An aerosol mist laden with deadly microbes filters through the air and is inhaled by an unsuspecting population in a U.S. city under attack by unknown terrorists. Their destructive intent--a secret for weeks as the germs incubate--is revealed only after the first casualties arrive at hospital emergency departments. Disaster officials move to contain the disease; but the system is soon overwhelmed, not only by people who are really sick, but also by thousands of healthy individuals whose growing anxiety yields false symptoms of illness. Public health and government relief efforts sag under the strain, and fearful crowds begin to react in ways that threaten the social fabric.

This scenario is so real, so potentially devastating, that the federal government will spend $11 billion this year alone to combat terrorism, whether biological, chemical or nuclear. In all, some 40 government agencies will play a role, and there are at least three bills pending in the U.S. Congress that aim to better organize the  agencies that must respond to an attack by foreign or domestic foes.

The hallmark of terror, by definition, is that it can disable an opponent by undermining confidence in its institutions. According to one government report, terrorism is, "The unlawful use of force or violence against persons or property to intimidate or coerce a government, the civilian population, or any segment thereof, in furtherance of political or social objectives." Yet despite the psychological component at its core and the enormous dedication of resources devoted to meet the threat, mental health experts say that more must be done to meet the behavioral issues that arise following an attack.

Robert J. Ursano, M.D., professor and chair of the department of psychiatry at Uniformed Services University of the Health Sciences in Bethesda, Md., told 

 that the mental health component is presently dramatically underfunded and underrecognized. "If you don't deal with the mental health issues," he said, "you won't have to worry about the other issues because the system will be overloaded [with mental health issues]."

Ursano, who is also the former chair and a current member of the American Psychiatric Association's committee on psychiatric dimensions of disaster, said that one of the reasons mental health does not receive the emphasis it deserves is the sheer magnitude of integrating a large number of government agencies. Some of the billions spent, he said, are often duplicative and not well-organized.

Not atypically, mental health issues are also marginalized to an extent. "I think people see it as a secondary line of concern, and they don't appreciate the reality of how individuals in communities will respond in such settings," Ursano said. "They get targeted toward the infectious agent without thinking about the complexity of the responses people will have. It's not to say that one shouldn't be dealing with how to identify infectious agents better [or] how to develop treatments for them--those are certainly of great concern--but if you don't address the mental health and psychological issues, all of that may go for naught."

In many respects, the psychological responses and need for psychiatric intervention in the case of a bioterrorist attack are similar to those in natural or other man-made disasters, but there are reasons that the biological weapons of mass destruction--smallpox, anthrax, botulism and plague--possess a unique character, Ursano said. For instance, there is a likelihood that the health care system will be flooded by people who exhibit "multiple unexplained physical symptoms." The prospect of an invisible destructive agent activates emotions that are difficult to manage, particularly when people organize in disruptive ways because they feel their safety needs are not being addressed by public officials.

Despite the specialized attention to behavioral responses required by a biological weapons attack, federal budget officials have yet to fund the work necessary to prepare, psychologist Brian W. Flynn, Ed.D., told 

. Flynn is the emergency coordinator for the Substance Abuse and Mental Health Services Administration (SAMHSA) and a rear admiral and assistant surgeon general in the U.S. Public Health Service.

"Over the past four years we have been completely unsuccessful in getting any funding from outside the agency with respect to bioterrorism," Flynn said. "Each year we propose a bioterrorism budget, and we have been completely unsuccessful. We've gotten very good support from HHS [U.S. Department of Health and Human Services], but it has been zeroed out each time at the Office of Management and Budget."

That failure means that important work is left undone. "We feel that we have to build a new field," Flynn said. "There is a need for the development of knowledge and development of models and protocols that simply don't exist. The interface between behavioral health and emergency health in a bioterrorism incident is going to be much greater than we typically see in natural disasters. Emergency room personnel aren't trained to make differential diagnoses; they don't have models; they don't have tools; so we need to build and test those tools and train those people. We also must get much more deeply into risk communication, which we see as having a very significant behavioral health component."

"It's a very real concern that we don't have much experience with bioterrorism," Carol Sue North, M.D., professor of psychiatry at Washington University School of Medicine in St. Louis, told 

. North, who has studied the psychiatric consequences for victims of disasters, added, "I'm a data person and I like to have data to [substantiate] what we would expect and what kind of things we might recommend The thing is, there aren't any data, because there haven't been many such incidents, otherwise we wouldn't be talking about worrying about it."

Under the circumstances, North said, the best that can be done is to extrapolate from research conducted following disasters of other sorts. "There are specific psychiatric diseases that will arise, and we know how to treat those no matter what form they come in," North explained. "If they get to us, we know how to treat them. The problem is psychiatric problems may flood the rest of the system. For example, somatizing or phobic people coming in and, thinking they've been exposed, demanding prophylaxis for the probable exposure. There's also the issue of coordination of efforts so that psychiatrists can come in and do what they're good at, and so the right people get to the doctors."

