What to Look for If You Suspect an Emotional or Behavioral Disorder

Among all the dilemmas facing a parent of a child with emotional disorders or behavioral problems, the first question-whether the child's behavior is sufficiently different to require a comprehensive psychological evaluation by professionals may be the most troublesome of all. Even when a child exhibits negative behaviors, members of a family may not all agree on whether the behaviors are serious. For instance, children who have frequent, severe temper outbursts or who destroy toys may appear to have a serious problem to some parents, while others see the same behavior as asserting independence or showing leadership skills.

Every child faces emotional difficulties from time-to-time, as do adults. Feelings of sadness or loss and extremes of emotions are part of growing up. Conflicts between parents and children are also inevitable as children struggle from the "terrible two' s" through adolescence to develop their own identities. These are normal changes in behavior due to growth and development. Such problems can be more common in times of change for the family - the death of a grandparent or family member, a new child, a move to the city. Generally, these kinds of problems tend to fade on their own or with limited visits to a counselor or other mental health professional as children adjust to the changes in their lives. At times, however, some children may develop inappropriate emotional and behavioral responses to situations in their lives that persist over time.

Parents May Search for Options to Seeking Professional Help

The realization that a child's behavior needs professional attention can be painful or frightening to parents who have tried to support their child, or it may be accepted and internalized as a personal failure by the parent.

Many parents are afraid that their child may be inappropriately labeled, and point out that the array of diagnoses, medicines, and therapies have not been agreed upon by all specialists. Still, others become alarmed after obtaining an assessment for their child only to discover that the evaluator believed emotional disturbances originate in family dynamics and that "parenting skills" classes were the best way to address the problem. While many parents will concede that they may need to learn new behavior management or communication techniques in order to provide a consistent and rewarding environment for their child, many also express deep anger about the blame that continues to be placed on families with children who behave differently.

Before seeking a formal mental health assessment, parents may have tried to help their child by talking to friends, relatives or the child's school. They may try to discover whether others see the same problems and to learn what others suggest they might try. Parents may feel that they also need help in learning better ways of supporting the child through difficult times, and may seek classes to help them sharpen behavior management skills or conflict resolution skills. Modifications in a child's routine at home or school may help to establish whether some "fine tuning" will improve performance or self-esteem. If the problems a child is experiencing are seen as fairly severe, and are unresponsive to interventions at school, in the community or at home, an assessment by a competent mental health professional is probably in order. An assessment will provide information which, when combined with what parents know, may lead to a diagnosis of an emotional or a behavioral disorder, and a recommended treatment program.

When Should Parents Reach Out for Professional Help?

So when is that magical moment when parents should recognize their child's behavior has surpassed the boundary of what all children do and has become sufficiently alarming to warrant a formal assessment? There probably isn't one. It is often a gradual awareness that a child's emotional or behavioral development just isn't where it should be that sends most parents on a quest for answers.

Perhaps the most important question of all for parents of school-age children to consider is, "How much distress is your child's problems causing you, the child, or other members of the family?" If a child's aggressive or argumentative behaviors or sad or withdrawn behaviors are seen as a problem for a child or members of his or her family, then the child' s behaviors are a problem that should be looked at, regardless of their severity.

While there is no substitute for parental knowledge, certain guidelines are also available to help families make the decision to seek an evaluation. In Help for Your Child, A Parents Guide to Mental Health Services, Sharon Brehm suggests three criteria to help in deciding whether a child's behavior is normal or a sign that the youngster needs help:

• The Duration of a Troublesome Behavior - Does it just go on and on with no sign that the child is going to outgrow it and progress to a new stage?

• The Intensity of a Behavior - For instance, while temper tantrums are normal in almost all children, some tantrums could be so extreme that they are frightening to parents and suggest that some specific intervention might be necessary. Parents should pay particular attention to behaviors such as feelings of despair or hopelessness; lack of interest in family, friends, school or other activities once considered enjoyable; or behaviors which are dangerous to the child or to others.

• The Age of the Child - While some behavior might be quite normal for a child of two, observation of other children of the youngster's age may lead to the conclusion that the behavior in question is not quite right for a five-year-old. Not all children reach the same emotional milestones at the same age, but extreme deviations from age-appropriate behaviors may well be cause for concern.

Attempts at self-injury or threats of suicide, violent behaviors, or severe withdrawal that creates an inability to carry on normal routines must be regarded as emergencies for which parents should seek immediate attention, through a mental health or medical clinic, mental health hotline, or crisis center.

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Parents will also want to consider whether their child's behavior could be influenced by other factors:

• whether a specific physical condition (allergies, hearing problems, change in medication, etc.) could be affecting the behavior;
• whether school problems (relationships, learning problems) are creating additional stress;
• whether the adolescent or older teen might be experimenting with drug use or alcohol; or
• whether changes in the family (divorce, new child, death) have occurred which may be causing concern for the child.

Considerations for Young Children

Special consideration needs to be given to identifying behaviors of concern in very young children. Their well-being is so connected with that of the family that services must be developed with and directed to the family as a unit. The goal of assessing and providing services to a young child should include helping families to articulate their own stresses and strengths. It is in the context of family that a child first explores his or her world and learns to adapt to the varied demands of families and the world at large.

Historically, many professionals have not been anxious to have a child "labeled and judged" at an early age. On the other hand, the earlier that parents and professionals can intervene in the life of a young child with delays in emotional and behavioral development, the better it is for both the child and the family. Early assessment and intervention require that parents be involved in both giving and receiving information about their child's development. Interviews with families and observations of their child to assess how well he or she communicates, plays, relates to peers and adults and is able to self-regulate behavior is useful in deciding whether the child has a developmental problem that needs attention.

Infants

Most often, the first indications that an infant may be experiencing significant problems will be delays in normal development. An infant who is unresponsive to his or her environment (doesn't show emotion, such as pleasure or fear that is developmentally appropriate; doesn't look at or reach for objects within reach or respond to environmental changes such as sound or light), who is over-responsive (easily startled, cries), or who shows weight loss or inadequate weight gain that is not explainable by a physical problem (failure to thrive), should have a thorough evaluation. If parents have questions about their child's development, they should call their child's pediatrician or family physician. Many doctors who include young children in their practice will have materials available for parents on normal childhood development.

Toddlers

Toddlers may have a tremendous range of behaviors that would be considered developmentally appropriate, depending on the child's own history. However, any significant delays (six months or more) in language development, motor skills or cognitive development should be brought to the attention of the child's pediatrician. Children who become engrossed in self-stimulating behavior to the exclusion of normal activities or who are self-abusive (head banging, biting, hitting), who do not form affectionate relationships with care providers such as babysitters or relatives, or who repeatedly hit, bite, kick or attempt to injure others should be seen by their pediatrician or family physician and, if indicated, by a competent mental health professional.

