Over-stressed teens can develop anxiety disorders and depression. Here's how parents can help and techniques for teens to decrease stress.

Teenagers, like adults, may experience stress everyday and can benefit from learning stress management skills. Most teens experience more stress when they perceive a situation as dangerous, difficult, or painful and they do not have the resources to cope. Some sources of stress for teens might include:

• school demands and frustrations
• negative thoughts and feelings about themselves
• changes in their bodies
• problems with friends and/or peers at school
• unsafe living environment/neighborhood
• separation or divorce of parents
• chronic illness or severe problems in the family
• death of a loved one
• moving or changing schools
• taking on too many activities or having too high expectations
• family financial problems

Some teens become overloaded with stress. When it happens, inadequately managed stress can lead to anxiety, withdrawal, aggression, physical illness, or poor coping skills such as drug and/or alcohol use.

When we perceive a situation as difficult or painful, changes occur in our minds and bodies to prepare us to respond to danger. This "fight, flight, or freeze" response includes faster heart and breathing rate, increased blood to muscles of arms and legs, cold or clammy hands and feet, upset stomach and/or a sense of dread.

The same mechanism that turns on the stress response can turn it off. As soon as we decide that a situation is no longer dangerous, changes can occur in our minds and bodies to help us relax and calm down. This "relaxation response" includes decreased heart and breathing rate and a sense of well being. Teens that develop a "relaxation response" and other stress management skills feel less helpless and have more choices when responding to stress.

Parents can help their teen in these ways:

• Monitor if stress is affecting their teen's health, behavior, thoughts, or feelings
• Listen carefully to teens and watch for overloading
• Learn and model stress management skills
• Support involvement in sports and other pro-social activities

Teens can decrease stress with the following behaviors and techniques:

• Exercise and eat regularly
• Avoid excess caffeine intake which can increase feelings of anxiety and agitation
• Avoid illegal drugs, alcohol and tobacco
• Learn relaxation exercises (abdominal breathing and muscle relaxation techniques)
• Develop assertiveness training skills. For example, state feelings in polite firm and not overly aggressive or passive ways: ("I feel angry when you yell at me" "Please stop yelling.")
• Rehearse and practice situations which cause stress. One example is taking a speech class if talking in front of a class makes you anxious
• Learn practical coping skills. For example, break a large task into smaller, more attainable tasks
• Decrease negative self talk: challenge negative thoughts about yourself with alternative neutral or positive thoughts. "My life will never get better" can be transformed into "I may feel hopeless now, but my life will probably get better if I work at it and get some help"
• Learn to feel good about doing a competent or "good enough" job rather than demanding perfection from yourself and others
• Take a break from stressful situations. Activities like listening to music, talking to a friend, drawing, writing, or spending time with a pet can reduce stress
• Build a network of friends who help you cope in a positive way

By using these and other techniques, teenagers can begin to manage stress. If a teen talks about or shows signs of being overly stressed, a consultation with a child and adolescent psychiatrist or qualified mental health professional may be helpful.

Source: American Academy of Child and Adolescent Psychiatry, Jan. 2002

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Perhaps one of manic-depression's best-known champions, the writer and actress shows us how she wrangles her many moods.

CARRIE FISHER'S DRUG USE WAS A WAY TO "DIAL DOWN" THE MANIC IN HER. "I WANTED TO PUT THE MONSTER IN THE BOX. DRUGS MADE ME FEEL MORE NORMAL."

"HOW MANIC AM I?" ASKS Carrie Fisher as she climbs around her hillside with a potted plant. Dressed in a sleek black suit, she positions the shrub in an empty spot. "How's that?" Later, she points to a horticulture article highlighting a garden in a rainbow of color. "That's what I want." She confesses that lately, while she's writing, she looks at her garden and gets up to readjust the trees and flowers that are yet to be planted. The garden is her latest obsession.

Fisher is up-front about her manic behavior. At first glance, she doesn't seem any crazier than the rest of us. But when she pulls out her medications, you think again. All the little capsules and tablets--prescription drugs to tame her bipolar disorder--are organized in a weekly container. "Sunday, Monday, Wednesday," she mimics that famous scene from The Godfather.

She takes nearly two dozen pills a day. But recently, she blew off her daytime dosages and the result was a weeklong escapade that ended in a tattoo parlor on the west side of Los Angeles. Her manic side drives her to impulses, and as she notes, "Impulses become edicts from the Vatican." Fortunately, for her sake, two friends accompanied her. "They were concerned about me." And with good reason.

Nearly four years ago, the writer and actress suffered what she calls a "psychotic break." At the time, she was experiencing a deep depression--just getting out of bed to pick up eight-year-old daughter Billie was a major feat. She was also improperly medicated. She ended up in the hospital. There she was riveted to CNN, convinced that she was both the serial killer Andrew Cunanan as well as the police who were seeking him. "I was concerned that when he was caught, I would be caught," she recalls.

Her brother, filmmaker Todd Fisher, feared that he was going to lose her. "The doctors said she might not come back." Awake for six days and six nights, she recalls hallucinating that a beautiful golden light was coming out of her head. Yet the confusing thing about her mania, says Todd, is her ability to remain articulate, clever and funny. Todd says she launched into a Don Rickles-like diatribe, "ripping everyone who came into her room."

Ex-partner Bryan Lourd, who has remained a friend, was by her side. She said to him, "She's in the chair, she let me out. I have to talk to you. I can't take care of Billie on my own."

At the hospital, she couldn't bear seeing her mother, actress Debbie Reynolds, and asked that she not visit her. The two remain close--actually, Reynolds bought the house next door.

FISHER ROLLS AROUND ON HER BED and does somersaults. "I have to get out of here," she pleads. We hop into her station wagon and head for the San Fernando Valley. At a garden nursery, we walk up and down the footpaths looking for color. She picks up purple roses and orange star clusters. While she talks about her garden, "I want everything to be right," she is all too aware of her obsessive tendencies. Yet her mania may well be an important part of her brilliance.

The daughter of Reynolds and 1950s crooner Eddie Fisher, Carrie watched her father run off with actress Elizabeth Taylor. "An unpleasant experience," as she puts it. Although she had an absent father, she knows she resembles him in the most worrisome way. She notes that he is an undiagnosed manic-depressive, "He bought 200 suits in Hong Kong, was married six times and bankrupt four. It's crazy."

In her teens, what she wanted most was to be near her mother, so Carrie made her Broadway debut in Irene at age 15. Reynolds was the star of the show. Not long after, Fisher played the scene-stealing nymphet in the movie Shampoo, then she was immortalized as Princess Leia in that metal bikini. Her role in the classic Star Wars trilogy shot her into superstardom.

This kind of celebrity, though, comes with trappings. It was sex, drugs and late-night partying with Hollywood heavies like John Belushi and Dan Akroyd. One night, she was so high Akroyd made her eat. She choked on a Brussels sprout, so he performed the Heimlich maneuver. Then he proposed to her.

Her longtime friend, director and actor Griffin Dunne, says she made partying look fun. "Getting stoned was a part of all our lives when we were younger. Her abuse only became apparent later to me. I told her she was taking too many pills, but of course I was drunk at the time, so I wasn't making a lot of sense."

Marijuana, acid, cocaine, pharmaceuticals--she tried them all. Being on the manic side of bipolar disorder, her drug use was a way to "dial down" the manic in her. In some respects it was a form of self-medication. "Drugs made me feel more normal," she says. "They contained me."

But her addictions were serious. At her worst, she took 30 Percodan a day. "You don't even get high. It's like a job, you punch in," she recalls. "I was lying to doctors and looking through people's drawers for drugs." Such relentless abuse landed her in rehab, at age 28, after she overdosed and wound up with a tube down her throat to pump her stomach. In the end, her misadventures were recounted in her autobiographical novel, Postcards From the Edge.

Writing, her secret ambition, helped her stay focused. Postcards won her wide acclaim. Later still, she continued to gain adulation when she wrote the book's screenplay. The film version, in fact, starred friend Meryl Streep as the drug addicted heroine.

When she wrote Postcards, she says she was, "uber-involved" in her 12-step recovery and subsequent addiction support groups, but not all her issues were addressed. Her friend Richard Dreyfuss told her that she suffered from more than just drug addiction. "You don't walk down the street, it's a parade."

Dunne never thought of Fisher's problem as a mental illness. That is, until he misplaced a rug she had lent him. She was very understanding and told him not to worry. Yet, four years later, Fisher brought up the rug. "She was furious about it, as if it just happened. Then we talked a few days later and the rug was not that big a deal."

At first, Fisher may have ignored her friends, but she eventually found a psychiatrist, proper medication and a support group for manic-depressives. "When the group started talking about their medications, it was such a relief," she remembers. She has since become vocal in the struggle for mental health care. Earlier this year she lobbied for more funding to treat mental illness at the Indiana statehouse.

Fisher has two moods, Roy the manic extrovert and Pam the quiet introvert. "Roy decorated my house and Pam has to live in it," she quips. If a home is any indication of one's state of mind, then Fisher's mind is both playful and bizarre. A chandelier dangles from a tree along the driveway and signs such as "beware of trains" hang everywhere.

Her 1933 ranch style home, once owned by Bette Davis, is littered with details that reveal her comic nature. One painting in her bedroom depicts Queen Victoria tossing a dwarf. And inside a triptych in the dining room you find an effigy of Princess Leia.

Throughout the house, there are irreverent references to the Princess, but as Fisher puts it, "Leia follows me like a vague smell." Her metal bikinied space babe is perhaps one of the most downloaded images on the Web. You would think, though, that Fisher's accomplishments as a writer might have eclipsed any memories of Leia. Since she wrote Postcards, she has written two additional novels.

One, Surrender the Pink, was about her relationship with ex-husband and pop icon Paul Simon, to whom she was married for 11 months. For Fisher, his words had a certain soothing rhythm. "Except when the words are organized against you, of course." She says she really didn't fit the stereotype of wife, and as her friends put it, there were two flowers and no gardener.

Fisher is perhaps one of the more productive manic-depressives. She has script-doctored countless Hollywood films including Milk Money and Sister Act. She is even hosting a talk show for Oxygen Media. And in recent years, she has written screenplays; one for Showtime is about a manic depressive writer who ends up in a mental hospital.

From working with her, Streep found how very disciplined Fisher is. She is focused and stays on task. For Fisher, working in spurts that may coordinate with her manic highs can be a good thing. "She has wonderful, undeluded inspirations. She has told me that she is sometimes reluctant to ameliorate a productive state by dulling it with medication," says Streep.

Friend and actress Meg Ryan agrees that Fisher has some tendencies to mess with herself, but she gets herself back in line. "She manages this disease with enormous integrity. She's a great example of how to do it, and she's very serious about it. She's serious about being a good mom and a good friend."