Responsibilities still need to be delineated, North said, especially when it comes to managing what could be large groups of people and the emotional tides that will flow through them. "A lot of what happens looks psychiatric but may not be per se psychiatric," she said. "A lot of people who get excited and come in and bollix up the system maybe aren't psychiatrically ill and are simply scared."

While there are things officials can do to help calm the masses, it is still not particularly clear as yet who bears the primary responsibility for assuring these things get done, North told 

. "The way it stands is maybe that hasn't been figured out."

According to the second annual report issued late last year by the federally funded Advisory Panel to Assess Domestic Response Capabilities for Terrorism Involving Weapons of Mass Destruction, there is still much to do, including developing a coordinated national approach. Particularly with respect to bioterrorism, "The key issues are insufficient education and training in terrorism-related subjects, minimum capabilities in surge capacity and in treatment facilities, clear standards and protocols for laboratories and other activities, and vaccine programs," the panel members wrote. "A robust public health infrastructure is necessary to ensure an effective response to terrorist attacks, especially those involving biologic agents."

In May, President George W. Bush assigned Vice President Dick Cheney the task of overseeing the national effort of dealing with weapons of mass destruction. In addition, an Office of National Preparedness, under the jurisdiction of the Federal Emergency Management Agency, will "serve as the focal point for the coordination and implementation of preparedness and consequence management programs for dealing with the threat of weapons of mass destruction," director Joe M. Allbaugh said in a statement to congressional committee members.

"It's good to have some senior leadership addressing the topic of how these multiple organizations are going to relate to each other, which is one of the issues in any type of disaster, but even more so in the area of bioterrorism," Ursano said. He is hoping that the new emphasis will result in considering mental health consequences.

"There have been a lot of activities about training first responders, and 120 cities have been identified and training efforts have taken place in those cities," Ursano explained. "So for the last several years there have been substantial amounts of funds, but in those settings mental health frequently gets overlooked--more than overlooked, it gets specifically zeroed out."

A 319-page study published last October by the Henry L. Stimson Center, a nonprofit think tank in Washington, D.C., agreed that wasteful government spending substituted "pork" for "preparedness" and that "throwing money at the problem is a costly substitute for effective government." Among the report's findings, it urged, "To prevent hospitals from collapsing during an infectious disease outbreak, cities should have workable plans to care for the unaffected and the mildly or moderately ill, including the establishment of field care centers where medical exams could be conducted, prophylactic drugs dispensed, and counseling provided, as appropriate."

Richard C.W. Hall, M.D., a private practice forensic psychiatrist in Maitland, Fla., and clinical professor of psychiatry at University of Florida College of Medicine, has consulted with various federal agencies since the Oklahoma City bombing, after which public interest in psychiatric casualties increased. In the wake of a biological weapon attack, how people will react will depend on the facts of any given situation, but patterns do emerge.

"The issues are usually not ones we think of," Hall told 

. "If a city has 200,000 bodies to dispose of in a week, the normal morgue system doesn't work you need some way to incinerate the bodies. If you have a contaminated water supply or you have to put troops in a city to cordon off areas that may be infected, then you've got an issue of whether people are trapped and if they can get out of an infected area. Will soldiers fire on civilians? Will civilians break curfew? Will parents try to reunite with their children? All those kinds of things come up."

Meanwhile, he said, the population will likely divide into thirds. "The initial reaction is disbelief, and then about a third of the people panic and they start consuming resources," Hall said. "About a third of the population is numb but compliant, they do what they're told to do and follow orders. And about a third of the population wants to take charge and, if they don't get a chance to do it, then they get oppositional and they start to form an opposition group."

As a result, Hall said it is important that preparedness programs include components that offset these effects. At the onset, high quality communications are needed for all types of reactions. The third of the population that wants to get involved and do something positive needs to know what they can do; the other third that is numb but compliant needs clear directions; and the rest of the population needs very structured systems. All of these issues must be addressed in any disaster plan.

Spencer Eth, M.D., vice chancellor and clinical director of the department of psychiatry at Saint Vincents Hospital and Medical Center in New York City and professor of psychiatry at New York Medical College, said that mass hysteria is a likely outcome of a biological weapon attack, but dealing with it will be complicated because of the number of real victims. In a real terrorist attack, "you're also going to have real people who have been injured and traumatized and all sorts of psychiatric issues to deal with other than the generally self-limiting mass hysteria. But the problem with the mass hysteria is that people do very dumb things when panicking."

While planning is important, there are limits. "Once it starts, you're kind of hanging along for the ride," Eth said. There are limits to how much anyone will be able to control the multi-faceted consequences of a bioterrorist attack, agreed Ursano. "I don't think one controls them. One tries to anticipate, one tries to prepare and one tries to have the resources available to meet the needs. And, in doing that, one can decrease the level of disruption, the degree of fear and, hopefully, the loss of life."

