisions about their care are truly informed and in their interest? Whatever the stakes for the drug companies, the stakes for patients are infinitely higher.

    My own thoughts on the article of the month in the left column....
    kathleen howe

    I'm turning 50 years old in July. My life journey has been quite a ride for me. In some cases I've been so entirely inept, naive or lacking knowledge in common everyday occurences because of my upbringing. Being raised in a "Cinderella" or "fairy tale" world can cause you great injury & pain.
    In other cases, I've been exposed to some truly traumatic & hurtful situations that needed to be taken care of, but were ignored because I was never taught any coping mechanism, life skills & was forbidden to have feelings & emotions.
    As a child, living in Syracuse, New York, President Kennedy was assasinated. It was a traumatizing crisis when you are in elementary school & the whole nation stops because the President was murdered. I remember being taken out of school, then school was cancelled & then I had to go to my grandmother's house because my mom worked.
    Everyone kept comparing me to that little Caroline Kennedy. We are exactly the same age & share the same birth date. Her little brother was the same age as my brother which was another factor that people were always talking about. Poor Caroline... Poor little boy...
    I was confused & mystified about death. My parents didn't think children needed to be exposed to death, funerals, visiting hours or anything morbid like that. My great grandfather died just before this & I wasn't allowed to go to the funeral.
    Then the Vietnam War emerged into our lives. Soldiers came back from that war, broken, mentally & physically broken. Society casting America's finest into a negative light, rejecting their needs, abhoring the flashbacks, the nightmares, the drug & alcohol addictions that our military was suffering from fighting for our country.
    The military wasn't voluntary. There was a draft. There wasn't a mental health system in effect at all. These poor souls, who had seen the most horrendous things, were left to their selves to figure out how to cope. I can't imagine their pain. The men & women serving our nation would leave their family a wonderful father & husband, friend, son, daughter, sibling - then come back a dysfunctional emotional mess. They'd return as someone else who survived the war only a mere shadow of themselves before the war.
    One dark night, one of those camoflaged veteran's of that war, was having a flashback in my front yard. He was crawling around on his belly, he had a machine gun, he had been throughout our neighborhood, shooting the gun, seeing things that weren't there.... I'm sure he was intensely afraid. He fired at the police, the firefighters who were there for support. He shot out the windows of the cars parked alongside the street.
    They finally caught him. I had the same nightmare for about 10 years from that night. My parents never brought up the subject again. I cried more nights than not, after the dream, wanting to be comforted, to understand, to know it wasn't going to happen, that war guy... crawling up the drain spout alongside our bathroom window.
    I didn't want him to crawl into the window while my father was bathing us, my brother & sister & I. I didn't want to watch him shoot everyone in my family in front of me... and then it was my turn. I was naked. I was ashamed of being naked because I hated my father giving me a bath with my brother and sister. I got shot every time right in the same spot. He shot me in the stomach. Someone had told me as a little girl that getting shot in the stomach was the most painful place. I would wake up then, after feeling that horrible pain.
    I'd be sweating. I'd have a real life stomach ache. I would be crying. Sometimes, it would seem so real that I'd take the chance of being in trouble from my father. We weren't allowed to go to their bedroom door to tell them we were afraid. He would yell at us. "Get back in your bed! Quit crying or I'll give you something to cry about!"
    Today there are thousands of military personnel coming back from Iraq and Afghanistan. They (a very large percentage of them) will have post traumatic stress disorder. Already the government isn't ready for them. Already those coming back from war with head injuries, amputated legs, arms, blind, burned.... they need our support & understanding. Their mental & physical welfare is being ignored.
    But what about their families? What about the sons and daughters of these heroes? Can you imagine the fear, the pain & heartache, the confusion, and the anger they are feeling. Loneliness for their fathers and mothers, feelings of fear that their loved one will die, and then total collapse when they see a parent who has an amputated limb. Who is preparing them for this?
    Just being exposed to a brief encounter with a Vietnam vet experiencing a flashback, shooting his machine gun, lights & sirens and seeing my parents in fear caused me to have the same nightmare for 10 years. What about what's going on right now? What about it? Who is willing to help someone? We all need to help.

    When I was in high school, I was everyone's friend. I had no enemies. I didn't belong to a clique. Every person was my friend. I would spend the night at the class girl geek's house because I liked her. She was different, but I still liked her. I refused to make judgments about people. I didn't care what people thought. Most people were nice to me. If they weren't nice to me, I still was nice to them. This experience actually happened.
    But now as a mother with kids in school, I'm always amazed at how the cliques are - the jocks - the geeks - the gangs - the nerds - the goths - the christians - it's always some kind of group. Then within the group there is all kinds of contention as to who is the most popular in the group. It's insane! I tell my kids about how I got along with everyone and they look at me as if to say, "That's the biggest lie you've ever told!"
    Now there is school violence. Now kids are singled out & bullied into submission to someone. They're humiliated, intimdated, hurt physically and emotionally, they're literally abused & it's okay. It happens and no one stops it. Kids sign bullying pledges that they won't do it and it still goes on because no one gets paid enough to enforce it.
    The moral stature of our youth today has been made clear. Our youth, in general, have no sense of the values of compassion, empathy, volunteerism, helping others, understanding and openness for diversity. They're not generally tolerant. There are some who are all of that, and that's great, but this comment isn't about the ones who "get it." It's written for the parents of those kids who don't "get it."
    It's written for those kids old enough to understand themselves and who "don't get it" and don't care if they do or don't. If we don't start taking care of each other, seeing needs in people that aren't being met, being kinder, more aware, more empathetic, compassionate and genuinely friendly - there will be more of what happened at Virginia Tech. It's written all over the attitudes of today's youth.
    Hey man... I didn't do anything to that kid....
    That's right man.... You didn't do a thing... like see what was wrong with him. Like why didn't someone ask him if he needed a friend. He felt excluded. He felt alone. Then he was angry because the attitudes of others were even more hurtful and this caused him more distance.
    Let's teach our kids what's right...
    It's on our shoulders, parents........
    Let's teach our kids what kindness is.

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