Fisher takes her role as parent very seriously. In fact, she will not take on any projects that might compromise her time with Billie. Streep notes, "Some mothers tend to use a high-pitched voice with their children. Carrie doesn't." She speaks to her daughter like a friend.

That loyal family and friends surround her is a testament to her character. After her hospitalization, she threw a well-attended party. "I was worried about how everyone would react to me." But as always, her humor saved her. She rented an ambulance and a gurney that had a life-size cutout of Princess Leia hooked up to an IV. "She plucks out that thing that would destroy the rest of us. Then she makes fun of it," says Streep. "I'm sure it saves her."

In her own words

A chat with Carrie Fisher

Q: Many of us know you as Princess Leia, the invincible heroine of Star Wars. Are you invincible?

Carrie Fisher: No. I don't think that anybody's invincible, but I can certainly outlast things. I don't want to be thought of as a survivor because you have to continue getting involved in difficult situations to show off that particular gift, and I'm not interested in doing that anymore.

Are you saying you'd like to have some peace in your life?

I don't want peace, I just don't want war.

At what point in your life did depression or mania become evident?

I was diagnosed at 24, but I had been seeing a therapist since I was about 15. I didn't like the diagnosis. I couldn't believe the psychiatrist told me that. I just thought it was because he was lazy and didn't want to treat me. I was on drugs, too, at the time, and I don't think you can accurately diagnose bipolar disorder when someone is actively drug addicted or alcoholic. Then I overdosed at 28, at which point I began to accept the bipolar diagnosis. It was [Richard] Dreyfuss who came to the hospital and said, "You're a drug addict, but I have to tell you that I've observed this other thing in you: You're a manic-depressive." So maybe I was taking drugs to keep the monster in the box.

What happened after the hospitalization?

I spent a year in a 12-step program, really committed, because I could not believe what had happened--that I might have killed myself. During that year, I started having episodes that were very unpleasant and very intense. Someone would hurt my feelings, and I would get upset and stay upset for hours. I'd sit in my house sobbing, unable to stop, inconsolable. Sometimes I'd get very frustrated, I broke a lot of phones. This was embarrassing to me because I really didn't think of myself as temperamental and spoiled. There was a lot of shame associated with some of the behaviors that I had. I went to a doctor and told him I felt normal on acid, that I was a light bulb in a world of moths. That is what the manic state is like. He put me on lithium. I liked that for a while, but soon I missed my little pal, my up mood. I didn't fully accept the bipolar diagnosis. I thought, well, everybody's moody...maybe I'm just telling myself a story. Maybe there's no such thing. Maybe it's an exaggeration. I went to Australia to do a film. I went off the lithium, and if I was ever manic, it was then. It came back with a vengeance and it wanted to go traveling and we (me and the mood and my brother) ended up in China because it was near. I looked at a map and I thought, "It's only six inches away. That's great."

So now you're in China, totally manic, and you're off your medication.

Yes, and a lot of it was funny in the beginning. I would just go on these rambles. For example, we went to the Great Wall of China and they said, "The left side is where the Chinese people go up, and the tourist side is on the right because it's easier..." And I thought, "They're lying to me," because I knew that at Disneyland, the left side of the Matterhorn was faster than the right side. This is the kind of logic I have when I'm manic.

When did you finally accept the fact that you were suffering from bipolar disorder?

I didn't accept it fully until I had the psychotic break four years ago, in 1997. There was a lot of pressure in my life. I was still wrangling with my moods, and I was living in a house, which is a lot of responsibility. I had a child, and for her sake I was trying to act as if I hadn't been hurt by her father, who had left me for a man. I was hiding, and I am not used to doing that. I just started to feel weirder and weirder, and I think I was improperly medicated. I was intermittently on drugs at this time too. I got unbelievably depressed. My daughter was going to camp, and I would get up every day out of this bed, this swamp, and go pick her up. That was the most complicated thing in the world. I don't know how I did it. It must have been very unpleasant for her. I went to a doctor who gave me all these new medications that sounded like they came from Venus--they had no vowels in them--and something very bad happened. The medications collided, and I became very, very ill. I collapsed, I stopped breathing, and I was taken to the hospital where they sent me home and put me on a "medication vacation." I didn't sleep for six days, and I was scared. My mind split open, and some bad thing oozed out, and that's what I was left with. I thought that if I fell asleep I would die. I wasn't connecting at all, but I kept talking and talking and talking. At a certain point, I lost my mind. The birthing was over, and I got to the other side of the looking glass. When I went back to the hospital, I was hallucinating.

How long was the treatment?

I'm not sure how long I was in the hospital, but I was an outpatient for five months. Afterward, my friend Penny Marshall and I had our big annual party. All the tables had IV hookups on them with colored water, and the cake was me in bed with Penny visiting. It was performance art. It was beautiful.

How are you now?

I'm fine, but I'm bipolar. I'm on seven medications, and I take medication three times a day. !his constantly puts me in touch with the illness I have. I'm never quite allowed to be free of that for a day. It's like being a diabetic.

Do you feel at this point that the problem is under control?

No. I feel that the medication that I'm on can handle it, but I still have the impulse to ride the "white lightning" again.

Do you have a message for people who suffer with bipolar disorder?

Oh, yes. You can outlast anything. It's complicated, it's a job, but it's doable. One of the greatest things that happened for me was that psychotic episode. Having survived it, I now know the difference between a problem and an inconvenience. Bipolar disorder can be a great teacher. It's a challenge, but it can set you up to be able to do almost anything else in your life.

You do seem like Princess Leia, after all--conquering foes even darker than Darth Vader. Is there turmoil in your future?

Most likely. I would like to keep that to a minimum. But now I know how to put these things in perspective.

Treating Bipolar Disorder: Present and Future

Bipolar disorder is a long-term illness requiring long-term treatment. Mood-stabilizer medications remain the mainstay of treatment. Lithium's effectiveness has been well-established for more than 30 years, end carbamazepine end valproate have also become widely accepted first-line treatments in the past decade. In general, these medications are effective in controlling symptoms of both depression and mania or agitation.

Antidepressant medications used to treat unipolar depression are a common supplement to mood stabilizers, but may actually trigger high or manic episodes--especially if used alone. These treatments are at least moderately effective for 50 to 75 percent of bipolar disorder sufferers.

Unfortunately, these standard treatments are often ineffective or only partially effective. To address this gap, recent research has identified several promising alternatives. Newer or atypical antipsychotic medications such as olanzapine, risperidone and quetiapine appear to help control manic episodes. Several new anticonvulsant or antiepilepsy drugs such as lamotrigine, topiramate end gabapentin may also help stabilize mood when traditional medications prove ineffective. Five years from now, there should be a wider range of effective mood-stabilizer medications to choose from.

Several forms of psychotherapy or counseling have also been developed specifically for treatment of bipolar disorder. Cognitive and behavioral treatments focus on recognizing early warning signs, interrupting unrealistic thoughts and maintaining positive activities. Social rhythm therapies focus on maintaining healthy patterns of sleep, activity and social involvement, while family therapies look at the ways family interactions can either support or undermine stability and health. Recent research suggests that these treatments may be valuable treatment components, adding significant benefit to medication management.

To successfully treat bipolar disorder, persistence is key. Different treatments help different people, and individual response to a particular treatment is difficult to predict. Side effects of medication also vary widely and unpredictably, but if treatment is unsatisfactory, good options likely remain. The one common element in any successful treatment is a long-term partnership with healthcare providers.

--Gregory Simon, M.D., M.P.H.

Carrie's Biography

1956: Born to Debbie Reynolds and Eddie Fisher

1972: Broadway debut in Irene, starring her mom

1975: Attended Central School of Speech and Drama, London. Appeared in first film, Shampoo

1977: Through 1983: Appeared in the classic Star Wars film trilogy as Princess Leia

1983: Married pop icon Paul Simon, divorced after 11 months

1987: Wrote autobiographical novel, Postcards From the Edge

1990: Wrote novel Surrender the Pink, about her marriage to Simon and wrote screenplay for Postcards

1992: Gave birth to daughter, Billie Catherine

1994: Wrote novel, Delusions of Grandma

2000: Cowrote These Old Broods, starring Debbie Reynolds

Since 1980s: Appeared in films--including When Harry Met Sally as witty best friend

Since 1990s: Script-doctored films including Hook, Sister Ret, Lethal Weapon 3, Outbreak, The Wedding Singer

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Sunday Times of London
DECEMBER 09 2001

It has a brutal history. We don't know how, or even if, it works. So why do we still give electric shocks for depression? Kathy Brewis investigates.

Some countries refuse to use it. Scientists have little idea how it works, and precious few doctors have been properly trained to administer it. But in contrast with much of the rest of Europe, patients in Britain are routinely sedated and shot through with electricity, in an attempt to fix their troubled minds. The horror stories surrounding electroconvulsive therapy (ECT) abound. This is the poet Sylvia Plath's grimly eloquent account from her autobiographical novel The Bell Jar: ''Don't worry,' the nurse grinned down at me. 'Their first time, everybody's scared to death.' 'I tried to smile, but my skin had gone stiff, like parchment. Doctor Gordon was fitting two metal plates on either side of my head. He buckled them into place with a strap that dented my forehead, and gave me a wire to bite.

'I shut my eyes. There was a brief silence, like an indrawn breath. Then something bent down and took hold of me and shook me like the end of the world. Whee-ee-ee-ee-ee, it shrilled, through an air crackling with blue light, and with each flash a great jolt drubbed me till I thought my bones would break and the sap fly out of me like a split plant. 'I wondered what terrible thing it was that I had done.'

In the popular mind, ECT is barbaric, a brutal abuse of power by men in white coats. Its portrayal in films such as One Flew over the Cuckoo's Nest and famous real-life cases from the 1950s and 60s have only added to the guilty verdict. Ernest Hemingway, given about a dozen shocks in an attempt to ease his recurring depression, found the resulting memory loss unbearable and shot himself a few days later. 'What is the sense of ruining my head and erasing my memory, which is my capital, and putting me out of business?' he asked. Vivien Leigh underwent a series of shock treatments as part of a 'care' regime for manic depression, which left her, as her husband Laurence Olivier put it, with 'slight but noticeable personality changes... She was not, now that she had been given the treatment, the same girl that I had fallen in love with'.

So far, so damning. So how can ECT continue to be used as a treatment for depression, albeit with modifications (now the patient is anaesthetised, and a muscle relaxant is given to prevent the body jolting and possible broken bones)? The answer is simple: it is still used because most psychiatrists believe that it does some good - that it can even save lives. The Royal College of Psychiatrists, the professional body to which all psychiatrists belong, claims an 80% success rate for the estimated 12,000 Britons who receive ECT for severe depression each year. But there is a reason why ECT has been so demonised, beyond the violent images and a level of distrust of psychiatrists: nobody has adequately explained what goes on when those 220 volts zip through your brain. 'It works, we're just not sure how,' psychiatrists say. One doctor described it thus: 'Psychiatrists are constrained to tuning very high-tech internal combustion engines, but they are only allowed to listen to the exhaust note. Sometimes slamming the bonnet makes it go. If it works, why not?' Which sounds scarily cavalier.