Articles

The threat of a bioterrorist attack is very real and should be of real concern to those in the health care field. While federal government budgets have been requested to address the mental health aftermath of such attacks, they have been repeatedly denied. Psychiatrists will be needed to help treat panic and hysteria among populationsthose who are affected, those who are not but believe they are and those who are left to pick up the pieces.

Bioterrorism Looms Are We Prepared?

Managed behavioral health care organizations (MBHOs) -- the so-called carveout programs for managing psychiatric benefits in managed care -- have taken an increasingly large share of the health care market during the last eight years but are coming under fire from physicians who believe patients with mental illness are victims of discrimination.

In 2000, the number of Americans covered under carveout plans jumped 13.4% to 169.1 million, up from 149.1 million in 1999. In 1993, carveouts accounted for only 70.4 million members.

Last year also saw official resolutions from both the American Medical Association and the American Psychiatric Association raising the issue of discrimination in carveouts and calling on the industry to take steps to ensure that mentally ill patients are not stigmatized.

"It is discriminatory in the sense that the mentally ill get treated differently [from] every other patient in medicine," Lawrence B. Lurie, M.D., chair of the APA's managed care committee, told 

 "When the day comes that there's no more stigma for the mentally ill, there shouldn't be a separate program for mental illness."

Lurie added, "We fought very hard in California to get parity for patients. Now we're fighting to get parity with other physicians -- the same Relative Value Schedule. This is discrimination. If a psychiatrist isn't being treated like other physicians, that's a professional problem that needs to be addressed."

"Mental health is just like cardiac health, lung health or any other branch: It's a medical problem," Herman I. Abromowitz, M.D., a member of the AMA's board of trustees, told 

. "We realize the practicality -- that many patients are covered under these programs -- but we tried to set up standards of principles that we hope managed care companies will follow."

Carveout programs initially were designed to bring a measure of expertise to the provision of health care benefits for mental illness. Working either as subcontractors to benefit plan companies or directly contracting with employers in some cases,  mental and behavioral health organizations structure programs specifically for employees and their dependents who require specialized care.

"In terms of the care that you get, the carveout company can get you better care, because you've got people whose only job is to deliver behavioral health care," Pamela Greenberg, executive director of the American Managed Behavioral Healthcare Association (AMBHA), told 

 "We have the expertise. The individual is getting better care because of that, and because it is separate from the HMO." The AMBHA represents 10 major carveout companies that provide benefits, in aggregate, for more than 65% of the individuals covered by MBHOs.

Greenberg denied that her industry is discriminatory. "A lot of people want to go to a specialized cancer treatment clinic. Are you going to argue that the cancer patient is discriminated against? In many cases, the separate is separate because it's better and more specialized."

In the early days of carveouts, the medical profession watched them with a wary -- if trusting -- eye. The 1998 APA 

Handbook for the Development of Public Managed Care Systems 

said, "For programs with some managed care experience or expertise, a fully or partially carved-out approach, managed by specialty experts, may be the optimal first approach." But, it added, "For areas with experienced and mature provider systems, addressing all needs through a single health plan may provide better integrated care, including the often overlooked linkages between specialty and primary care."

More recently, that acceptance has been on the wane. Physicians are concerned about the difficulty of coordinating care for a patient with both physical and mental illness who is covered under two different health plans.

Roland Sturm, Ph.D., a senior economist at the Santa Monica, Calif.-based think tank RAND, agreed that coordination can be a problem. He explained to 

 "That might be a bad thing. If employers split their health benefits, the doctor has to deal with different companies. That can be a drag. The split between benefits can be problematic, not just for the psychiatrist, but also for the primary care physician."

"You'll get approval for one initial visit, and then maybe they'll authorize one or two more," Lurie said. "You have to ask for more authorizations. It takes time to do that. Limited authorizations is one problem. Or they'll authorize one visit and then only medication visits after that, or send the patient to see a psychologist for follow-up. With that split kind of treatment, it's hard to know who's responsible. It's not a good practice of treatment."

Barry F. Chaitin, M.D., co-chair of the department of psychiatry and human behavior at University of California at Irvine, told 

 "Many psychiatrists feel that the system is so onerous they won't participate," leading to shortages of psychiatrists to care for patients in carveout programs.

In addition, some physicians believe that singling out psychiatric patients may circumvent laws requiring parity in insurance plans for physical and mental illness.

Last May, the APA assembly adopted a report that found, "This practice reinforces the stigmatization of psychiatric illness, isolates psychiatrists and other mental health practitioners from the medical care systems, and promotes 'cost shifting' at the expense of quality patient care."

"The other issue," Lurie said, "is that you have two different companies, and they may each say that the other is responsible for payment of services. So you get into a jurisdictional fight. It will usually get solved, but it may take years."

Last December at the interim meeting of the AMA House of Delegates, a report similar to the APA's was presented, leading to the adoption of a strongly worded resolution.