First Children

Especially with a first child, parents may feel uneasy, uncomfortable, or even foolish about seeking an evaluation for their very young child. While sorting out problems from developmental stages can be quite tricky with infants and toddlers, early identification and intervention can significantly reduce the effects of abnormal psychosocial development. Careful observation of infants and toddlers as they interact with caregivers, their family or their environment is one of the most useful tools that families or physicians have since many mental health problems cannot be diagnosed in any other way.

The Individuals with Disabilities Education Act (IDEA) requires states to provide services for children from ages three through twenty-one who have disabilities and established an Early Intervention State Grant Program (part H of the IDEA) to serve infants and toddlers from birth through the age of two. The law specifies that states who apply for and receive funds under Part H must provide a multi-disciplinary assessment of infants or toddlers who are experiencing significant delays in normal development, and identify services appropriate to meet any identified needs in a written Individual Family Services Plan (IFSP). As of this writing, all states are receiving funds to provide services to infants and toddlers. Parents who have questions related to preschool or early intervention programs should call their local school district offices or their state Department of Health or Human Services for guidance.

Cultural Considerations

Appropriate assessment of a child's mental health or emotional status is key to developing appropriate school or mental health services. For children who are cultural or racial minorities, parents will want to know how, or if, those differences will affect assessment results.

Tests, by their very nature, have been developed to discriminate. If everyone taking a test scored the same, then the test would be of no use. What's important, though, is that tests discriminate only in those areas they were designed to measure - such as depression, anxiety, etc. - and not along measures such as cultural background, race, or value systems.

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If the professional who is responsible for assessment is not of the same cultural background as the child, parents should feel free to ask what his or her experiences have been in cross-cultural assessment or treatment. Professionals who are sensitive to issues of bias related to language, socioeconomic status or culture found in assessment tools should willingly share such information with parents.

One way of minimizing the effects of cultural bias in obtaining an appropriate diagnosis is to utilize a multidisciplinary approach to assessment involving persons from different backgrounds (teacher, therapist, parent, social worker) in completing the assessment. Several questions to consider are:

• Do the various professionals agree with one another?
• Did the professionals use family information about the child's functioning at home and in the community to aid in making a diagnosis?
• Does the family believe the assessment is accurate?

When a multidisciplinary approach is not practical or available, the person providing the assessment should give a battery of tests to reduce the effects of bias in an individual test when making a determination that a child needs mental health services.

If children from specific ethnic or cultural groups appear to be over-represented in the program that has been selected or recommended for a child, parents should carefully examine the procedures for determining their child's placement.

If parents decide that the placement decision was not influenced by racial or cultural bias, that perspective can increase confidence in the therapeutic program selected for their child.

Where Should Parents Seek Assessment for Their Child?

Once parents have decided that their child or adolescent has behaviors that deserve at least a look by a mental health professional, the question then becomes where to turn for an evaluation.

If the child is of school age, a first step could be to approach the school's special education director and request an assessment by the school psychologist or teacher. If the family doesn't want to involve the school at this point, there are several other places to turn for an evaluation.

A family doctor can rule out physical health issues and refer families to an appropriate child or adolescent psychologist or psychiatrist. Also, many hospitals and most community mental health centers offer comprehensive diagnostic and evaluation programs for children and adolescents.

An assessment can be costly, but there are some supports available for families. For instance, most insurance companies will cover all or a portion of the costs of an assessment or, Medical Assistance Medicaid) will cover costs for eligible families.

For Medicaid-eligible children, the Early and Periodic Screening, Diagnosis and Treatment Program (EPSDT) provides preventive health care, including screening (assessment), diagnosis, and appropriate mental health services.

Under EPSDT, a screen is a comprehensive health evaluation, including the status of a child's emotional health. A child is entitled to periodic screenings, or an interperiodic screening (between normal screening times) whenever a physical or emotional problem is suspected and is entitled to receive health services to address such problems from any provider (public or private) who is a Medicaid provider. Because of the number of changes being proposed in the Medicaid program at the time of this writing, it is a good idea for parents to check with their state Medicaid office if they are concerned about services under the EPSDT program.

Other parents, particularly those in rural areas, may want to first approach their county's public health nurse or mental health services director. Either may be able to direct them to an evaluation program available in their area.

Community mental health centers are also a good source of help, and can be less expensive than seeking out a private doctor or mental health professional. Parents will want to ask for professional staff with experience in evaluating the mental health needs of children if in doubt, ask for the credentials and expertise of the professional who is assigned to work with the child. Credentials should be offered and should be displayed in the professional's workplace.

© 1996. PACER Center, Inc.

I extend my grateful thanks to PACER for graciously allowing me to reprint this timely, informative article.

HealthyPlace.com comprehensive information on Childhood Mental Disorders.

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Job very stressful? Ways to cut down on your workload, relieve stress, anxiety and depression. Keep from being emotionally drained, burned out.

You haven't seen the bottom of your in-box in months.

You've gone from 9-to-5 to 8-to-7 -- and that's on a easy day.

In short, you've got too much to do with too few resources and not enough patience to deal with the stress that's building in you every day.

You're not alone.

In recent insurance industry studies, nearly half of American workers say their job is "very or extremely stressful" and 27 percent said their job was the greatest source of stress in their life.

More specifically, a study by the Northwestern National Life Insurance Company found that 53 percent of supervisors and 34 percent of non-supervisors consider their jobs highly stressful.

The following tips can help you cut down on your workload -- and your stress:

• If possible, don't take on any new projects that will demand a lot of your time or come due during the time of another large project.
• Take care of as much routine work in advance of the stressful time as possible.
• Ask yourself: Can someone else do it? Can something be delayed? Can I substitute something else? Is it essential?
• Find a time-planning system that helps you.
• Concentrate on the most important tasks first.

Some national studies suggest that, on average, corporations lose about 16 days annually in productivity per worker due to stress, anxiety and depression.

Researchers find that employees are "emotionally drained" and "burned out" at the end of the day. One primary cause of those feelings is working too much or taking on more responsibility than one can handle.

Wanting to do more for the office team is an honorable goal. But when you take on too much and start to slip -- you should step back and examine what you're doing.

There are ways to handle stress and your workload before they get the best of you -- and that's the one thing you always want to contribute to your job.

Copyright © 1996 American Psychological Association

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USA Today Series
12-06-1995

The electrodes were placed on her head. With the push of a button, enough electricity to light a 50-watt bulb passed through her skull.

Her teeth bit hard into a mouth guard. Her heart raced. Her blood pressure soared. Her brain had an epileptic-style grand mal seizure. Then, Ocie Shirk had a heart attack.

Four days later, on Oct. 14, 1994, the 72- year-old retired health department worker from Austin, Texas, was dead of heart failure - the leading cause of shock-related death.