There has, however, been a scientific drive to understand ECT. In recent years, various hypotheses have been put forward to explain how ECT might be acting on the brain, all of which assume that depression is a physical illness. One theory is that inducing a seizure causes a shift in the body's neuroendocrine system so that stress hormones are kept in balance. Another is that artificially inducing a seizure somehow taps into the brain's natural ability to stop seizures. A third idea is that the electricity somehow changes the level of chemicals in the brain. These are tiny pieces of an intricate jigsaw that may or may not fit together one day.

Now leading researchers here and in the United States are making an extraordinary claim: ECT works by causing brain cells to be renewed. It has been known since the mid-1990s that new nerve cells (neurones) form throughout a person's life in the hippocampus, a brain structure known to be involved in memory and emotion. An American team led by Professor Ronald Duman at Yale university, and others, suggest that depression, particularly if it is stress-associated, results from the death of vulnerable neurones in a region of the hippocampus called CA3. Some of the features seen in depression, such as poor concentration and memory, could reflect this loss of nerve cells - indeed, brain scans of severely depressed patients show that the hippocampus is smaller than it should be. Both antidepressants and ECT have been shown to induce brain cells to produce a protein called brain-derived neurotropic factor (BDNF), which promotes the growth, repair and resilience of neurones. It has been observed that, following ECT, new neurones form and existing ones sprout new connections. Various studies taken together have led to a dramatic hypothesis. 'The research suggests depression causes neuronal cells to be damaged and antidepressant treatments cause the neurones to be regenerated,' says Professor Ian Reid of Dundee university. 'It may be that some of the treatments that people think are rather crude are in fact quite effective rescuers of the dying neurone.'

If this turns out to be true, the potential applications could go beyond treating depression to more obvious neurodegenerative conditions such as Alzheimer's and Parkinson's diseases.

ECT's origins go back to the turn of the 20th century, when mentally ill patients tended to be locked up in asylums and left. Psychiatrists started to experiment with a variety of new 'treatments' for the severely ill, including lobotomy and temporary, insulin-induced coma. One doctor had the idea, based on the (untrue) belief that epilepsy and schizophrenia could not coexist, of injecting epileptics with serum from schizophrenic patients, and injecting schizophrenics with the stimulant Metrazol to induce a seizure. The latter was a hideous procedure - the patient would convulse violently and often vomit - but for mysterious reasons it tended to reduce the symptoms.

In the 1930s, Ugo Cerletti, an Italian psychiatrist, wondered about using electricity as a way to induce a seizure more quickly than with Metrazol. With his assistant, Lucio Bini, he experimented on dogs and found that, yes, electricity could indeed induce a fit. They also sent their assistants to observe pigs being stunned by electricity before slaughter - clearly it was important to get the dose right. By 1938, Cerletti and Bini felt ready to test their method on a human. Their subject was a Milanese man who had been found mumbling incoherently to himself in the railway station. Electrodes were applied to his temples, an orderly put a rubber tube between his teeth to stop him biting his tongue, and the electricity was applied. The patient's muscles jolted but he was not rendered unconscious. 'Not again, it's murderous!' he pleaded - but they carried on. After several shocks they stopped, and he spoke more coherently. After 10 treatments, they claimed, the patient was released 'in good condition and well-oriented', and a year later he had not relapsed.

Now, 63 years later, a refined version of ECT is the treatment of choice for severe depression that has not responded to other treatments, such as antidepressant drugs and psychotherapy. Each year, thousands of people receive ECT and quietly get on with their lives afterwards.

One such person is Professor John Lipton, 62, a university lecturer in the north of England. A softly spoken man, he describes how, 20 years ago, the pressures of academia led to a bout of depression so severe that he more or less ceased to function and finally attempted suicide. 'I bypassed the GP to the extent of overdosing and was taken to the local psychiatric hospital,' he says. 'I was lucky in that there was a new psychiatrist who had worked in research. He suggested ECT. When you're depressed, you're not all that rational. You don't have confidence in your own judgment. You're in a high state of fear, so any rumours you've heard about treatment are likely to be accentuated. I knew that ECT can affect the memory badly. I thought it might damage my ability to work.' The psychiatrist suggested that Lipton should have unilateral treatment, with electrodes placed on one side of his head only, to cause less memory loss.

'You have a headache afterwards,' he recalls. 'It does affect your memory quite badly at the time. It's hard to tell if it's disorientating. If you are depressed, you're not really noticing much that's going on, anyway. A colleague came to see me and it became apparent that he had visited me the previous week, but I had no recollection of it.'

Lipton was in hospital for more than three months. Part of his recovery, he admits, may have been the removal of everyday pressures. 'I can only say that I gradually felt easier in a way that was other, more than just being in there. I began to see things in a more positive light. Actually, it's very civilised. You walk along a corridor, wait outside the treatment room, you go in, lie down, they make you comfortable, and then they inject you. You wake up and you're on a trolley. You collect a series of little bruises from the injections. There's no doubt that your memory does suffer, but I've survived perfectly well in academic practice for 20 years since.'

His memory impairment continues - though it is usually referred to in psychiatric literature as 'temporary'. 'I feel as though there's a part of my memory system that doesn't retain very well,' he says. 'My wife will tell me things that I've said to her and I've no recollection of ever having known it, let alone said it. My capacity to remember things of a trivial sort has disappeared. If I want to be sure to remember something when I go home, I put a note in my sock. I associate it with that time because I had an exceptionally good memory before. But it doesn't seriously impinge on my life.' Not that he wants everybody to know about it, though - he asked that his name be changed for this article.

If this sounds like too easy an acceptance of the side effects of ECT, consider how bad a state Lipton was in before the treatment. His physical symptoms included stomach cramps, a constant feeling of heaviness, tiredness and anxiety and a perpetual state of terror. 'Everything frightens you and you don't know why you're frightened, but you are,' he says. The symptoms became worse, to the extent that he had to take a spare pair of socks to work every day because by mid-morning his feet were squelching around in perspiration. He also had severe dandruff. Finally it was too much. 'I thought, 'I can't stand months of this, feeling permanently suicidal while I wander around hoping I might recover - let's get out of it now while I've still got the courage to do it.''

Yet ECT has many detractors. Campaigning bodies such as the Citizens Commission on Human Rights (CCHR), an offshoot of the Church of Scientology (which is opposed to most aspects of psychiatry) wants ECT to be banned. Brian Daniels from CCHR will tell you that ECT has been used in Nazi concentration camps and other heinous institutions. This may be true, but it misses the point. The answer to misuse is not non-use but correct use. Opponents also used to point to the broken bones resulting from ECT convulsions. Nowadays, however, thanks to the muscle relaxant, the only sign of the electricity passing across their brain is the patient's toes twitching. But this does mean that a higher dose of electricity is needed to obtain a seizure.

Daniels is adamant that ECT has no positive effect. 'All they've done is numbed the person to the point where whatever was troubling them has been completely masked. If you were bashed over the head with a sledgehammer and then told to walk off down the street, you'd walk off going, 'Ow, my head hurts,' but you wouldn't think about your problem.'

He points to people like Diana Turner, 55, who was in her 20s when she had six 'doses' of ECT at a clinic in Worthing, West Sussex. 'Some of the other patients must have had far more than me; they were like zombies,' she recalls. Turner had gone to her GP complaining of headaches. Looking back, she says, they resulted from the tension of running a home; she had three children under the age of four. But she was diagnosed as suffering from depression and referred to a psychiatrist. 'On my second visit, he said, 'If you don't want to take tablets, I've got another treatment that might make you feel better.' So I said I'd try it.' She doesn't remember being told what it was. She was taken to a clinic once a week.

'I lay down and I had to take my shoes off. They said, 'We're just going to give you an injection in the hand,' which they did. The next I knew, I was being shook awake. I was in so much pain, my husband would have to undress me and put me to bed. It took about an hour for me to remember who I was and why I was there.' She returned five times.

'I thought you had to feel worse before you felt better,' she says. 'I was very, very naive in those days.' Finally her husband agreed that she shouldn't return to the clinic. She has memory problems now, including a blank spot that stretches across a year of her daughter's life, and has unsuccessfully tried to sue the clinic.

Pat Butterfield set up ECT Anonymous four years ago, after having ECT in 1989. All its 600 members insist that it has ruined or damaged their lives. It's not just the patients making such claims: their relatives back up their stories with statements like, 'My wife isn't the same as she was.' 'Once [doctors] have given you ECT, they're not willing to acknowledge your experience. They'd much prefer to tell you it's your original illness that's giving you problems,' says Butterfield. 'It [ECT] absolutely wrecks your psyche.' She claims most psychologists are against it. 'Psychologists get what's left of people after they've been through psychiatry.' (Psychiatrists are medically trained doctors; they tend to diagnose and treat depression as a physical ailment. Psychologists aim to help people surmount their symptoms by making sense of their experiences.)

One such psychologist is Lucy Johnstone. She is not popular with the medical profession. In a book published last year, Users and Abusers of Psychiatry, she suggested that problems such as depression and schizophrenia weren't illnesses at all but reactions to events in patients' lives. Two years ago, she published a paper detailing the negative psychological effects of ECT. 'There was a lot of anecdotal stuff, so I decided to investigate what ECT is like if you find it an unpleasant experience,' she says. 'Not everyone finds it unpleasant, but there's a significant minority who do - up to a third. What I found was people reporting very strong negative reactions which had left them feeling they couldn't trust staff. They had to pretend to be better, to avoid having ECT again. They used very strong terms like 'humiliated', 'assaulted', 'abused', 'shamed', 'degraded'. There's a lot of debate about whether ECT causes lasting intellectual damage, but this psychological damage seems to me to be just as important.'

Johnstone admits that she had a biased sample - of people who had responded to adverts specifically asking for subjects with negative experiences of ECT. 'Not everyone experiences ECT like that,' she admits. 'But if a significant number do, and if you can't work out in advance who those people are going to be, then you run a high risk of making people worse, not better.'

She believes that ECT and treatments like it have no place in the care of people suffering from depression. 'All the people I spoke to in my research said that, looking back, there were reasons why they were depressed: their mother had died, they were out of work. If that's the case, then obviously electricity through the brain isn't going to help.

If you think about it, there's no reason why an essentially random blow to the head should have a specific effect on some chemicals that may or may not be related to depression. It's so speculative that there's almost no logical chance of it being true. In psychiatry, a lot of theories are stated as facts.'