The AMA resolution was unequivocal. It included a preamble that began, "The AMA is opposed to mental health carveouts." It concluded, "RESOLVED, That our American Medical Association work to encourage payors to eliminate mental health and chemical dependency carveouts so that benefits for mental health and chemical dependency are managed and administered like other health care services." Between the preamble and resolution, it listed several principles that managed care providers should follow to protect patients in carveout programs and for accrediting bodies to use as a guide for evaluating carveout programs.

Among the principles advocated by the AMA were:

 Carveout programs should adequately provide for the appropriate diagnosis, evaluation and treatment of medical comorbidities.

 Where a cap on the number of mental health visits is imposed by a health plan, recertification for additional visits should be granted upon request by the treating psychiatrist, or other health care professional, without additional personal information from the patient.

 Third-party payers using mental health carveout programs should contract with MBHOs that have met the standards of recognized private sector accrediting bodies.

 Private sector accrediting bodies collecting quality assessment data of MBHOs should widely disseminate such information to the public.

 MBHOs should provide health plan enrollees with clear and easily understandable information on how to access the organization's mental health services.

 Removal of any barriers from their intake procedures that interfere with timely communication and collaboration between attending physicians and psychiatrists.

In addition, it called on AMA leadership to work closely with relevant specialty societies to develop strategies for corrective actions to eliminate discriminatory mental health policies in health plans.

Sturm believes that physicians are using the claim of discrimination to conceal other motives for opposing carveout programs. "Once someone says it's the principle and not the money, you know what it's about," he explained.

"Carveouts have been successful in containing costs, and the doctors don't like it. The one bad thing you can say about them is that the benefits usually are very limited. In order to manage benefits, you need a managed care company. The combination of managed care and carveouts has been good. It's increased access to care. More people are getting into the system. In intermediate services, like substance abuse, there are more services being provided. The follow-up rates are better. Under fee-for-service, the follow-up rate was maybe 50% or 60%. Under carveouts, for example, the follow-up rate for detox is in the high 70s. That's a crude indicator of quality," Sturm says.

But, he conceded, "Some carveouts do a terrible job. It's hard to get authorizations, but that's a flaw of specific companies, not carveouts as a group. Some of them seem to have a lack of psychiatrists in their network. The time to the first appointment may be longer than desirable. But it's not because the carveouts try to prevent patients from getting care, but because there are no doctors. Here I don't have any strong national data, just anecdotal data, but it's of concern to the carveouts."

Greenberg explained that authorization policies often reflect the wishes of the employers who use MBHOs. "It could go down to the contract level. One company may have a number of different policies, depending on its contracts and what the purchasers are asking for. People forget the role of purchasers in this. We go in with a menu of options for the purchaser, and then they choose. It is typical that there would be approval automatically for a certain amount of visits, and then periodic approval needed thereafter. Those types of policies or procedures were put in place to try to create an accountable system. That hearkens back to the whole reason we've got managed behavioral health care. In the old days, it was unaccountable and costs were escalating. We created accountability."

Charles G. Ray, president and chief executive officer of the National Council for Community Behavioral Health Care, pointed out to 

that, despite the efforts of managed care, health costs continue to rise faster than other segments of the economy. "The health care price index is going up two to three times as fast as the Consumer Price Index," he pointed out. "It's the benefits that are being compressed."

"We agree that there are many situations right now where the benefits are less," Greenberg acknowledged. "We support having parity. That was the No. 1 issue for our members, to have the federal government pass the mental health parity law. We're in a working coalition with both the APA and the AMA. We're all in agreement there."

So far, though, none of the parties are talking about the issues relating to carveouts directly. "Not yet," Greenberg said when asked if AMBHA has heard from AMA or APA about their resolutions. "We do have medical directors of managed care companies on our committee," added Lurie. "We do discuss the issues with them, but we don't go and meet with the industry itself or the CEOs." Abromowitz said that the AMA has not engaged directly in a dialogue, but "I'm sure it's going on in many areas of the country."

"Carveouts are here in full force," said Greenberg. "It's better to work with us than to make a statement that carveouts are bad and then just leave. That doesn't do anybody any good. This is something we believe is important and that we want to work on. For some providers who have an opposition to carveouts, their opposition is really to managed care. Their end goal is to go back to a fee-for-service environment. It's a masquerade for trying to go back to the old-style system, which wasn't accountable."

Carveout programs for behavioral health care are becoming more common. Who do they benefit3/4the patient, the doctor or the insurance company?

Carveouts: Specialization or Discrimination?