After years of decline, shock therapy is making a dramatic and sometimes deadly comeback, practiced now mostly on depressed elderly women who are largely ignorant of shock's true dangers and misled about shock's real risks.

Some lose already fragile memories. Some suffer heart attacks or strokes. And some, like Ocie Shirk, die.

A four-month USA TODAY investigation found: The death rate for elderly patients who receive shock is 50 times higher than patients are told on the American Psychiatric Association's model ECT consent form. The APA sets the chance of dying at 1 in 10,000. But the death rate is closer to 1 in 200 among the elderly, according to mortality studies done over the past 20 years and death reports from Texas, the only state that keeps close track.

Shock machine manufacturers greatly influence what patients are told about shock's risks.

Virtually all "educational" videos and brochures shown to patients are supplied by shock machine companies. And the APA's 1-in-10,000 death rate estimate is attributed to a book written by a psychiatrist whose company sells about half the shock machines sold each year.

Shock therapy is strongly regaining favor among psychiatrists as a treatment for depression. Although exact figures are not kept, one indication of the trend comes from Medicare, which paid for 31% more shock treatments in 1993 than it did in 1986.

The elderly now account for more than half of the estimated 50,000 to 100,000 people who receive shock each year, with women in their 70s getting more shock than any other group. In the 1950s and 1960s, young male schizophrenics got most shock therapy.

Shock therapy is the most profitable practice in psychiatry, and economics strongly influences when shock is given and who gets it.

In Texas, the only state that keeps track, 65-year- olds get 360% more shock therapy than 64-year-olds. The difference: Medicare pays.

Shock treatment may shorten the lives of the elderly, even if it doesn't cause immediate problems.

In a 1993 study of patients 80 and older, 27% of shock patients were dead within one year compared to 4% of a similar group treated with anti-depressant drugs. In two years, 46% of shocked patients were dead vs. 10% who had the drugs. The study, by Brown University researchers, is the only study of long-term survival rates in the elderly.

Doctors rarely report shock treatment on death certificates, even when the connection seems apparent and death certificate instructions clearly indicate it should be listed.

For this story, USA TODAY reviewed more than 250 scientific articles on shock therapy, watched the procedure at two hospitals and interviewed dozens of psychiatrists, patients and family members.

Outside of medical journals, accurate information about shock is sketchy. Only three states make doctors report who gets it and what complications occur. Texas has strict reporting requirements; California and Colorado less stringent rules.

The information that is available raises serious questions about how shock therapy is practiced today, particularly on the elderly.

"We've learned nothing from the mistakes of my generation," says psychiatrist Nathaniel Lehrman, 72, retired clinical director of Kingsboro state mental hospital in New York. "The elderly are the people who can least stand" shock. "This is gross mistreatment on a national scale."

A changing image

Monday, Wednesday and Friday morning is shock therapy time in hospitals across the country.

Most patients get a total of six to 12 shocks: one a day, three times a week until the treatment is finished. Patients generally receive a one- or four-second electrical charge to the brain, which causes an epileptic-like seizure for 30 to 90 seconds.

The American Psychiatric Association information sheet for patients says: "80% to 90% of depressed people who receive (shock) respond favorably, making it the most effective treatment for severe depression." Psychiatrists who do shock therapy also are convinced of its safety.

"It's more dangerous to drive to the hospital than to have the treatment," says psychiatrist Charles Kellner, editor of Convulsive Therapy, a medical journal. "The unfair stigma against (shock) is denying a remarkably effective medical treatment to patients who need it." Psychiatrists say shock therapy is a gentler procedure today than it was in its heyday in the 1950s and 1960s, when it was an all-purpose treatment for everything from schizophrenia to homosexuality.

And advocates say it's nothing like its portrayal 20 years ago in the movie One Flew Over the Cuckoo's Nest, which showed electroshock being used to punish mental patients.

The movie helped send shock therapy into decline and prompted laws across the nation making it hard to give shock treatment without the patient's written consent.

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Because of abuse in the past, shock is seldom done now at state mental hospitals, but mostly at private hospitals and medical schools.

The language is softer today, too, reflecting an effort to change shock's image: Shock is "electroconvulsive therapy" or, simply, ECT. The memory loss that often accompanies it is called "memory disturbance." These changes come as doctors expand shock's reach - to high-risk patients, to children, to the elderly - altering the profile of who gets shock therapy so much that the typical patient now is a fully insured, elderly woman treated for depression at a private hospital or medical school.

Someone like Ocie Shirk.

Died in recovery room

Shirk, a widow coping with recurring depression, already had one heart attack and suffered from atrial fibrillation, a condition that causes rapid heart quivers.

On a Monday at 9:34 a.m., Oct. 10, 1994, she received shock therapy at Shoal Creek Hospital, a for-profit psychiatric hospital in Austin. She had a heart attack in the recovery room. Four days later, she died of heart failure.

Yet shock therapy isn't mentioned on Shirk's death certificate, despite repeated instructions on the form to include every event that may have played a role in the death.

The medical examiner confirms that shock should have been on the death certificate. "If it happens so close after (shock) therapy, it definitely should be listed," says Roberto Bayardo, Austin's medical examiner.

Gail Oberta, chief executive of Shoal Creek Hospital, declines comment on Shirk. But she says, "When I checked all our records and went through all the reviews we do, there were no deaths related to ECT." A Texas Department of Health investigation found Shirk's treatment didn't meet the required standard of care because her medical records did not include a current medical history or physical that would let doctors accurately assess shock therapy's risks. The hospital agreed to correct the problem.

In addition to Shirk, state records show two other patients died after shock therapy at Shoal Creek. Asked about these deaths, Oberta repeats: "We could find no correlation between deaths of patients and receiving ECT at this facility." Getting to the facts behind shock-related deaths is very difficult even in Texas, which in 1993 became the only state with a strict law on shock therapy. The law, passed after lobbying from shock opponents, requires all deaths that occur within 14 days of shock therapy be reported to the Texas Department of Mental Health and Retardation.

In the 18 months after the Texas law took effect, eight deaths - including the three at Shoal Creek - were reported out of the 2,411 patients who received shock therapy in the state. About half those who received shock were elderly.

Six of the eight dead patients were older than 65.

Stated another way: 1 in 197 elderly patients died within two weeks of receiving shock therapy. The state does not release enough information to know if shock caused the deaths.

Nationally, record-keeping is almost nonexistant.

The Centers for Disease Control reports shock therapy was listed on death certificates as a factor in only three deaths over the five years ending 1993 - a number so low that it contradicts even the most favorable estimates of shock mortality.

The CDC records shock-related deaths under a category called "Misadventures in Psychiatry." "For obvious reasons, doctors are reluctant to list anything that falls into this category," says Harry Rosenberg, head of mortality data at the CDC, "even though we encourage them to be forthright."

Elderly deaths: 1 in 200

The American Psychiatric Association shock therapy task force report has been the bible of shock practice since its publication in 1990. It says 1 in 10,000 patients will die from shock therapy.