Even within the psychiatric profession, there is wide dissent over the use of ECT. It is rarely used in Canada, Germany, Japan, China, the Netherlands and Austria, and Italy has passed a law restricting its use. In the US, where more than 100,000 people are treated each year and numbers are increasing, we find one of its strongest critics: Peter Breggin, the director of the International Center for the Study of Psychiatry and Psychology in Bethesda, Maryland. Breggin has been arguing against ECT since 1979. He says that it 'works' by causing a head injury. The aftereffects of such an injury are memory loss and temporary euphoria, which last for up to four weeks - effects that, he claims, can be mistaken for improvement by physicians and patients alike.

Even those committed to using ECT admit that its efficacy varies. The Royal College of Psychiatrists has commissioned two surveys into the quality and scope of ECT treatment in England and Wales over the past 20 years, both conducted by Dr John Pippard. The first, in 1981, made some appalling findings. 'Only one in four doctors received some tuition, but often not until after he had begun administering ECT,' Pippard noted; '27% of clinics had serious deficiencies such as low standards of care, obsolete apparatus, unsuitable buildings. Included in these were 16% with very serious shortcomings: ECT was given in unsuitable conditions, with a lack of respect for the patients' feelings, by staff who were ill-trained, including some who consistently failed to induce seizures.'

On his return in 1992, Pippard found that ECT clinics had improved in terms of equipment and environment. But he concluded: 'There has been little change in the way psychiatrists in training are prepared for and supervised in what they do in the ECT clinic.' Elsewhere, he said: 'ECT requires more of the psychiatrist than just pushing a button.'

This is because patients' seizure thresholds vary up to 40-fold. In other words, the level of electricity needed to induce a seizure varies dramatically from one individual to another. As far back as 1960 it was shown that the severity of side effects was proportional to the dose of electricity used. This may partly explain the negative experiences of some patients. If ECT were administered at the optimal seizure level for each patient, in ideal surroundings, its efficacy would almost certainly be improved. Practitioners admit that relapse rates are high. Nor is it universally accepted that ECT saves lives. The medical literature on suicide rates after treatment is inconsistent and, in a recent review, Breggin claimed that ECT increased the suicide rate. 'Patients frequently find that their prior emotional problems have now been complicated by ECT-induced brain damage and dysfunction that will not go away,' he wrote. 'If their doctors tell them that ECT never causes any permanent difficulties, they become further confused and isolated, creating conditions for suicide.' He accuses the American medical profession of a cover-up - psychiatrists protecting their own interests to avoid being sued by former patients. In his view, ECT should be banned.

Perhaps the thorniest issue in the ECT debate is consent. In Britain, under the Royal College of Psychiatrists' guidelines, valid consent must be obtained from the patient - based on their understanding 'the purpose, nature, likely effects and risks of treatment in broad terms'. Under common law, valid consent is required before any medical treatment can be given, except where the law provides authority to give treatment without consent. According to the 1983 Mental Health Act, a person is presumed to have the capacity to make a decision unless he or she is considered unlikely to take in, or unable to believe or properly weigh up, the relevant information. In other words, if your doctors believe you aren't in a state to know what's best for you, they will make the decision for you.

As one formerly depressed person put it, 'If you're bad enough to need that sort of treatment, how can you possibly be in a state to make a sound judgment on it?' When it is deemed that any delay in treatment would be life-threatening, patients are treated without their consent. For this to happen, they must first be sectioned, a decision taken by two independent doctors and an independent, specially trained social worker, who must agree that there is no alternative. For ECT to be administered, the opinion of a third doctor must be sought. Still, treatment without consent is interpreted by some as the arrogance of the medical profession versus the powerlessness of the patient. The mental health charity Mind holds that nobody should have ECT against their wishes, whatever their mental capacity.

However, a recent study by Dundee and Aberdeen universities had some surprising results: 150 patients who had received ECT two weeks earlier were asked: 'Did ECT help you?' Of these, 110 said yes. Of the 11 among them who had not consented, nine also said yes. It is possible that some try to give the 'right' answers to health-care professionals, and that two weeks after treatment they may be too confused to give a true answer. But it is hard to dismiss these findings. Think of the alternatives, and the desperate need of those to whom ECT is given. Cognitive behavioural therapy has proved as effective as antidepressant medication for moderate depression, but there is a long waiting list. Antidepressant drugs, on the other hand, are unsuitable for pregnant women, as they can affect the foetus, and they have side effects that the elderly are far less able to tolerate. For them, ECT is often prescribed instead.

A governmental committee set up in 1999 to investigate ECT as part of an overall review of the 1983 Mental Health Act recommended that it continue to be used, within strict guidelines, both with and without patient consent. The committee's findings and recommendations were published in a white paper at the end of last year, and legislation is being drafted for a bill that will be debated in parliament.

Research is under way into a proposed alternative to ECT: repetitive transcranial magnetic stimulation (rTMS), which stimulates the brain using a magnetic field and is not thought to impair memory. But at present it is of limited use. ECT is here to stay, at least for the near future, and research into how it works continues.

'If we understood how ECT worked in detail, then we'd have the opportunity to replace it with something better,' says Professor Reid. Meanwhile, he has instructed his colleagues that if he ever has a severe depression, is not eating or drinking and is trying to kill himself, 'Please make sure I get the right treatment.' He says that if he, or anyone he cared about, had a depressive illness to the point of being suicidal, he would want them to have ECT: 'A psychotic depression is like your worst nightmare.' It's the one statement on which everybody agrees.

next: Woman Says Electric Shock Treatment Destroyed Her Life
~ all Shocked! ECT articles
~ depression library articles
~ all articles on depression

In Niuean, the message said: "I have been given electric shock by the people, Mum. The pain is very bad."

The writer: Hakeaga (Hake) Halo, then aged 13, writing to his grandmother in Auckland from Lake Alice Psychiatric Hospital near Wanganui in 1975. The medium: a speech bubble written in Niuean next to a smiling face at the end of a letter. In the letter itself the boy assured his family, in English, that the nurses and psychiatrists at Lake Alice were treating him well.

"You are not allowed to seal the letters, so they can read them and make sure nothing had been written bad about the staff and the hospital," he says. "If anything happens bad, they just rip it up and throw it in the rubbish. That happened to everyone that writes some letters. "You have to write a letter saying, 'No problem.' But all the time, deep down, you are still thinking and wondering, 'What can I do to get my message out to my parents?'

"I just praise the Lord for the guy that explained to me to draw a happy face at the end of the letter and write a message in Niuean in the speech bubble. They thought, 'He's just saying, Hi Mum'." Hake Halo's messages, with help from a courageous teacher at Lake Alice, Anna Natusch, eventually reached the Auckland Committee on Racism and Discrimination (Acord) and, through it, the Herald, which published a front-page story in December 1976.

The next month, the Government appointed a judicial inquiry. Although the judge, W. J. Mitchell, found that electric shocks were not used as a punishment, he confirmed that Halo was given shocks eight times, six of them without anaesthetic. A quarter of a century later, another Government finally apologised this month to Halo and 94 other "children of Lake Alice" who fought a four-year battle for compensation. The state has paid them $6.5 million, of which just over $2.5 million has gone to their lawyers.

The case is not just of historical interest. Electric shock treatment is still practised in 18 New Zealand public hospitals, although these days with anaesthetic. And it is doubtful whether we yet have the ideal answer for difficult children of the kind sent to Lake Alice.

Hake Halo was born in Niue in 1962 and adopted by his grandparents. The family moved to Auckland when he was 5 and he started school knowing no English. He suffered from epilepsy. He told the Weekend Herald this week: "They put me into a special class ... I couldn't speak English, so they said I'm a handicapped." Judge Mitchell's report said the boy was referred to the School Psychological Service because of "behavioural difficulties" in his first year of school. Two years later, he was admitted to the children's hospital for "hyperactivity."

After cutting his hand on a window when he was shut out of class, he was sent to a psychopaedic hospital. He changed schools, but began appearing on police files when he was just 11. "I was getting into trouble with the law all the time and stealing - mixing around with the wrong friends," he says. Judge Mitchell's report said that, at 13, Hake Halo threatened his mother with scissors and tied string around the neck of a baby cousin. He was sent to Owairaka Boys' Home, and soon afterwards to Lake Alice.

His psychiatrist there, Dr Selwyn Leeks, in a passage which outraged Acord, reported:

"He was to be a living memorial to the inadequacies of the immigration system in New Zealand. He behaved very much like an uncontrollable animal and immediately stole a considerable amount of staff money and stuffed it into his rectum. He was faecal smearing, attacking and biting all who came near him."

The medical records confirm that he had a course of electro-convulsive therapy (ECT). The way he describes it now, he actually got electric shocks of two kinds. When the shocks were for "treatment", the shock was so intense that he became unconscious instantly. In his report, Judge Mitchell accepted the psychiatrists' word that ECT always had this effect.

But Halo says there were other times when he did not lose consciousness, and felt "the worst pain that you can ever feel". "It just feels like someone is whacking your head with a sledgehammer, like someone whacking at full speed," he says. "There are purple lines going through your eyes, ringing in your ears at the same time.

"But the worst part is the pain. You are lying down, then your whole body is jumping up on the bed. Once they turn it off, you fall back down on the bed."

On these occasions, Halo believes that he did not have ECT at all, but what psychiatrists call "aversion therapy" - what you or I would call "punishment". He was alleged to have held a child's hand on a hot radiator, and to have bitten other children - claims he denies.

"I was named as an 'uncontrollable animal' in there. I swear to God I was never that."

He believes he was also given the drug paraldehyde as a punishment. This was injected just above the buttocks and was so painful that it was impossible to sit down for several hours. "Dr Leeks or the staff nurses will do it - Dempsey Corkran and Brian Stabb are the only two that I can remember," he says.

Before going to Lake Alice, he says, the epilepsy he had suffered in early childhood had gone. But after the electric shocks it returned, and he still suffers from both epilepsy and "these old attacks". He still suffers memory loss which began with the electric shocks. "You go to jobs, they tell you what to do, then you forget about it."

Halo is married with four children aged 8 to 19. He is now a lay preacher in the Church of God and works as a volunteer with the elderly. But throughout his life the memory loss and recurring epileptic fits have made it impossible for him to keep a job, apart from one seven-year stint at PDL Plastics "because the foreman understood my problems".

WHAT Lake Alice did to Halo and other children in the 1970s is in some ways unique. It became a psychiatric hospital only in 1966, and closed in 1999. The Child and Adolescent Unit was created in 1972, and closed in 1978 after the public horror aroused initially by the Halo case. Apart from the 95 former patients who have just won their case against the Crown, there may be around 50 others who were in the unit up to 1977, when Dr Leeks left. The Government is offering compensation to them, too, if they contact the Ministry of Health.

Shane Balderston, who was in the adolescent unit for a weight problem, says hearing people get electric shocks was "terrible". "I know one boy out there, he was a newcomer, he pinched money off the office table and stuck it up his bottom. He went for a shower one night and they found it, and he was sent to a room nude and got a needle in his testicles."