During a performance at a summer concert in a park in San Diego last year, I realized that I had been "doing" Elvis since 1957 -- a year longer than he did himself. I have been a singer since childhood, and in 1985, I formed the first of several iterations of "Dr. Elvis and the Immortals," a '50s and '60s oldies band. In addition to the music of the era performed by four other musicians/vocalists, the group has had a continuing stream of immortal guest performers whose personae and music I have stolen. I have been transformed into Buddy Holly, Jerry Lee Lewis, Elvis Presley, Mick Jagger, Chuck Berry, Little Richard, Fats Domino, Ray Charles and Roy Orbison -- complete with outfits, wigs and makeup. Over the years we have played in many venues, including private parties, nightclubs, parks, the San Diego Sports Arena, the Playboy Mansion and the American Psychiatric Association annual meeting. In the early years, we played almost weekly. Now, the band may play a few times a year, supplemented by an occasional appearance of The King at a wedding.

You might think psychiatry and rock 'n' roll seem irreconcilable. Not so. First of all, one must consider that all the wisdom of the Western world is contained in rock 'n' roll. Not convinced? Consider these gems, for instance: "When you find your sweetheart in the arms of your friend, that's when your heartaches begin," or "You can't always get what you want, but if you try sometime, you might find you'll get what you need," or "War (good God, y'all) what is it good for? Absolutely nothing."

Besides the value of rock 'n' roll for understanding human nature, life and psychiatry, my training and experience in psychiatry has helped me enormously in my rock 'n' roll career. It has helped me walk into the audience and interview unsuspecting and vulnerable people in an impromptu and maximally embarrassing fashion. Psychiatry has helped me differentiate the fan having a good time listening to "Heartbreak Hotel" from those with displaced de Clerambault's syndrome or erotomania bestowing gifts upon The King. When Little Richard prances and cavorts through the crowd in his sequined butterfly blouse flirting with some of the x-chromosomally challenged, my training in violence prevention has taught me to avoid those men holding a beer bottle upside down in their fist. Psychodynamic understanding adds meaning to the appearance of a banana that has fallen down the leg of Mick Jagger's black leather pants. Sensitivity to the moods of others has helped me assess when Roy Orbison's sorrow and tearfulness might be excessive, as well as who might be offended when Ray Charles sings facing the wrong way or falls off the stage, or when "The Killer" Jerry Lee Lewis (after a mistaken appearance by Jerry Lewis yelling "Lady") refuses to perform until the specifications of his contract are met (a minimum of three underage girls in the audience).

Why risk life and limb (and reputation)? Regression in the service of the ego is fun. There is nothing like losing oneself in a performance, especially a constantly changing series of roles that demand such an admixture of musical knowledge and talent (vocal when good, comedy when not), physicality, suspension of reality, narcissism, sadism, and exhibitionism. In other words, fun.

The aesthetics of music speak (or sing) for themselves. Music has the capacity to transform our spirits and souls. It works for me as a recipient and, combined with a sense of mastery, as a producer. In this form, it has allowed me the great opportunity and pleasure to entertain others; to see the laughter, joy or poignancy in their faces; to bring a different and more immediate meaning to the lives of others than I do in my daily work with patients or students. God forbid an academic or a physician should live out their inclination to be in the spotlight and feed off their audience. Although few of my patients (but many colleagues and trainees) have witnessed my performances, none have been confused, and some have felt the experience added to our relationship. Through it all, these experiences have enhanced my life, giving me the opportunity to embrace life more fully and to participate in history even as I imitate it.

My greatest pleasures in performing have been associated with my children. After years of causing them untold embarrassment, they have all come to enjoy attending my shows, and they often bring friends along. Two of my children arranged for me to perform mock wedding ceremonies at their high school dance for Las Vegas Night and even performed with me as backup on a couple of numbers. Recently, my youngest child, a film major at University of California at Berkeley, completed a film project called "My Daddy Is Elvis."

A final vignette: at the 1999 APA annual meeting in Washington, D.C., at Constitution Hall, I had the good fortune to participate (with two very talented local vocalists-psychiatrists) in a performance of the "Three Tenors." After solos by "Jos Carreras" and "Plcido Domingo," I (as "Luciano Pavarotti") was straining to complete "La Donna Mobile" when I suddenly "collapsed" and was dragged off by one leg by the stage hand to the apologies of Carreras and Domingo who proceeded to sing "O Solo Mio" as a reluctant and guilt-ridden duo. Midway through their performance, I arrived in my gold lam fringed jumpsuit to establish a dueling version of "It's Now or Never," ending in a reconciliation of the Three Tenors in its finale.

Stephen R. Shuchter, M.D., professor of clinical psychiatry and associate director of residency training at University of California, San Diego, spends his "down" time performing as Elvis and other rock 'n' roll legends. In these efforts, he expresses his creativity and brings delight to those he entertains. Lessons from each "career" have helped his success in the other.

The Former Secret Life of an Elvis Impersonator

There has been a lot of water over the dam in the 10,000 years since the beginnings of agriculture and complex urban societies. For the million and a half years preceding that, human social organization had been more or less the same. Even while developing upright posture, tools and language, those species that carried the DNA sequence that defines the hominid line -- 

 -- roamed their mostly African ranges in small hunter-gatherer bands thought typically to consist of 20 to 30 closely related individuals. In this evolutionary context, if you helped someone survive (e.g., shared your food, nursed the injured) you could reasonably expect to receive help in return when you needed it. You and your comrade had a history together and such mutual helping benefited you both, bettering the odds that your own DNA sequence and/or your friend's (likely very similar) would propagate through time.