This estimate is included on the APA's model "informed consent" form, which patients sign to prove they've been fully informed of the risks of shock treatment.

The source for this estimate: A textbook written by psychiatrist Richard Abrams, president and co- owner of shock machine manufacturer Somatics Inc. of Lake Bluff, Ill.

Somatics is a private company. Abrams won't say how much of the company he owns or how much he earns from it.

"I don't know where they got that (estimate) from," Abrams says of the 1-in-10,000 death rate.

When pointed to page 53 of his 1988 textbook Electroconvulsive Therapy, where the death rate appears twice, Abrams notes that the number was dropped from the 1992 edition.

His updated textbook states the death rate differently, but Abrams agrees it amounts to the same thing.

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Abrams' revised book says a death will occur once in every 50,000 shock treatments. He says it's fair to assume that the average patient gets five treatments, making the death rate about 1 in 10,000 patients. Five shocks is average because some patients stop their treatment early.

Abrams' figures are based on a study of shock deaths that psychiatrists report to California regulators. But USA TODAY found that shock deaths are significantly underreported in California and elsewhere.

At a recent professional meeting, for example, a California psychiatrist told how shock therapy caused a stroke in one of his patients. The man, in his 80s, died several days later. But the death was never reported to state regulators.

Consistently, the studies of elderly death rates conflict with the 1-in-10,000 estimate: A 1982 Journal of Clinical Psychiatry study found one death among 22 patients aged 60 and older. A 71-year-old woman had "cardiopulmonary arrest 45 minutes after her fifth treatment. She expired despite intensive resuscitative efforts." Two men in the study, ages 67 and 68, suffered life- threatening heart failure but survived. Seven more had less serious heart complications.

A 1984 Journal of American Geriatrics Society study - often cited as proof of shock therapy's safety - found 18 of 199 elderly patients developed serious heart problems while receiving shock. An 87-year-old man died of a heart attack.

Five patients - ages 89, 81, 78, 78 and 68 - suffered heart failure but were revived.

A 1985 Comprehensive Psychiatry study of 30 patients age 60 and older found one death. An 80-year-old man had a heart attack and died several weeks later. Four others had major complications.

A 1987 Journal of the American Geriatrics Society study of 40 patients age 60 and older found six serious cardiovascular complications but no deaths.

A 1990 Journal of the American Geriatrics Society study of 81 patients age 65 and older found 19 patients developed heart problems; three cases were serious enough to require intensive care. None died.

These studies looked only at complications that occurred while a patient was undergoing a series of shock treatments; long-term mortality rates were not considered.

Taken together, the five studies found three of 372 elderly patients died. Another 14 suffered serious complications, but survived. These results are similar to a study of shock therapy deaths done in 1957 by David Impastato, a leading shock researcher of the time.

He concluded: "The death rate is approximately 1 in 200 in patients over 60 years of age and gradually decreases to 1 in 3,000 or 4,000 in younger patients." Impastato found heart problems were the leading cause of shock-related death, followed by respiratory problems and stroke - the same pattern as in recent studies.

"The claim that 1 in 10,000 people die from shock is refuted by their own studies," says Leonard Roy Frank, editor of The History of Shock and a shock opponent. "It's 50 times higher than that." But Abrams, who has reviewed the studies, calls it "irrational and incomprehensible" to attribute so many of the deaths to shock itself. Even if a patient has a heart attack minutes later - as Ocie Shirk did - Abrams says, "it may very well not be ECT-related." Duke University psychiatrist Richard Weiner, chairman of the APA task force, also believes studies show the 1-in-10,000 estimate is accurate and disagrees the elderly death rate could be as high as 1 in 200.

"If it were anywhere near that high, we wouldn't be doing it," Weiner says. He says health problems, not age, cause the appearance of a higher death rate among elderly.

Still, some doctors who consider shock therapy a relatively safe treatment are concerned about the complications in elderly patients.

"Almost every death in the literature is an elderly person," says William Burke, a University of Nebraska psychiatrist who's studied shock and the elderly. "But it's hard to hazard a guess on a death rate because we don't have the data."

Shock is profitable The financial incentives of performing shock may be driving the increase in its use.

Shock therapy fits well into the economics of private insurance. Most policies don't pay for psychiatric hospital stays after 28 days. Drug therapy, psychotherapy and other treatments can take much longer. But shock therapy often produces a dramatic effect in three weeks.

"We're looking for more bang for the buck in health care today. This treatment gets people out of the hospital fast," says Dallas psychiatrist Joel Holiner, who performs shock.

It is also the most profitable procedure in psychiatry.

Psychiatrists charge $125 to $250 per shock for the five- to 15-minute procedure; anesthesiologists charge $150 to $500.

This bill for one shock at CPC Heritage Oaks Hospital in Sacramento, Calif., is typical: $175 for the psychiatrist.

$300 for the anesthesiologist.

$375 for use of the hospital's shock therapy room.

The patient got a total of 21 shocks, costing about $18,000. The hospital charged another $890 a day for her room. Private insurance paid.

Those figures add up. For example, a psychiatrist who does an average of three shocks a week, at $175 per shock, would increase his or her income by $27,300 a year.

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Medicare pays less than private insurance - the payment varies by state - but it is still lucrative.

Before turning 65, many people are uninsured or have insurance that does not cover shock. Once someone qualifies for Medicare, the chance of getting shock therapy soars - as the 360% increase in Texas shows.

Stephen Rachlin, retired chairman of psychiatry at Nassau County (N.Y.) Medical Center, believes shock therapy is useful treatment. But he worries that financial rewards may influence its use.

"The rate of reimbursement by insurance is higher than anything else a psychiatrist can do in 30 minutes," he says. "I'd hate to think it's done solely for financial reasons." Psychiatrist Conrad Swartz, co-owner with Abrams of Somatics Inc., the shock equipment manufacturer, defends the financial rewards.

"Psychiatrists don't make much money, and by practicing ECT they can bring their income almost up to the level of the family practitioner or internist," says Swartz, who performs shock himself.

According to the American Medical Association, psychiatrists earned an average of $131,300 in 1993.

A doctor says 'no'

Michael Chavin, an anesthesiologist from Baytown, Texas, participated in 3,000 shock sessions before he stopped two years ago, worried he was hurting elderly patients.

"I began to get very disturbed by what I was seeing," he says. "We had many elderly patients getting repeated shocks, 10 or 12 in a series, getting more disoriented each time. What they needed was not an electroshock to the brain, but proper medical care for cardiovascular problems, chronic pain and other problems." In Chavin's view, when the cardiovascular system is dramatically stressed in the elderly, doctors risk triggering a fatal decline.