Warren Garlick, now an information technology consultant in Chicago, counts himself lucky for getting ECT without anaesthetic only once when he was in the unit between 1974 and 1977. He remembers being "thrown against the wall and given a chokehold" when he misbehaved.

Carl Perkins, later a member of the Maori reggae band Herbs, says several staff members once got him angry by tipping over a jigsaw and making him put it back together while he was in the unit in 1973. When one of them hit him on the head, he pushed the jigsaw off the table. One of the male nurses then jumped on him and gave him an injection of paraldehyde. Then he was wheeled into a bedroom and given an electric shock - the first of what he now believes was a series over the next two weeks. During that fortnight his grandfather visited, and was devastated to see a "zombie".

Perkins now plans to complain to the Law Society over the $2.5 million in fees and costs which the lawyers took out of this month's payment, and to lodge a claim with the Waitangi Tribunal to compensate for his "unlawful incarceration".

Sir Rodney Gallen, a former High Court judge who was hired to share out the $6.5 million among the claimants, concluded in his report that the children at Lake Alice "lived in a state of terror". "The administration of unmodified [without anaesthetic] ECT was not only common, but routine," he found. "What is more, it was administered not as a therapy in the ordinary sense of that word, but as a punishment ...

"Statement after statement claims that children were subjected to ECT administered to the legs. This seems to have occurred when children had run away from the hospital ... "Several claim, and there is corroboration from other unrelated statements, that ECT was administered to the genitals. This seems to have been imposed when the recipient was accused of unacceptable sexual behaviour."

Sir Rodney found that other punishments included injecting paraldehyde, solitary confinement without clothing, and in one horrifying case a 15-year-old boy was alleged to have been locked in a cage with an insane man. "He crouched in the corner being pawed by the particular inmate, screaming to be released." How could such things possibly have happened in God's own country?

Dr Leeks, now practising in Melbourne, is under legal advice not to talk because he faces possible disciplinary and legal actions now that the Government has admitted fault and apologised to his Lake Alice patients.

But he told the Weekend Herald: "The treatment itself is being grossly misrepresented, but aversion therapy - as it was given, not as it is said it was given - was fairly effective, and there was improvement, which didn't altogether last, for a large number of them. "For the ones who are complaining, it obviously didn't last, or didn't last as long as it might have. "The ones that had it are a relatively small number of the total youth that went through."

Dempsey Corkran, the charge nurse in the adolescent unit from 1974, says: "I worked for 34 years in that job [Lake Alice], and I felt really good about the things I did. Now I'm feeling like a criminal." Brian Stabb, who arrived from Britain as a long-haired 25-year-old nurse at about the same time Corkran took over, says Corkran made it clear there would be no more use of electric shocks as punishment. He says Corkran was "a superb model of nursing". "There was a family atmosphere, we became family figures," Stabb says. "Dempsey was the father figure, one of the female staff became the mother, I was a kind of big brother."

As in any family, there was discipline. Stabb remembers giving Hake Halo an injection after finding him in the corridor with a smaller boy. "He had his hand on the hot water pipe of the radiator and was burning the boy." Asked whether the injection was paraldehyde, he says: "It may have been ... When you have incidents of violence, especially ongoing, and you want to sedate the boy, paraldehyde was often the drug of choice."

Yet Stabb accepts that there was some cruelty. Once, he objected after he helped Leeks give an electric shock without anaesthetic to a youth who had run away. Leeks told him not to question his clinical judgment, and reminded Stabb that he lived in a hospital house. "I think that Dr Leeks put himself above being personally affected by administering such treatment, and in so doing, failed to recognise the development of his own sadism and that of some of the staff that worked for him."

STABB, who later blew the whistle publicly on "cultural safety" when he was a health tutor at Waikato Polytechnic in 1994, believes the main flaw in the system in the 1970s was that psychiatrists were "all-powerful". That has changed, he says. Nurses are now trained to question doctors rather than just carry out orders. ECT is now done with an anaesthetic. But it is still common. Margaret Tovey, who organised a recent national ECT seminar, says 18 public hospitals in New Zealand run ECT clinics.

"It is most commonly used for severe depressive disorders, and there are some cases in mania and schizophrenia where it may be an appropriate treatment as well," she says.

Dr Peter McColl, a psychiatrist at North Shore Hospital, says most clinics of any size would do two or three ECT sessions a week, with an 80-90 per cent success rate in jolting people out of depression. The Health and Disability Commissioner's office has received only four complaints about ECT since the office was set up in 1996. Three of those were too outdated to be considered, and the fourth is still being investigated.

With the old mental asylums gone, psychiatric patients have been moved into the community - a policy that Brian Stabb worries may have been pushed too far to save money. "If you look at the inpatient beds in New Zealand for 10 to 16-year-olds, in mental health units I doubt that you would have 12 to 14 beds," he says. He believes the best way to deal with difficult children is to work with the whole family.

In one community in Finland, he says, the incidence of schizophrenia was cut by 85 per cent over 10 years by sending in a team of mental health professionals to help families as soon as trouble started.

But Stabb also believes that there is still a place for asylums: "A place of rest and peace away from the community for a short period of time can be a healing experience."

The president of the Psychological Society, Dr Barry Parsonson, says "aversion therapy" is no longer an accepted procedure because people tend to revert to their old behaviour as soon as the punishment stops. Instead, he recommends finding ways to positively reinforce good behaviour.

None of these changes can restore peace of mind to the 150 teenagers, such as Hake Halo, whose lives were traumatised forever by what they experienced at Lake Alice. But perhaps the full realisation of what happened there may be a spur to finding better ways to help young people who get into trouble.

Lawyer Goes After Lake Alice Doctor

27.10.2001
By SIMON COLLINS
New Zealand Herald

The lawyer who won a $6.5 million payout for 95 former patients of Lake Alice Psychiatric Hospital says he is now "highly likely" to seek a criminal prosecution of the psychiatrist who was in charge of the hospital's adolescent unit, Dr Selwyn Leeks. The move, if accepted by the police, would mean extraditing Dr Leeks from Melbourne, where he now practises.

It follows a formal Government apology this month to the former patients, who all claim to have been given electric shock treatment or injections of a painful sedative, paraldehyde, as punishment for misbehaviour in the clinic during Dr Leeks' tenure between 1972 and 1977. Their Christchurch lawyer, Grant Cameron, has written to all the patients seeking their consent to pass their files to the police. "I believe there is a prima facie case to show that he [Dr Leeks] committed either 'assault on a child' or 'cruelty to children', both of which are offences under the Crimes Act," he said. "There are other offences relating to 'assault' which may also apply.

He said the case did not come under any of the categories where time limits on prosecutions apply.

"In a lot of these cases, the direct evidence of individuals is compelling, and in many cases it is corroborated.

"I think it is highly likely we will be lodging a complaint with the police."

He said complaints may also be laid against half a dozen other staff "who assisted in the application of ECT [electro-convulsive therapy] or gave it directly without a doctor, or gave paraldehyde in cases where they shouldn't have, or physically assaulted claimants or locked them away in solitary confinement in circumstances where there was no justification."

next: Testimony of John M Friedberg M.D. Neurologist
~ all Shocked! ECT articles
~ depression library articles
~ all articles on depression

The causes of terrorism fear and war fear and how to cope with persistent fear of terrorism and war.

Dr. Cox is President and Medical Director of the National Anxiety Foundation. The word "National" in National Anxiety Foundation refers to the nation of the United States of America. The following medical information is written specifically for the enlightenment of the citizens of the United States of America. However, in the international scope, terrorism affects almost everyone on earth. Citizens of every country may be helped by this information.

War and terrorism are powerful causes of fear. A change in behavior caused by fear is the desired effect and the purpose of terrorism. Combating this fear is not just desirable. Combating this fear is the duty of each and every citizen. And helping other citizens to fight this fear is the duty of every citizen. Mitigating your fear and alleviating fear in others is your obligation. But how do you fight fear?

You will notice I am not using the word anxiety here. I use the word fear. Anxiety often refers to the feeling or emotion of fear when the cause of the emotion is sometimes obscure. I don't think the phrases "terrorism anxiety" or "war anxiety" make much sense after September 11, 2001. Terrorism fear and war fear makes a lot of sense to me. People during this time of terrorism are not unclear about where their fear is coming from. They know exactly what they are afraid of and it is not an irrational anxiety.

First, to understand fear more completely, let's consider what the opposite of fear is. A lot of unpleasant emotions have an opposite emotion. Opposites are words like good and bad, up and down, and light and darkness. Some emotions have opposites, like sad and glad. The emotion fear actually has two opposites when one really thinks about it. The two opposites of fear are (1) courage and (2) peace of mind. To eliminate fear, we should replace it somehow with one or both of its opposite emotions - courage or peace of mind.

To change an emotion from one emotion to another, you must change the thoughts that lead to that emotion. That is because, except in the case of a so-called "clinical imbalance psychiatric disorder," our emotions stem from our thoughts. If I think fearful thoughts, guess how I am going to feel emotionally? I am going to feel afraid; but, if I exert effort to force myself to think courageous and brave thoughts, or to think peaceful, calm thoughts, I am going to feel how? I am going to feel more brave or feel more peace of mind.

Every time you feel afraid, it should help to think courageous thoughts or calming thoughts. This is not rocket science. If you have ever had a friend who was frightened and you tried to console them, what did you tell them? You didn't agree with them and tell them that whatever dangerous possibility they were afraid of was certain to occur. No, you tried to reassure them that in your opinion they overestimated the actual risk of harm and the situation was not as dangerous as they told themselves it was.

It can help to identify and write down what fearful thoughts you are thinking. Often, when you write down on paper your actual fearful thought and then read it, you can more easily see that it is untrue or that it is an exaggeration of a very unlikely risk of harm. Once you realize you are thinking an exaggeration, you can more easily change your thought to a less frightening or less exaggerated thought. That less frightening thought will lead to a less frightening emotion. Here are some examples of irrational, fearful thoughts and some improved, truthful, less frightening thoughts.

FLYING

Irrational fear thought:

"I think I'm likely to die from an attack by terrorists if I fly on an airline. I am going to cancel my ski trip" (this thought causes fear).

Braver and calmer, rational alternative thought:

"I refuse to scare myself by allowing myself to predict catastrophes that are going to happen to me. The truth is that I don't have a crystal ball. The truth is that I don't know the future. Something bad might happen to me but that is unlikely. There were about 5000 planes aloft in the United States air space at the moment the Word Trade Center was attacked. In that two-hour period that the World Trade Center was attacked, there were only 4 planes out of about 5000 that were attacked; therefore, about 4,996 planes were not affected. Even on September 11, 2001 at 9:00AM my risk of my plane being hijacked was only 4 chances out of about 5000. So there were 4996 chances out of about 5000 that my plane would have arrived safely even on that morning of 9/11/2001. With the increased security, safeguards and watchfulness, it is probably even much safer to fly today than it was that day. Flying never was guaranteed to be completely safe. Several planes crash every year around the world, but that risk didn't keep me from flying in the past. This terrorism risk adds only a very tiny risk to the overall risk that I previously accepted without giving it much thought" (this sensible thought alleviates fear by leading to a braver and calmer emotion).