Such is the story evolutionary theorists have been telling us for the last 30 years about the origin of mutual helping behavior, or in their language,

, in humans and many other social species. The fulfilling inner experience we helpers have, according to these theorists, is epiphenomenal to the calculus of gene propagation; it is a good feeling that simply reinforces the most adaptive behavior just as surely as the "cute response" that moves mothers to nurture and protect their offspring. (The analogous response in mice can be removed by knocking out a gene called Fos-B; indifferent mother mice lacking it let their children starve.)

It is no wonder that this story has fallen mostly on deaf ears in the mental health community. Most of us resent having our most cherished ideals reduced to organic chemistry, even if we are comfortable wielding chemotherapeutic treatments. And yet, incomplete as it is -- and often half-baked, as presented in many popular books -- the evolutionary argument, in my experience, casts a revealing light on the personal evolution of many a psychiatrist.

Most of us begin as idealists eager to care for people, but few remain deeply engaged with large numbers of very needy patients after a decade or so. Aside from leaving the profession, there are two adaptive escape routes. (This was equally true before managed care, although the proportion of psychiatrists choosing each has been altered by it.) Both are attempts to survive the overwhelming emotional pain and need in whose path modern society places psychiatrists as specialized professionals expected to deal with it -- in exchange for pay -- and under circumstances wholly unlike those in which our capacity to meet needs and to solace pain developed.

In one typical escape from this overwhelming situation, the established psychiatrist in private practice progressively sets limits on the number and severity of cases they see. The chaotic borderlines or those with refractory Axis I syndromes are left to the big systems or to the newer private practitioners.

A second escape route, open to academic and institutional psychiatrists, is the retreat into some form of professional detachment. This appears variously as a theoretical or research orientation; focus on therapeutic technique, administrative procedure and systems management; or, more simply, the superficial med-check routine.

A third, non-sanctioned escape leads psychiatrists to impairment, addiction and boundary violations with patients. The latter will be our main concern here. I will argue that it can be seen as a perverse attempt to get reciprocal altruism to really work; to get something tangible back from patients by way of meeting personal needs inappropriately.

At best, experienced psychiatrists pick and choose where they get deeply involved, consciously aware of the need to conserve themselves for the long haul. Whatever their chosen escape from the undiluted, overwhelming needs of limitless numbers of patients, they do not turn up their noses at colleagues who have responsibly chosen another. And at worst, the private-practice therapists sneer at their institution-based colleagues for overmedicating patients and not listening to them, while the institutional psychiatrists sneer back at the psychotherapists for avoiding the heavy work: large numbers of very difficult patients.

Rarely does either group see a connection between its own choice and that of the third, impaired and/or boundary-violating group. We quickly distance ourselves from them without so much as a "There but for the grace of God go I." If we deal with our unconscious fear of falling into this quicksand ourselves with unalloyed moralistic denial, we label these "fallen" psychiatrists as sociopathic predators. (Of course, a small minority of them are.) Or, if our intellectual defenses have a more sophisticated polish, we may come up with some Kohutian verbiage about grandiose mirror transferences and narcissistic merger. Whatever our preferred explanation, we are steadfastly talking about something that happens to other people.

These explanations (particularly the Kohutian verbiage) are not without merit as far as an understanding of individual psychology is concerned. But they serve to distract us from an incontrovertible fact that both Darwin and Freud, in their different ways, brought to our attention some while back.

Human beings were not genetically designed to live in the social world in which they now find themselves. Psychotherapy and medicine are among the "helping professions" unknowingly assigned to deal with the personal consequences of this simple fact. In focusing on the individual psychopathology of each fallen psychiatrist -- I use the language of Eden purposefully here -- we neglect the collective significance of the phenomena of boundary violation and impairment themselves.

In the modern professionalized situation, the bottom drops out of small-group reciprocal altruism. As isolated and anonymous individuals encounter each other, having little past or future together, two things happen. The first is that, without the support of a true community, the limits of an individual helper's resources are reached sooner and more often. There are not enough helpers to go around. The second is that the help-seeker often brings a greater backlog or depth of unmet need, as well as depth of frustration if current needs are not met, to each encounter. In this context -- on purely Darwinian grounds -- altruism ceases to be so attractive. Competing and more immediate self-preservation instincts gain a stronger position. The helper often shifts, under their influence, to strategies that are sure, in the near term, to conserve resources: ways of obtaining immediate gratification or discharging uncomfortable affect at the help-seeker's expense. It is in this perverse sense that the helper is trying to make his originally altruistic involvement deliver some reciprocal benefit, or at least stop being a drain.