"As an anesthesiologist, what I do for three to five minutes can have serious consequences later," Chavin says. "But psychiatrists cannot bring themselves to admit any harm from ECT unless the patient gets electrocuted to death on the table while being videotaped and observed by a United Nations task force.

"These deaths are telling us something. Psychiatrists don't want to hear it." Chavin, then chief of anesthesiology at Baycoast Medical Center, stopped doing shock in 1993, reducing his income by $75,000 a year.

He says he feels ashamed that his waterfront home and pool were partially financed by what he considers to be "dirty money." In spite of his growing doubts, Chavin didn't quit doing shock right away. "It was hard to give up the income," he says.

First, Chavin turned away patients. "I'd tell the psychiatrist: 'This 85-year-old woman with high blood pressure and angina is not a good candidate for repeated anesthesia.' " Then, to confront his doubts, he began looking at the research on shock therapy. "I found it was done by psychiatrists who do electroshock for a living," Chavin says.

He finally quit doing shock and another anesthesiologist took over. Two months later, on July 25, 1993, a patient named Roberto Ardizzone died from respiratory complications that began as he received shock therapy.

The hospital stopped doing shock altogether.

By Dennis Cauchon, USA TODAY

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USA Today Series
12-06-1995

Although shock therapy has been performed for decades, researchers still don't know precisely how it works to combat depression.

"We've been looking for 50 years, but ECT causes many changes, and we haven't pinned down which one has the anti-depressant effect,'' says Charles Kellner, editor of Convulsive Therapy.

The major theories:

Neurotransmitter theory. Shock works like anti-depressant medication, changing the way brain receptors receive important mood-related chemicals, such as serotonin and dopamine and norepinephrine.

Anti-convulsant theory. Shock-induced seizures teach the brain to resist seizures. This effort to inhibit seizures dampens abnormally active brain circuits, stabilizing mood.

Neuroendocrine theory. The seizure causes the hypothalamus, part of the brain that regulates water balance and body temperature, to release chemicals that cause changes throughout the body. The seizure may release a neuropeptide that regulates mood.

Brain damage theory. Shock damages the brain, causing memory loss and disorientation that creates a temporary illusion that problems are gone. Shock supporters strongly dispute the theory, advanced by psychiatrist Peter Breggin and other shock critics.

"Not only hasn't the Breggin brain damage theory been proven, it's been disproven,'' says shock researcher Harold Sackheim of Columbia University.

By Dennis Cauchon, USA TODAY

USA Today Series
12-06-1995

For the first time in four decades, children and adolescents are being used as subjects of significant new shock therapy studies.

The studies are being done quietly at respected schools and hospitals such as UCLA, the Mayo Clinic and the University of Michigan.

Shock therapy's use is on the rise, especially among the elderly. Children and other high-risk patients are receiving more shock as well, mostly as a treatment for severe depression.

Children still account for a small percentage of shock patients, and no national estimates exist.

But at a seminar for shock therapy doctors in May, one-third of psychiatrists raised their hands when asked if they did shock on young people.

University of Pennsylvania neuroscientist Peter Sterling, a shock opponent, calls the child studies "horrifying. . . You're shocking a brain that is still developing."

California and Texas ban shock therapy on kids under 12. Most states permit it with approval of two psychiatrists and a parent or guardian.

Shock researchers met in Providence, R.I., in the fall of 1994 to discuss early results of the new studies, mostly unpublished.

"There's no evidence that electroconvulsive therapy affects brain development of children in any permanent way," says researcher Kathleen Logan, a Mayo Clinic psychiatrist.

"Parents and patients have been receptive in a vast majority of cases," Logan says. "We do a lot of education. We show them a video and the ECT suite. They're so desperate that they'll give it a try."

The latest child shock researchers compare their results to the pioneering work in the field: a 1947 study by psychiatrist Lauretta Bender.

Bender's study reported on 98 children (ages 3-11) shocked at Bellevue Hospital in New York. She reported a 97% success rate: "They were better controlled, seemed better integrated and more mature."

In 1950, Bender shocked a 2-year-old who had "a distressing anxiety that frequently reached a state of panic." After 20 shocks, the boy had "moderate improvement."

But in a 1954 follow-up, other researchers could not find improvement in Bender's children: "In a number of cases, parents have told the writers that the children were definitely worse," they wrote.

Today's researchers interpret Bender's study as evidence that shock works, at least temporarily.

The new studies are again reporting great success. A UCLA study had 100% success in nine adolescents. The Mayo Clinic found 65% were better. At Sunnybrook Hospital in Toronto, 14 who received shock spent 56% less time in the hospital than six who refused the treatment.

Ted Chabasinski, who as a 6-year-old foster child was shocked 20 times by Bender, says the research is unethical and should stop.

"It makes me sick to think children are having done to them what was done to me," says Chabasinski, a lawyer. "I've never met anyone other than myself who's functional after being shocked as a child."

By Dennis Cauchon, USA TODAY

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note: article written 11-95

The fate of persons born with ambiguous genitals (also called hermaphrodites, or intersexuals) was the focus of debate when sexual scientists from around the world met in San Francisco earlier this month. Before modern medical understanding of endocrinology and advances in surgical techniques, such individuals made their way in the world as best they could. For the past forty years, however, medical technologies have been widely used to force such unruly bodies to conform more closely to male or female shapes. This policy has been implemented almost entirely without public scrutiny, in hospitals throughout the US and other industrialized countries.

In a symposium titled "Genitals, Identity, and Gender," held at the annual convention of the Society for the Scientific Study of Sex, sex researcher Dr. Milton Diamond, of the University of Hawaii Medical School, and psychologist Dr. Suzanne Kessler, of State University of New York at Purchase, found a receptive audience for their criticism of medical treatment of hermaphrodites. Dr. Heino Meyer-Bahlburg, a member of the team which treats hermaphrodites at Columbia University's Presbyterian Hospital in New York, was on hand to offer the clinician's point of view.

Man without a penis-a woman?

Diamond had dramatic news for the assembled sexologists; he presented a follow-up on the famous case of the twin boys. One of these identical twins had lost his penis at age 7 months in a circumcision accident, in 1963. On medical advice, the boy was reassigned as a girl, plastic surgery used to make his genitals appear female, and female hormones administered during adolescence to complete the metamorphosis. The change of sex was facilitated and monitored at Johns Hopkins Hospital, a leading center for medical treatment of hermaphrodites.

In 1973 and 1975, Dr. John Money of Johns Hopkins, a leading expert in pediatric psychoendocrinology and developmental psychology, reported the outcome as favorable. In the ensuing twenty years, the case of the penectomized twin has taken on immense significance; it is cited in numerous elementary psychology, human sexuality, and sociology texts. Most importantly, the case influenced medical thinking about treatment of hermaphroditic infants. Medical texts now recommend that boys born with a penis that is "too small" be reassigned as girls, just as the twin was.Surgeons remove their penises and testes and construct a vagina, and a pediatric endocrinologist administers hormones to facilitate female puberty.