ANTHRAX

Fearful, irrational thought:

"I am going to try and talk my family out of going to Florida to visit my aging parents. We will all catch anthrax and die."

Braver and calmer, rational alternative thought:

"I refuse to upset myself by allowing myself to predict that a catastrophe will happen to me and my loved ones. Several million people live in Florida and only a few persons have contracted anthrax in the whole state; and out of all of those, only one or two died. My farmer grandfather once had sheep that contracted anthrax, but nobody panicked about it. It makes no sense to avoid a trip to Florida when last year I went to Central America knowing I could catch drug resistant malaria (which I know is fatal). I refuse to let terrorists win by changing the way I do things. I am going to stop frightening myself about anthrax and go to Florida and live my life the way it is normal and right to do" (These thoughts fight fear by leading to the braver and calmer emotion).

POISON WATER

Irrational fearful thought:

"I am afraid to drink anything. What if terrorists poison the water supply?"

Braver and calmer, rational alternative thought:

"I refuse to scare myself out of drinking water and other beverages because of this irrational exaggerated thinking. Although it's possible that a terrorist might try to poison some reservoir somewhere, it is extremely unlikely. There are thousands of water systems in this country. The odds are slim that terrorists would target the water system in my local area to contaminate. Testing and water treatment would probably eliminate such contamination anyway" (This logical thought fights fear by leading to a braver and calmer emotion.).

MASS GATHERINGS AT PUBLIC EVENTS Irrational fearful thought: "I am not going to the World Series. There might be a terrorist attack." Braver and calmer, rational alternative thought: " I refuse to scare myself out of activities that I enjoy by allowing myself to think scary thoughts that are very unlikely to happen. I am a patriot. I am going to do more than tape up an American flag on my car window. Winston Churchill, during the darkest hours of the German air attack on England, rallied his countrymen with the motto, 'Deserve Victory.' I am going to live my life as normally as possible. I'll do this as a patriot and as a defeat to terrorists who seek to have citizens of my country cower from their usual way of life. By doing this, I will do my part to 'Deserve Victory'."

Survival Tools For Alleviating Terrorism Fear:

Courage

• Fly airlines again
• Travel on business and for pleasure
• Invest in securities

Patriotism

• Enlist in the armed forces
• Fly or display an American flag
• Register to vote (and vote)
• Run for public office

Distraction

• Read a novel
• Engage in a hobby
• Paint the house
• Buy a pet
• Get back to your everyday routines.

"Hope for the best. Be prepared for the worst"

• Have 3 gallons of drinking water per person stored.
• Have food that does not require refrigeration or cooking.
• Have a flashlight and batteries, matches and candles.
• Have some currency cash on hand.
• Have a weeks supply of regularly taken medications.

Decrease stimulus

• Turn off excessive TV news
• Change the topic in conversation from catastrophe, doom and worry

Relaxation

• Exercise
• Go to bed early
• Take a hike in the woods with your family or friends
• Do something that you enjoy like going for a drive, or playing with your dog.

Self-expression

• Put your feelings into words
• Talk to a friend about your fears. Listen to their fears.
• Write a journal to express your thoughts and feelings

Compartmentalize

• Allocate only a reasonable amount of time to each of your stresses

God

• Go to church
• Donate to Charity (church, National Anxiety Foundation, Red Cross, Salvation Army)
• Prayer

Humor

• Listen to a Carl Hurley tape
• Watch a comedian monologue about terrorism
• Read political cartoons

Reason and Logic

• Stop expecting the worst
• Think of how very unlikely harm is to come to you or your loved ones

For Children:

• Tell them that they really are safe.
• Keep to your usual routines.
• Keep them from seeing too many frightening pictures of the events.
• Teach them repeatedly not to play with white powder as a joke or prank. It is not funny. It is illegal. It is disrespectful to their country and their fellow man.
• Teach them to respect all people including Muslims and those appear to be "Persian".

How do I know if I need professional mental health help?

There is no simple way you can be sure about this, but here are some guidelines, any one of which might suggest it to be worthwhile to have an assessment visit with a mental health professional:

• Being an actual, direct victim of terrorism
• Excessive nightmares about terrorism
• Loss of normal emotions toward loved ones
• Feeling numb emotionally
• Unusual change in sleep habits or appetite
• Excessive fatigue
• Loss of interest in usual activities
• Unusual startling to sudden noises
• Excessive crying or guilt feelings.
• Can't go to work
• Drinking alcohol excessively or taking non-prescribed drugs
• Persons who know you intimately think you should get help

What might a mental health professional do to help me?

Most people will not require treatment by a mental health professional. Unfortunately, a few persons who were actual victims of injury or who were there and witnessed the injury of others may suffer from post-traumatic stress disorder (PTSD). PTSD can be treated with talk therapy, medication, or both. Talk therapy is special counseling or psychotherapy. Some of these persons may benefit from a PTSD medication such as Paxil (paroxetine) or fluoxetine. Some persons may require anxiety medications such as alprazolam. Depressed patients may require an antidepressant, for example, Celexa (citalopram), Effexor XR (Venlafaxine), Paxil (paroxetine), Remeron, or Wellbutrin (bupropion).

Seeking help

What kind of health care professional should I see if I want a consultation?

The first step should be to have a medical evaluation to determine the proper diagnosis. Your family physician is the good place to start. Tell him or her what has been happening to you and that you wonder if you might have PTSD, depression or another anxiety disorder. Print this document, circle the items that concern you, and show it to the doctor.

After the evaluation perhaps the doctor will tell you that you do have a disorder. Then what? You may wish to see a psychiatrist.

Psychiatrists are physicians (MD's or DO's). A psychiatrist who is experienced in treating such disorders is perhaps the most qualified single professional to deal with the problem. There is a national shortage of psychiatrists. There may not be one in your area, or your HMO may not allow you to be seen by one of their psychiatrists. In these instances, seeing your regular doctor for medication and consulting a psychologist for cognitive-behavior therapy is good. Psychologists are not physicians (instead of M.D. or D.O., they may have other abbreviations after their name such as Ph.D. or Ed.D. or Psy.D.). If a psychologist isn't available for therapy, a social worker that is familiar with this therapy can be very helpful.

Terrorism is a terrible and evil thing. We all despise those who have inflicted this scourge on today's world. We look forward to days when we all feel a little safer at home and abroad. Until that time there are things we can and must do to help our loved ones our neighbors and ourselves. I hope this information has helped you.

Stephen Michael Cox, M.D.
President / Medical Director
National Anxiety Foundation

Dr. Cox wishes to gratefully acknowledge the helpful assistance of The Center for Post Traumatic Stress Disorder in preparing this work.

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Older girls with ADHD are going undiagnosed and untreated. Many of these girls with ADHD also have depression and anxiety.

Older girls with attention deficit hyperactivity disorder are more likely than younger girls to also suffer from depression and anxiety, according to a new study. These girls also often have higher IQ scores than boys with the same diagnosis, the researchers found in the study published in the October issue of the Journal of Developmental and Behavioral Pediatrics.

Taken together, the findings suggest that ADHD may express itself in girls in ways not predicted by previous research, says lead author Pamela Kato, Ph.D. It is also likely that these girls relatively high verbal IQ scores has acted as a barrier to an ADHD diagnosis.

Although millions of children have been diagnosed with ADHD, some believe the disorder is actually under-treated, particularly in girls. According to Kato and her colleagues in the Department of Pediatrics at Stanford University School of Medicine, most studies on ADHD have addressed only boys. The studies that have included girls usually had very few, so the accuracy of diagnostic tests when applied to girls may be called into question.

The researchers reviewed the medical charts of 75 girls who had been diagnosed with ADHD to determine what characteristics they might share regardless of their age, and which features of their disorder might differ among those who were aged four to eight and from age nine to 19. They also compared the girls more generally to boys.

The researchers found that older girls, in contrast to younger ones, often internalized their feelings, were withdrawn, complained about their physical health, had social problems and showed symptoms of anxiety and depression.

Studies on boys, in contrast, have suggested that depression and ADHD seem to develop independent of each other. According to Kato, this new study showed "the nature of the association between the course of theses two disorders in females is unclear" and should be studied.

"Older girls with ADHD in our study also showed areas of strength," Kato says. "We were able to identify a large proportion of older participants by their higher verbal IQ scores," a finding she termed "unexpected because ADHD symptoms have been consistently associated with lower IQ scores, especially verbal IQ scores."

There did not appear to be differences between the age groups of girls with regard to the severity of difficulties with attention and disruptive and impulsive behaviors.

Kato suggests that girls who are being tested for ADHD should also be assessed for depression and anxiety disorders.

Source: Center for the Advancement of Health press release

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Discrimination, stigma and poverty often contribute to minorities not receiving treatment for mental disorders, according to a report presented by U.S. Surgeon General David Satcher.

In a supplement to his first-ever report on mental health in 1, Satcher emphasized that blacks, Hispanics, Asians/Pacific Islanders, American Indians and Alaskan Natives face the greatest challenges, partially because so many within those communities have gone without treatment or have been given substandard care.

"The failure to address these disparities is playing out in human and economic terms across the nation - in our streets, in the homeless shelters, public health institutions, foster care systems, in our prisons and in our jails," Satcher said at a meeting of the American Psychological Association in San Francisco.

The 200-page report, "Mental Health: Culture, Race and Ethnicity," cites poverty and lack of insurance as key factors why many minorities do not receive proper mental health care. It found that racial and ethnic minorities are less likely than whites to have access to treatment, and those who do often receive a lesser quality of care.

"Cost and stigma are two major barriers that we must overcome," Satcher said. "Many insurance plans do not cover the cost of mental health care, and few people can afford to pay for those services out of their pockets."

Satcher urged mental health workers to use such factors as language, religion and folk healing to reach out to patients, or at least to understand and appreciate their cultural differences.

In addition to research, Satcher also said more education and work is needed on the "front lines" with primary care providers and social workers. He said their knowledge of mental illness should be boosted to educate minorities about psychiatric disorders and to help patients receive the right care.

"While we cannot change the past, we certainly can help to shape a better future," Satcher said. "This report offers a vision for overcoming these disparities."

The study found 22 percent of black families are living in poverty, and about 25 percent are uninsured. And while the rate of mental illness among blacks is not higher than whites overall, mental disorders are more prevalent among blacks in vulnerable populations such as the homeless, the incarcerated and children in foster care.

Hispanics also share a similar rate of mental disorder with whites, but Hispanic youth suffer a higher chance of suffering from depression and anxiety. In addition, about 40 percent of the Hispanic population in America reported they do not speak English well. The rate of uninsured patients is highest among Hispanics, at 37 percent - double that of whites.