We in psychiatry have become quite skilled at constructing high-minded theoretical rationales for rejecting needy, messy patients. They need to experience limit-setting, to develop internal motivation and so on. It is for their own good. (Interestingly, some of the more successful innovative treatments for difficult patients, like assertive community treatment teams and a more relapse-forgiving substance-abuse treatment, throw these compliance rationales out the window. They dilute the patients' need through team approaches and group modalities that recall the hunter-gatherer bands of yore.) The sense of emotional relief that occurs after "limiting" patients out of our lives should tip us off that something instinctual, not just theoretical, is going on.

There is another form of objectification aside from the purportedly theoretical one of limiting patients out. It leads to exploitation of the help-seeker for the helper's own gratification. Here, too, one sometimes finds that boundary-violating therapists have constructed quite a coherent theory about what their patients needed to experience. Most overt therapist-patient sexual boundary violations occur in this context, but there are more subtle possibilities as well.

I recall a photograph of a female therapist taken by her male patient in a playful moment, which was later used in a chronicle of the eventual therapeutic disaster. I imagine this therapist luring the damaged child she saw in her patient and bringing his (and thus, her own) playfulness back to life in her misguided efforts to heal him (herself). Again, this was not true altruism, though it may have seemed like a quintessentially intimate experience. The therapist could not follow through, in real life, on the intimacy that her behavior seemed to promise and that the unfortunate patient took literally. The devastated patient later suicided.

The fact that each member of this therapeutic dyad may have, at the moment captured by the photograph, felt wonderfully close to the other obscures the deeper reality that the therapist's behavior was selfishly, not altruistically, motivated on the level that we are describing.

To summarize, there are two opposite modes of objectifying patients and their needs: "technical" limit-setting (to which, granted, there sometimes is no viable alternative) and boundary-losing "symbiosis." Between these there is a needle to thread: the hard work of remaining engaged and distinct. One tries to keep one's boundary, containing and processing one's own evoked affects while maintaining contact with the patient in order to help them in a parallel process. This very tall order is the concern of much of the modern psychoanalytic literature. Successfully done, it is altruistic, but the long-term payoffs -- money, status, gratitude (these first three are iffy), the exhilaration of mastery -- are far more abstract than the exemplary "hunk of meat" that rewarded our altruistic forebears for their efforts and presumably helped select their genes for dissemination.

It is no wonder that we so regularly fall short of this therapeutic ideal of engaged distinctness. Our behavioral genetics were designed for the earlier situation and are inadequate for the present one. We are trying to cross the ocean in a cardboard canoe. When we see that it is leaking, there is a strong motivation to jump ship and swim for shore.

Thus, viewed in the cold light of evolutionary theory, modern psychiatry, in both its psychopharmacologic and psychotherapeutic aspects, is often in the business of making new and better defense mechanisms to help us bearers of the human hunter-gatherer genome to cope with our unprecedented social situation. We psychotherapists, from whose ranks the boundary violators usually come, try to reconstruct an Eden that never was, in which altruism and its accompanying warm feelings can operate unfettered by the context of real community and real participation in one another's lives. There is a regressive longing for the world of the perfectly nurtured child here, which is why speaking of the fallen psychiatrist and patient who act this out literally seems apt. Acted out or not, the psychotherapeutic Eden provides a respite from the anonymous post-industrial culture outside the door, an Eden wherein patient and therapist alike feel heard and are seen as people of individual worth rather than objects manipulated by market forces.

Meanwhile, psychopharmacology and the more directive sorts of therapy (those that correct "irrational beliefs") are busy building a different kind of Eden in which, if you can't be one of the few at the top of the modern dominance hierarchy, at least you can have (with our assistance) approximately the same balance of neurotransmitters. A selective serotonin reuptake inhibitor can do this for you directly, or a "corrected" cognitive schema of your place in the world can do it indirectly (but verifiably, according to before-and-after metabolic neuroimaging studies).  Or, if society's demands remain beyond reach, perhaps stimulant medication can help you attain a more acceptable level of productivity, with the enhanced security and lifestyle options that accrue to those who can maintain it.

Myths can be life-giving at times, destructive at others. If psychiatry has any remaining potential as a socially progressive force, this Eden is one myth we need to lose. We must awaken from the unconscious thrall it still has over our professional lives in the form of unexamined assumptions and misconceptions about the work we do. In its modern psychiatric and psychotherapeutic versions, the renascent Garden of Eden myth now serves to distract us from consciously integrating our own discoveries about who we humans really are and how we really got here. It obscures the truths about modern life that impinge equally on those psychiatrists who succeed and those whose careers visibly go off course.