But in fact, according to Diamond's report, the penectomized twin steadfastly refused to grow into a woman, and now lives as an adult man. She didn't feel or act like a girl. She often discarded the estrogen pills which were prescribed at age 12, and she refused additional surgery to deepen the vagina which surgeons had constructed at 17 months of age, despite Hopkins staff's repeated attempts to convince her that life would be impossible without it. "You're not gonna find anybody unless you have vaginal surgery and live as a female," the twin recalls a Hopkins physician telling her.

The twin was not convinced. "These people gotta be pretty shallow, if that's the only thing I've got going for me. That the only reason people get married is because of what's between their legs. If that's all they think of me, I've gotta be a complete loser," the fourteen year old thought.

By age 14, the twin was able to convince her local physicians, if not the specialists at Hopkins, to help her to live as a male once again. He received a mastectomy and a phalloplasty, he began a regimen of male hormones, and he adamantly refused to ever return to Hopkins.

Although the Hopkins staff were aware of the twin's resistance to medical intervention intended to make a woman of him, for nearly two decades they have dismissed questions about the outcome of this important case because the twin was "lost to followup." In discussion following Diamond's presentation, sexologists expressed shock and dismay that they had been allowed continued to teach and to write that the penectomized twin had been successfully transformed into a woman, for twenty years after the care providers involved knew that the experiment had been a tragic failure. Vern Bullough, the distinguished historian, stood to denounce the Hopkins team and John Money as having acted unethically in the matter.

Who has the power to name?

"Medical standards allow penises as short as 2.5 cm to mark maleness, and clitorises as large as 0.9 cm to mark femaleness. Infant genital appendages between 0.9 cm and 2.5 cm are unacceptable." The audience laughed, but Kessler had accurately summarized mainstream medical practice in "managing" infants and children with unusual genitals. At most hospitals, surgeons will remove clitoral tissue from a child born with such in-between genitals, to produce more acceptable female genitals. In others, surgeons transfer tissue from other parts of the body to try to build a larger penis. No one has ever performed studies to determine the long term effect on sexual function of these genital surgeries.

Kessler noted that physicians and parents refer to such genitals as "deformed" before surgery and "corrected" after surgery. In contrast, many of those who have been subjected to surgery label their own genitals as having been "intact" before surgery, and "mutilated" afterward. These individuals are beginning to come together to form an intersex advocacy movement, most notably in the form of the San Francisco-based Intersex Society of North America (ISNA, PO Box 31791 SF CA 94131, ).

Kessler presented a poll of college students' feelings about "corrective" genital surgery. Women were asked to imagine that they had been born with a larger than normal clitoris, and that physicians had recommended surgery to reduce its size. One fourth of the women indicated that they would not have wanted the clitoral reduction surgery under any circumstance; one quarter would have wanted surgery only if the clitoris caused health problems, and the remaining 1/4 would have wanted the size of their clitoris reduced only if the surgery would not have entailed any reduction in pleasurable sensitivity.

Men were asked to imagine that they had been born with a smaller than normal penis, and physicians had recommended reassigning the boy as female and surgically altering the genitals to appear female. All but one man indicated that they would not have wanted surgery under any circumstance. They seem to be saying that they believe they could live as men in our culture, even with tiny penises.

Finally, Kessler presented communications from parents of girls whose clitorises had been deemed "too large" by physicians, and surgically reduced. In some cases, the parents had noticed nothing unusual about their daughters' clitoral size; physicians had to teach the parents that the clitoris was unusual enough to warrant genital surgery.

A clinician's point of view

Meyer-Bahlburg defended the practice of genital surgery on children. Without surgery, he said, they are likely to be rejected by their parents, and teased by other children. He offered the example of one infant whose father was so disturbed by her large clitoris that he attempted to rip it off with his fingers, resulting in a trip to the emergency room. An ISNA representative stood to denounce the father's action as child abuse, which cannot justify surgery on the infant.

Medical intervention has been predicated on the notion that quality of life is possible only for individuals who conform to male or female sex and gender. But in recent years, the possibility of a third gender, of non-conformance, has come to the fore. There are several threads to this discourse. Anthropologists and ethnographers have identified third gender categories in many cultures, such as the Berdache in Native America, the Hijra in India, the Xanith in Oman, and many others. Non-conforming gender roles are also in evidence in the growing transgender movement, which has rebelled against medical policy which offered services to transsexuals only if they conformed adequately to mainstream heterosexual male or female roles.

But most important, Meyer-Bahlburg acknowledged, is the growing intersex advocacy movement. This movement, represented most forcefully by ISNA, is beginning to speak out against the harm of genital surgery and of secrecy and taboo surrounding intersexuality. "I believe that this new third gender philosophy is going to have a beneficial and quite profound effect on medical intersex management, but that it will take quite a while," said Meyer-Bahlburg. In response to a question from the audience, he indicated that he would begin to advocate less surgery for "minor" cases of genital abnormalities.

Bo Laurent, a doctoral student at the Institute for Advanced Study of Human Sexuality in San Francisco, is a consultant to the Intersex Society of North America.

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Skeptics cling to old images, psychiatrists say

By Andrew Fegelman
CHICAGO TRIBUNE

Unbeknownst to her, Lucille Austwick became the poster girl for patient-rights advocates and psychiatry's skeptics.

"The Rosa Parks of electroshock" is how one publication described the 82-year-old retired telephone operator, a patient in a North Side nursing home.

Across the country, psychiatrists closely monitored her court case in Chicago. It examined whether Austwick, without her consent, could be given electroshock therapy to try to lift her out of depression that had caused her to stop eating. Psychiatrists believed that a ruling preventing the treatment would represent a serious setback for electroshock.

Ultimately, Austwick never received the treatment after doctors concluded that her condition had improved. But her case, and an Illinois Appellate Court ruling earlier this month prohibiting the treatment even after Austwick no longer needed it, has crystallized one of the most controversial and unusual debates in psychiatry.

Critics call it shock treatment. Doctors prefer the more benign "electroconvulsive therapy," or ECT. It is the administration of electrical charges to the brain to treat mental disorders, usually severe depression.

It isn't the first line of psychiatric treatment, but neither is it infrequently used. Experts estimate that 50,000 to 70,000 electroshock treatments are administered annually in the United States.

Electroshock first was deployed to treat mental illnesses in 1938. And for decades, controversy has surrounded its use, misuse and associated problems, ranging from broken bones to death.

While psychiatrists say techniques have vastly improved over the decades, the image of electroshock remains unsettling for many Americans.

There is R.P. McMurphy, the character played by Jack Nicholson in the film version of "One Flew Over the Cuckoo's Nest," undergoing doses of electricity to render him docile.