Overall, minorities share the same prevalence of mental disorders as whites, the study reports. That rate excludes high-risk groups such as those who are homeless, incarcerated or institutionalized.

The overall annual prevalence of mental disorders nationwide is about 21 percent of adults and children.

The report found that sparse research made it even harder to predict the level of need within smaller groups such as American Indians, Alaska Natives, Asians and Pacific Islanders.

American Indians and Alaskan Natives are 1.5 times more likely to commit suicide than the overall population, Satcher said. Asian Americans have the lowest rate of utilization of mental health services of all groups, and those who do seek help are usually those with very severe conditions.

More minorities working in the mental health field could help minorities feel more comfortable seeking help, Satcher said.

"We cannot wait until we have enough African American psychologists or American Indian or Hispanic psychiatrists," Satcher said. "We must today find a way to make our system more relevant to the need of these populations."

Source: Associated Press, August 27, 2001

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How exposure therapy helped one of the youngest children in the country officially diagnosed with separation anxiety and panic disorders.

In the picture: Lindsey Marble is one of the youngest chlildren in the country officially diagnosed with separation anxiety and panic disorders.

A Girl Fights to Overcome Panic Attacks

She is scared to go to sleep, to swim, even to eat her favorite foods symptoms that can easily be dismissed as simply difficult childhood behavior.

But Lindsey is not putting up a fight just to stay up past her bedtime. She is one of the youngest children in the country officially diagnosed with separation anxiety and panic disorders.

"It's basically the feeling that you would have if you were really in intense danger," said Donna Pincus, a therapist at Boston University's Center for Anxiety Disorders. "There is really no actual threat there, but your body is reacting as if there is a threat."

Psychologists have long studied how anxiety disorders affect adults, but new evidence suggests an alarming number of children suffer from them as well. According to Pincus, one of Lindsey's doctors, anxiety disorders strike an astounding 10 percent of Americans under 18.

Causes: Genetics, Trauma, Copying Adults

Lindsey had her first panic attack while watching a television program about a family trapped by fire. "All of a sudden it felt like a knife was going through my heart," said Lindsey, who said she thought she was going to die.

Her father, who called an ambulance, recalled "a glossy look" in Lindsey's eyes. "She was terrified."

Lindsey's fears snowballed, and her growing fears trapped her. She was afraid to go to bed. Then she panicked at the thought of eating or swimming. And from the moment the school bus dropped her off after school, she was overwhelmed by irrational fear that she would never make it the short way down the street to her home.

"I run really quick because I feel someone's coming at me," said Lindsey. "People kidnapping me or killing me. I'm afraid someone's going to shoot me."

Doctors are not sure what originally brought on Lindsey's fears. Anxiety disorders can be inherited, or they can be brought on by trauma. New research shows it can be absorbed by children simply from observing the anxious behavior of those around them.

"If a parent gets very, very anxious in certain situations, or that person sees a spider and that produces a lot of fear in that parent, children learn from their parents," said Pincus. "Inadvertently, parents could be teaching their kids to be fearful."

Exposure Therapy as Treatment

Lindsey was treated with psychotherapy, but she continued to suffer from panic attacks. Then she was treated with exposure therapy at Boston University, a treatment previously used only on adults. She was taught to cope with the fears she had been trying to avoid — including the nausea and shortness of breath that come along with it.

"We want them to feel very fully everything they're experiencing and not chase away the feelings," said Pincus. "We know that the pain is temporary... We know that the anxiety will come down."

After only a few weeks in therapy, Lindsey experienced a noticeable difference in her anxiety. By following the program, for example, she was able to overcome her urge to get out of bed repeatedly every night, and slept with the closet door closed, which had previously worried her.

"She was petrified. She was scared to do tons and tons of stuff. And now the new Lindsey can do all the stuff that she couldn't before," said her mother.

Lindsey not only finished the fourth grade with straight A's, but she is also no longer afraid of swimming, eating or sleeping.

Source: ABC News, Aug. 22, 2001

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What accounts for the huge increase in the number of children diagnosed with attention deficit hyperactivity disorder (ADHD) and the use of Ritalin? Dr. Lawrence Diller analyzes the explosive growth of the ADHD diagnosis and Ritalin use.

I've practiced behavioral pediatrics in an affluent San Francisco suburb for over twenty years. In that time I've evaluated and treated nearly 2500 children for a variety of behavior and performance problems. I never imagined during my early years of practice that one diagnosis would so come to dominate not only my work, but America's children in general.

That diagnosis is attention deficit hyperactivity disorder, or ADHD.

A Diagnosis on the Rise

I had always encountered hyperactive children or kids who performed poorly at school. Stimulant drugs, the best known of which is Ritalin(methylphenidate), have always been one of the interventions I used to help these children and their families. These children were mostly boys, aged six to thirteen. But in the early 1990's, I began to see with increasing frequency a new type of ADHD candidate. These children were both younger and older than the previous group that met my criteria for ADHD and received Ritalin. There were also many more girls. Some of them weren't even kids. Older teenagers and adults (initially the parents of the children I evaluated for ADHD) wondered whether they too had ADHD.

But most strikingly, these new candidates for the ADHD diagnosis were far less impaired in terms of behavior and performance than my earlier patients. Many of these children behaved quite well in my office. Many were getting passing grades, even B's, at school, but were not "meeting their potential." Most of these children tended to have their biggest problems at school, or only at home when it came to doing homework.

Did Tom Sawyer have ADHD?

Boys still predominated over girls in the number presenting for evaluations for ADHD. But their problematic behaviors could just as well be viewed as an extreme of the normal variations one attributes to the male gender. Indeed, I began to wonder if boyhood, at least in my community, had become a disease. I mused if Mark Twain's Tom Sawyer walked into my office in the late 1990's whether or not he too after several visits might also leave with a prescription for Ritalin.

Ritalin production up 740 percent

I became interested in the ADHD epidemic I was witnessing and quickly learned that my experience wasn't unique. Stimulants are, by far and away, the predominant medical treatment for ADHD and are prescribed overwhelmingly for only that indication. In that sense, they serve as a marker for how much ADHD is being diagnosed in the population. Because stimulants are abusable, the Drug Enforcement Administration (DEA) tightly monitors and controls their legal production and distribution in the U.S. The DEA's records showed that between 1991 and 2000, annual production of methylphenidate rose by 740 percent, or over fourteen tons produced per year. Production of amphetamine, the active ingredient of Adderall and Dexedrine, two other stimulants used for ADHD, multiplied twenty-five fold during the same period. In the year 2000, America used eighty percent of the world's stimulants.

Most of the other industrialized countries use Ritalin at one-tenth the American rate. Only Canada, which uses half our per capita rate, comes close to using stimulants the way we do.

Many have hailed the increase of Ritalin use in our country as simply a treatment catching up to a previously under-diagnosed condition. Others are alarmed at this unprecedented rise in the diagnosis of ADHD and Ritalin use in America. Whether good or bad, this large rise in Ritalin use tells us a great deal about the way we view and address problems of children's behavior and performance at the beginning of the 21st century.

Patterns of Prescription

The answer to the question "Is Ritalin over-prescribed or under-prescribed?" is "Yes". It depends on the community you assess, and its threshold for the ADHD diagnosis and Ritalin use. Ritalin use rates from DEA data (reported in several research studies and most recently by the Cleveland Plain Dealer's county-by-county national survey) widely vary within the U.S.—from state to state, community to community and even school to school.

For example, Hawaii perennially is the state with the lowest per capita Ritalin use in the nation. Hawaiians typically use Ritalin at one-fifth the rate of the highest using states, which tend to be eastern states like Virginia or Midwestern states like Michigan. There are various "hot spots" of Ritalin use. The best documented is a three-cities cluster in the southeast corner of Virginia, where one in five white boys was taking Ritalin at school (G.Lefever, ET AL, American Journal of Public Health, September, 1999). Overall rates were probably higher than twenty-five percent since many children only take medication at home before the start of the school day. The DEA maintains that virtually every state has pockets of high use rates that are centered near a college campus or clinic that specializes in the evaluation and treatment of ADHD.

Racial/ethnic disparities

At the same time, there are areas where Ritalin is hardly used at all, especially in rural areas (the Cleveland Plain Dealer featured a county in New Mexico) and within the inner city.

Socioeconomic differences or unequal access to care are not the only reasons for differences in diagnosis and stimulant use rates. There are clear ethnic differences between who does and doesn't use Ritalin. African American children are conspicuously absent in the ADHD/Ritalin epidemic. Missing too are children from Asian American families, though the reasons for the under-representation are different for both groups.

On average, neither group tends to trust or utilize mental health services as frequently as white Americans. Many Asian American families simply raise their children differently in the early years, employing stricter standards and techniques compared to their white American counterparts. Many African Americans seem especially suspicious of a neurological label of ADHD to account for their children's problems, which may be partly attributed to poor schools and neighborhood environments. African Americans in urban communities are also uneasy about what they perceive to be similarities between Ritalin and crack cocaine, which devastated black communities in the 1990's. These opinions were expressed by the NAACP Legal Defense Fund when public hearings were held by the DEA over decontrolling Ritalin in the mid-nineties.

Indeed, the ADHD/Ritalin epidemic appears to be a primarily white middle-upper middle class phenomenon. The best demonstration of these ethnic-racial disparities comes, ironically, from HealthCanada, a federal department responsible for helping Canadians maintain and improve their health. The data and its conclusions were debated in an article and a series of letters in the Canadian Journal of Medicine. They examined Ritalin use rates in two large cities in British Columbia separated only by a short ferry ride. Victoria, a highly homogeneous white middle class community, used Ritalin nearly four times as much as Vancouver, a far more cosmopolitan, polyglot city with large numbers of people of Asian descent. All families were enrolled in a national health plan, which covered visits for ADHD, so access to care cannot explain this striking difference.

Neurological factors

Neurological factors alone, felt to be the basis of the official ADHD diagnosis, do not account for the extreme variation in Ritalin use. While children with severe impulsivity and hyperactivity exist in all populations in every country of the world, these are not the majority receiving stimulant medication in America today. Rather, economic, social and cultural factors are strongly implicated in the real world diagnosis of ADHD and who does and doesn't get Ritalin.

An Explanation

Why this huge increase in the use of Ritalin during the 1990's? I propose a number of factors involved in the explosive growth of the ADHD diagnosis and Ritalin use. By the early 1990's we, as a society, accepted the notion that poor behavior and performance in children are caused by a brain disorder or chemical imbalance. American psychiatry over the previous twenty years turned 180 degrees from the previous Freudian model, which blamed Johnny's mother for all of his problems, to a biological model of mental illness, which blamed Johnny's brain and genes.

The Prozac connection

The success and popularity of the anti-depressant Prozac, which was introduced in the late 1980's, cemented the notion of the brain-behavior connection in the public's imagination.

Prozac made taking a drug for an emotional problem in adults more acceptable and paved the way for the increased use of a psychiatric drug, Ritalin, in children.

Living in a pressure cooker culture

In my mind, a "living imbalance" rather than a chemical one has fueled Ritalin demand. In general, academic standards among the middle class have increased, and children are expected to reach certain milestones earlier and earlier. Children at three are often expected to know the alphabet and their numbers, children at five are expected to know how to read, children in third grade are learning multiplication and division, and so on. These are the expectations middle and upper middle class children face today.

The expectation is also that every child attains at least a four-year college degree in order to compete in the marketplace and survive economically in a post-technological world. By talent or temperament, many children are found wanting, and wind up taking Ritalin.

Changing parental habits

Nearly eighty percent of mothers now work outside the home, leaving many more young children in full-day childcare and many more school age children alone at home in the afternoons. Both parents are working longer hours to maintain their economic position, leaving them exhausted, and perhaps guilty at the end of their day when they finally get to see their kids.

Parents are further handicapped by current styles of American discipline of children.

"Politically correct" parenting practices propose that by effectively talking to children, conflict and punishment can be avoided. The fear of damaging a child's self image by even short-term immediate punishment is a significant handicap for parents today, as this type of direct, immediate discipline is a major motivator for children, especially for children with ADHD-type personalities. Of course ineffective discipline alone does not explain the explosion of ADHD diagnoses, but it is one piece of the puzzle. When children's behavior continues to be out of control, and punishment is not an option, then using a medication becomes very appealing.

Managed care, media, and the pharmaceutical industry

Until the last few years, average class sizes were increasing even as curricula demands rose for the general classroom teacher. No wonder teacher complaints are often the catalyst that leads to an ADHD evaluation. Managed health care only exacerbated economic pressures, especially on pediatricians and family doctors, resulting in less time in evaluations and treatment and a rise in the "quick fix" of Ritalin. Media tended to exaggerate the ubiquity of the ADHD diagnosis ("Does your child have this hidden disorder? Do you?"). Testimonials that recount the power of the Ritalin intervention belie the often complex courses and treatments necessary for myriad children's problems that get lumped under ADHD diagnosis.

The pharmaceutical industry's influence has been profound, both in determining the kinds of ADHD studies funded and published and in their drug promotions, advertising first to doctors (Adderall) and most recently directly to consumers (Concerta).

Federal educational disability law

All these factors were in place by the early 1990's and Ritalin production in the U.S., which has remained stable throughout the 1980's, took off beginning in 1991. The spark that set off all these socially combustible materials and led to the Ritalin boom was the change in the Federal educational disability law, IDEA. In 1991, IDEA was amended to include ADHD as a covered diagnosis for special educational services at school. Once parents (and teachers) learned that they could get help for their kids at school, they flocked to their doctors seeking the ADHD diagnosis and along the way received Ritalin for their children.

Nothing surprising about the effectiveness of stimulants

Ritalin "works." Stimulants in one form or another have been used for treating children's behavior for over sixty years. But the effects of Ritalin are not specific to treating ADHD.

Ritalin improves everyone's ability—child or adult, ADHD or not—to stick with tasks that are boring or difficult. Ritalin decreases everyone's impulsivity and therefore decreases motor activity. There is nothing paradoxical about low dose stimulants' effects on "calming" hyperactive kids. Higher doses "wire" both ADHD kids and normal adults: except children tend to dislike the experience of the higher doses while teens and adults can abuse the drug.

Conclusion

I'm not against the use of Ritalin in children. I am against Ritalin as a first and only choice for a wide variety of children's performance and behavior problems. Ritalin works but it is not a moral substitute for, or equivalent to, better parenting and schools for children. My role as a physician is to ease suffering. After a proper evaluation and an attempt to address issues of family and learning as best as possible, I will prescribe Ritalin if the child continues to significantly struggle.

But as a physician who prescribes medication for children, it is also my role to alert others about the economic, social and cultural factors that are involved in the ADHD diagnosis and Ritalin use in our country. To not raise alarm would make me complicitous with values and factors I feel are harmful to children and their families.

The huge rise in Ritalin use in our country is telling us we should reexamine our demands on our children and the resources we offer them, their families and their schools. It is a message we should heed not only for children with the ADHD diagnosis who take Ritalin but for all of America's children. We should be paying attention.

Originally published at Healthology.com, August 20, 2001
Copyright © 2001 Healthology, Inc.

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Electroconvulsive therapy's return stirs debate on use

George Ebert is not certain how many of his memories are missing. He can recall that during a 1971 tour of Ohio with his family, his mental state first began to deteriorate. He recalls hurriedly trying to "cleanse" his life by throwing away most of his belongings, and attempting to hitchhike in the middle of the night from Columbus to Texas with his son in tow on a search for God.

It was at an Ohio psychiatric hospital that same year that Ebert had his first experience with electroconvulsive therapy, then known as electroshock. The 15 treatments with the device, he said, left him temporarily unable to perform the simplest tasks and permanently unable to remember patches of his life.

"Afterwards, I was given a container of milk and I could not figure out how to hold it, and given a spoon and I didn't know what it was for," said Ebert, 58, an Oswego native who now runs the Mental Patients Liberation Alliance, an advocacy group in Syracuse that opposes the procedure.

ECT, long derided as a primitive and disruptive treatment for mental illness, has recently returned to the psychiatric mainstream, bringing calls for the state to monitor its use more closely than almost any other medical procedure. Though the treatment's technology has advanced significantly, state lawmakers, doctors and patients are now engaged in a vigorous debate that has dredged up the lingering stigma from ECT's early days.

Most of the machines may have changed since the time when Ebert received the treatment, but the issue of informed consent, what patients know about ECT's effects and whether they can be compelled to undergo it, has persisted.

The criticism has been exacerbated by a 1997 study of community hospitals in New York City, Westchester and Nassau counties. The study, by the New York State Psychiatric Institute based at Columbia University, found that 11 percent of patients were treated with outmoded ECT machines such as the one used on Ebert.

Underscoring the absence of government oversight of ECT, state regulators said they do not know where these antiquated machines are, or even how many people receive ECT treatment throughout New York in any given year. Individual complaints about ECT, as with any other medical procedure, are handled by either the state Commission on Quality of Care or a national commission that accredits hospitals.

Texas and Vermont have imposed severe restrictions on ECT. But the push for greater oversight in New York and elsewhere concerns doctors who say it will discourage hospitals from using the treatment.

"The truth of the matter is that this is now a very routine ," said Dr. Charles Kellner, professor of psychiatry and neurology at the Medical University of South Carolina. "Some of them would die by suicide if people are denied access to this."

Nationally, as many as 100,000 people receive ECT every year, according to the American Hospital Association. New York's Office of Mental Health tallies only how many people in state hospitals receive the treatment -- 134 last year.

The treatment has evolved since Ebert's family had him committed 30 years ago. Now, ECT is primarily administered to those who do not respond to medications. For years it has been recommended as a method of last resort. Physicians target electricity to the brain until the patient experiences a seizure. Some doctors believe the electricity alters existing electrical impulses in the brain to correct any chemical imbalance.

The first generation of ECT devices, called sine wave machines, were used liberally to treat a wide range of mental illnesses for decades. Proponents and opponents alike agree that, until very recently, the treatment was overused to control unruly patients. Crude in comparison to more modern versions, the early machines sent out intense bursts of electricity that often produced memory loss. The improved machines deliver less electricity in more brief pulses, causing less cognitive damage.

Until 1980, sine wave devices were the only machines on the market and today still evoke the images of the earliest electroshock treatments administered without muscle relaxants or anesthesia to soften the effects of the seizure.

The machines were immortalized in the 1975 film "One Flew Over the Cuckoo's Nest," where the patient played by Jack Nicholson thrashes uncontrollably during electroshock treatments.

"It's receiving a kind of attention that probably isn't driven by science questions but has generated a lot of emotional reaction," said Dr. John Oldham, chief medical officer for the New York State Office of Mental Health and director of Columbia University's psychiatric research institute. "It has been sensationalized."

But the introduction of newer machines has not quelled controversy about ECT. In one well-publicized case in 1999 on Long Island, Paul Henri Thomas challenged Pilgrim Psychiatric Center's right to administer the treatment against his will. Pilgrim had to go to court to proceed with the treatment. The hospital won the case in March, but Thomas has appealed and until it is resolved, the hospital is barred from treating him with ECT.

"It happens to be a procedure that is involved per patient in more court cases than any other," said Martin Luster, chairman of the state Assembly's Mental Health Committee. "There may be legitimate cases raised in terms of medications. We have not received the same outpouring of concern over medications as we have over ECT."

Luster (D-Trumansburg) has proposed legislation that would require every hospital in the state to inform patients about the benefits and side effects of ECT. Luster's bill also would require hospitals to obtain patients' written consent and routinely report the number of treatments to state regulators. In addition, hospitals would need to have alternative treatment nearby in case of an emergency.

But psychiatrists warn of the consequences of bringing a medical debate to the Legislature. In Texas, groups of ECT watchdogs, including the Church of Scientology, lobbied so successfully that state lawmakers entertained an outright ban of the procedure. Lawmakers ultimately prohibited doctors from performing ECT on anyone under 16 and required multiple recommendations before allowing the procedure on anyone over 65. They also required more stringent reporting practices and a separate consent form each time ECT is administered.

"For a legislature to intercede in a medical practice would inhibit its continued research," said Max Fink, an attending psychiatrist at Long Island Jewish Medical Center in New Hyde Park and a vocal ECT proponent. "ECT is an effective treatment that has saved many lives its availability is very spotty. State, municipal and many private hospitals do not have it available."

ECT advocates dispute that the existing sine wave devices pose any threat, though they agree the machines should not be used. Harold Sackeim, one of the authors of the 1997 study that found several machines still in use, called it "a small issue."

Sackeim would not disclose the location of the machines, citing confidentiality of the hospitals that participated in the study. Newsday contacted 40 hospitals for this story; none said they use sine wave machines.

Oldham said the sine wave machines, while less preferable than newer devices, still deliver valuable treatment with minimal side effects. "The evolution of transitioning to improved medical and surgical equipment is a process," Oldham said. "Hospitals can't immediately drop everything they've got. They have to do it in a planned, budgeted way."

Continued use of even a few machines has further galvanized opponents, who say it is representative of the greater problem of insufficient standards for ECT. Sackeim's study found that procedures vary from hospital to hospital, including how often a patient's memory is evaluated after treatment.

"The American Psychiatric Association has been warning people not to use sine wave for 20 years or more, but they're still there," said Linda Andre, who underwent the treatment in 1981. Andre, 41, of Manhattan, added that an independent agency was necessary to regulate ECT. She said psychiatrists "didn't do anything" to get rid of the sine wave machines before, and warned against having psychiatrists "police" themselves: "You can't put these kinds of things in their hands."

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