And then there is a humbled U.S. Sen. Thomas Eagleton (D-Mo.), bumped out as George McGovern's vice presidential running mate in 1972 after shamefully confessing to receiving ECT in the way a politician would admit marital infidelity.

Those lingering images have aided a movement that has continually battled to discredit electroshock.

One of the movement's soldiers is David Oaks, a community activist who runs the 1,000-member Support Coalition in Eugene, Ore.

The group bills itself as a patient-rights organization, but the tone of its pleadings have been decidedly anti-electroshock.

"The claims seem to be that anyone who would criticize psychiatry must be under the powers of some evil cult, and that is ridiculous," Oaks said. "What we are is pro-choice, that people get a range of alternatives, and that no force be used."

Oaks said his organization was attracted to Austwick's case by the question of whether electroshock could be used on a woman who never had consented to it.

To the dismay of psychiatrists, the group was allowed to file a brief in the Austwick case describing problems with electroshock.

The guru of the anti-electroshock movement is Dr. Peter Breggin, a Maryland psychiatrist.

Breggin once likened the treatment to a "blow to the head," saying it delivered the same kind of brain damage.

But most psychiatrists dismiss electroshock opponents as kooks and zealots. There is no better evidence, they say, than the fact that among the leaders of the anti-electroshock movement is the anti-psychiatry Church of Scientology and its Citizens' Commission on Human Rights.

"A lot of these groups aren't just against ECT, they are against psychiatry in general," said Dr. Richard Weiner, an associate professor of psychiatry at Duke University and chairman of the American Psychiatric Association's task force on electroshock.

"ECT has been the subject of a lot of public hearings, and it has always come out OK," Weiner said.

Still, no one can dismiss the successes of electroshock's critics. Their pinnacle came in 1983, when they pushed through a ban on electroshock within the city limits of Berkeley, Calif. The ban was later overturned in court.

But the legacy has lingered. California continues to have one of the toughest electroshock laws in the country, requiring full disclosure to the patient of reasons for the treatment, its duration and all possible side effects. Illinois law requires court approval of the treatment when the patient isn't able to consent to it.

That's how Austwick's case ended up in court.

But it became more than a case about her, creating an arena for much broader questions about the treatment in general. And it may have resulted in a serious setback to use of electroshock.

It wasn't supposed to be this way. During a hearing before the Appellate Court in May, Judge Thomas Hoffman warned that the Austwick matter was not supposed to be a case about the pros and cons of electroshock.

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Instead, he said, the issue was whether Austwick should have been given the treatment and what standards should be applied for answering that question, the judge said.

Although Austwick no longer needed the treatment, the Appellate Court decided that the precedent-setting case raised too many critical issues. It issued a ruling anyway saying shock therapy wouldn't be in Austwick's best interests.

The court noted the "substantial risks" associated with the treatment, including broken bones, memory loss and even death.

The ruling reflected the thinking of the opponents, and the Illinois Psychiatric Association criticized it for ignoring all the scientific evidence.

The use of anesthesia and muscle relaxants, psychiatrists said, have eliminated the incidence of broken bones.

As for memory loss, they conceded that it does occur but usually disappears.

Some patients, however, report some long-term memory loss that never dissipates.

Pyschiatrists also note that statistics show a death rate of only 1 for every 10,000 procedures performed.

Some doctors say the Austwick case illustrates the dangers of the courts trying to deal with science.

The Austwick ruling presented "not a very clear and fair description of a treatment that is really life-saving," said Dr. Philip Janicak, medical director of the Psychiatric Institute at the University of Illinois at Chicago.

"It is rooted more in impressions that go back 20 years than the facts about what modern techniques are involved."

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Date: Friday, January 6, 1995
CHICAGO TRIBUNE

Electroconvulsive or shock therapy should not be used for children under 16 because it may cause memory problems and too little is known about other potential hazards, a psychiatric consultant said Thursday.

Dr. Tony Baker, writing in the British medical journal Lancet, questioned the ethics of the treatment known as ECT, saying anecdotes of misuse and damage to unsuspecting and uninformed patients abounded.

In ECT, a short burst of electric current is sent through the brain to induce a convulsion. Although its use has declined, the therapy is still considered important for some patients with severe depression or schizophrenia.

Baker said such electric currents are associated with memory problems and that "young skulls have a lower electrical resistance and for the same electric charge will be exposed to higher current than other skulls."

The British consultant, an expert in childhood trauma, also said ECT should be conducted on those over 16 only under a license system.

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People with mental illnesses are particularly vulnerable to alcohol and drug abuse. Find out why and how dual diagnosis (mental illness plus substance abuse problem) can be treated.

In this era of community-based treatment and widespread availability of alcohol and other drugs, people with severe mental illnesses (e.g., schizophrenia, schizoaffective disorder, or bipolar disorder) are highly likely to abuse or be dependent on alcohol or other drugs, such as cocaine or marijuana. According to recent epidemiologic studies, approximately 50 percent of people with a diagnosis of severe mental illness also meet lifetime criteria for a diagnosis of substance use disorder.

Mental Illness and Susceptibility to Drugs and Alcohol

Just why individuals who are mentally ill are so prone to abuse alcohol and other drugs is a matter of controversy. Some researchers believe that substance abuse may precipitate mental illness in vulnerable individuals, while others believe that people with psychiatric disorders use alcohol and other drugs in a misguided attempt to alleviate symptoms of their illnesses or side effects from their medications. The evidence is most consistent with a more complex explanation in which well-known risk factors - such as poor cognitive function, anxiety, deficient interpersonal skills, social isolation, poverty, and lack of structured activities - combine to render people with mental illnesses particularly vulnerable to alcohol and drug abuse.

One further point about vulnerability is clear. People with an established mental disorder - probably because they already have one form of brain disorder - appear to be extremely sensitive to the effects of alcohol and other drugs. For example, moderate doses of alcohol, nicotine, or caffeine can induce psychotic symptoms in a person with schizophrenia, and small amounts of marijuana, cocaine, or other drugs can precipitate prolonged psychotic relapses. Accordingly, researchers often recommend abstinence from alcohol and other drugs for people with severe mental illness.

Substance abuse also appears to worsen health and social problems by contributing to poor nutrition, unstable relationships, inability to manage finances, disruptive behavior, and unstable housing. Substance abuse interferes with treatment as well. People with dual diagnoses (severe mental illness and substance disorder) are likely to deny alcohol and drug problems; to be non-compliant with prescribed medications, and to avoid treatment and rehabilitation in general. Perhaps due to their poor treatment compliance and psychosocial instability, people with both mental illness and substance abuse are highly vulnerable to homelessness, hospitalization, and incarceration.

The problems related to combined substance abuse and mental illness pose a substantial burden to the families of people with dual disorders. Surveys show that family members identify substance abuse and its attendant secretiveness, disruptive behavior, and violence as among the behaviors that are most disturbing. Even though relationships are strained by problems related to dual diagnoses, our research shows that families expend a great deal of time and money helping out in a variety of areas, from providing direct care to attempting to structure leisure time and increase participation in treatment. Furthermore, they are often unaware that their relative is abusing drugs or confused about how to respond to substance abuse, so education is greatly needed.

Getting Help for Dual Diagnosis

Although people with co-occuring mental illness and substance abuse desperately need help with both problems, the service system's organizational structures and financing mechanisms often provide barriers to obtaining treatment. The crux of the problem is that the mental health and substance abuse treatment systems are parallel and quite separate. Even though the majority of patients in either system have dual diagnoses, involvement in one system typically precludes or limits access to the other. In addition, both systems may attempt to avoid responsibility for clients with complicated problems.

Even when people with dual disorders are able to negotiate access to both treatment systems, they may have difficulty getting appropriate services. Mental health and substance abuse professionals often have different types of training, espouse conflicting philosophies, and use different techniques. For example, mental health professionals often view substance abuse as a symptom or response to mental illness and therefore minimize the need for concurrent substance abuse treatment. Similarly, alcohol and drug treatment professionals often emphasize the role of substance abuse in producing the symptoms of mental illness and therefore discourage active psychiatric treatment. These views can prevent accurate diagnosis and subject the client to a bewildering set of conflicting treatment prescriptions. Because many programs make no attempt to integrate treatment approaches, the client, with impaired cognitive capacity, is entirely responsible for the integration. Not surprisingly, the client often fails in this situation and is considered difficult or labeled as "treatment-resistant."

Over the past 10 years, treatment programs developed specifically for people with dual disorders have emphasized the importance of integrating mental illness and substance abuse interventions at the level of clinical care. For example, mental health programs for people with severe mental disorders can easily include substance abuse interventions as a core component of comprehensive treatment. Assertive outreach as well as individual, group, and family approaches to substance abuse treatment are incorporated into the comprehensive approach of the case management or mental health treatment teams. Because substance disorder is a chronic illness, treatment typically occurs in stages over several months or years. Clients must first be engaged in outpatient treatment. At this point, they often require motivational interventions to persuade them to pursue abstinence. Once they identify abstinence as a goal, they can use a variety of active treatment strategies to attain abstinence and to prevent relapses.

People with dual diagnoses clearly can be engaged in these programs. Over the short term, their regular participation in outpatient treatment results in decreased institutionalization. Over the long run - approximately two or three years - most people can attain stable abstinence from substance abuse. Because substance abuse is a chronic, relapsing disorder, treatment may take several months or years, and involvement in some form of treatment should continue for many years.

Unfortunately, at this point, integrated treatment programs are not widely available. Most occur as models or demonstrations. Cost is not the limiting factor because a substance abuse specialist can be hired as a member of the mental health treatment team at approximately the same salary as a mental health specialist. But the mental health system must be willing to take responsibility for this critical aspect of clients' lives and must sponsor the appropriate changes in service organization, financing mechanisms, and training. For example, effective integration of mental health and substance abuse treatments often requires cross-training of mental health and substance abuse providers to sensitize them to the philosophies and treatment techniques used in the different fields.

Families can be helpful in several ways: By being aware of the high rate of substance abuse among people who are severely mentally ill, by being alert to signs of alcohol or drug problems, by insisting that the mental health system take responsibility for addressing alcohol and drug problems, by pursuing drug and alcohol education, by participating in alcohol and drug treatments for their relatives, by advocating for the development of dual-diagnosis treatment programs, and by encouraging research into this critical area.

About the author: Robert E. Drake, M.D., Ph.D. is a Professor of Psychiatry, Dartmouth Medical School,

SOURCE: NAMI publication, The Decade of the Brain, Fall, 1994

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Complications

The federal government reimbursed the executive's company, which billed Medicare for between $20 million and $40 million in bribes that were disguised as salaries, the executive admitted.

Peter Alexis, former "administrator of the year" for Psychiatric Institutes of America, pleaded guilty to conspiracy and false-statement charges before U.S. District Judge Joe Kendall in Dallas. He said he helped bribe more than 50 physicians across the nation.

Mr. Alexis agreed to become a prosecution witness in a nationwide investigation, and prosecutors agreed not to seek additional charges against him.

Judge Kendall asked Mr. Alexis several times whether he was aware of the rights he waived with his guilty plea.

After Mr. Alexis repeatedly stated that he is voluntarily exposing himself to as many as 10 years' imprisonment, Judge Kendall replied: "I'm just wondering how many doctors out there in the Dallas-Fort Worth area aren't sleeping too well these days."

At Judge Kendall's request, Mr. Alexis explained his role in what he said was a companywide conspiracy. "I paid physicians to refer patients to our hospitals," Mr. Alexis said.

"So, it was just a mass kickback scheme? You were buying patients?" the judge asked.

"Yes, your honor," Mr. Alexis replied.

Mr. Alexis served for several years as administrator at Psychiatric Institute of Fort Worth. He became PIA's vice president for the Texas region in 1989 but resigned in 1990 after some patients complained that they had been hospitalized unnecessarily so that PIA officials could collect huge sums from insurance companies and Medicare programs.

He declined to comment after the hearing Monday.

"Mr. Alexis is the highest-ranking PIA executive to plead guilty, so far," U.S. Attorney Paul Coggins said. The continuing FBI investigation is nationwide in scope, Mr. Coggins said.

"There will be many other states affected by this investigation, " Mr. Coggins said. "We think this case may take months or even years to resolve."

Doctors weren't the only ones bribed, Assistant U.S. Attorney Christopher A. Curtis said. He said that illegal payments also went to therapists and social workers.

Psychiatric Institutes of America was absorbed last year by its corporate parent, National Medical Enterprises Inc.

Diana Takvam, a spokeswoman at NME's headquarters in Santa Monica, Calif., declined to comment on Mr. Alexis' courtroom statements.

Ms. Takvam, however, said NME is attempting to negotiate a settlement with officials at the Department of Justice and has "established a reserve of $375 million."

NME has not yet agreed to pay that money to the government, Ms. Takvam said.

Another NME official previously reported that the firm is selling or shutting down all of its psychiatric hospitals in Texas.

According to a written statement, NME officials hope that the proposed agreement with the Department of Justice "will close all open investigations of NME."

Judge Kendall told Mr. Alexis that he could not predict how many of the possible 10 years federal officials will recommend under sentencing guidelines. But he advised Mr. Alexis that federal law no longer permits parole, and he said the defendant should not expect a minimum sentence.

"Without even looking, I would guess that your guidelines . . . will be off the charts," the judge said. Judge Kendall did not immediately schedule a sentencing hearing for Mr. Alexis. He said he will wait to review the depth of Mr. Alexis' cooperation with prosecutors.

"The prudent thing to do would be to sentence you sometime off in the future," the judge said.

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