As responsible physicians we need, of course, to treat mental disorder, to prescribe medication, to perform psychotherapy. But our interventions are stopgaps, not solutions to the mismatch between our genetics and the culture we live in. Can we practice in such a way as to enhance our patients' perceptions about what is really going on in the social world? (Or validate those perceptions: in my experience, many patients see, in their own ways, exactly what is going on.) If not, we will remain in an ironic position: advocates of making the unconscious conscious, even as we unconsciously promise to do the impossible, or worse, act out the Eden myth with our patients. 

 have any chance of dealing with the evolutionary/cultural mismatch and its ubiquitously unrecognized consequences. We psychiatrists can begin to create community for ourselves as soon as we recognize that we are all fallen psychiatrists in a fallen world.

Stemming from evolutionary man and his simple, primitive act of help in exchange for help and Darwinian theory, Paul Genova, M.D., discusses the role reciprocal altruism plays in the "helping profession" of psychiatry.

Boundary Violations and the Fall From Eden

Although conventional electroconvulsive therapy (ECT) with bitemporal (BT) electrode placement in depressed patients commonly achieves remission rates greater than 80%, fears of the occasional prolonged cognitive effects inhibit patients and practitioners in its use. New research in ECT regarding variations in electrode placements among BT, bifrontal (BF) and unilateral (RUL) electrode placements is finding improved efficacy and a reduction in adverse memory effects. These findings strengthen the guidelines for delivering the most effective courses of ECT treatment. 

Bitemporal placement of the stimulating electrodes, one on each temple, is the conventional placement in ECT. This placement is widely used, effective and easy to administer. Bitemporal placement is used in the ongoing CORE Study Group, which is designed to assess the merits of different continuation treatments after a successful index course of ECT for patients with unipolar depression. The CORE Study Group is a collaboration of scientists at the Medical University of South Carolina in Charleston (Charles Kellner, M.D., Principal Investigator [PI]); the Mayo Clinic in Rochester, Minn. (Teresa Rummans, M.D., PI); Long Island Jewish (LIJ)-Hillside Medical Center in New York (Georgios Petrides, M.D., PI); and the University of Texas Medical Center at Dallas (Mustafa Husain, M.D., PI). The study began in February 1997 and is supported by grants from the National Institute of Mental Health.

The data are interim findings from the first phase of the study in which depressed patients were treated with BT ECT at 1.5 times the measured seizure threshold. After one week of remission, patients were randomly assigned to either continuation ECT or continuation pharmacotherapy with the combination of nortriptyline (Pamelor, Aventyl) and lithium, both sustained at minimum-measured, monitored blood serum levels, for six months.

The interim findings found that 217 (86%) of 253 enrollees completed the prescribed course of ECT in the first three years. Of these completers, 189 (87%) remitted. Remission is defined by the rigorous standard of a sustained reduction in the 21-item Hamilton Depression Rating Scale (HAM-D) greater than 60% and maximum scores of 10 or less for one week. Of all patients entered into the study, 75% remitted.

Sixty-seven of the patients (31%) were both psychotic and depressed and, of these, 64 (95%) achieved remitter status, a higher rate than among the nonpsychotic depressed (125/153, 83%). The psychotic patients responded faster and with greater reductions in HAM-D scores at all time points. The difference was evident after five ECT treatments and was sustained throughout the study.

The patients referred for ECT were severely ill. The average baseline HAM-D score was 37.8 for the psychotic and 33.8 for the nonpsychotic depressed patients. The baseline average HAM-D of 35 for all patients was reduced to 9.6. It took approximately seven ECT treatments for remission, an average of 16 days.

The older patients in this study recovered faster and to a greater degree than the younger patients. Of those between ages 18 and 45 years, the average baseline HAM-D was reduced to 12.7, while for those between 46 and 64 years and 65 and 85 years, the HAM-D scores fell to 8 and 8.5, respectively. The study found the antidepressant effect of BT to be robust among psychotic depressed and elderly depressed patients.

Bifrontal electrode placement -- each electrode on the brow over the outer canthus of the eye -- was re-introduced a decade ago in two Canadian studies that compared BF and BT at just over threshold energy dosing and RUL at 2.5 times the titrated seizure threshold (ST) (Lawson et al., 1990; Letemendia et al., 1993). When 40 depressed patients were assigned to one of three ECT electrode placement groups, they showed good therapeutic efficacy with BF, comparable to BT, with a sparing of the effects on verbal and nonverbal cognitive tests (Lawson et al., 1990). A follow-up study that assigned 59 patients to the same treatment groups reported greater benefits for BT and BF compared to RUL, with an advantage in adverse side effects for BF (Letemendia et al., 1993).

These results were independently confirmed in a study of 48 patients treated with either BF or BT (Bailine et al., 2000). Patients in both groups met remission criteria by the 12th treatment. Those treated with BF exhibited lesser effects on cognitive tests. A new replication study from the Canadian group found equivalent efficacy across the three placements, allowing the authors to conclude that treatment with BF electrode placement provides the best ratio of benefits to side effects and should be given at near threshold level to minimize cognitive effects (Delva et al., 2000).

Like BT, BF placement does not require a titration procedure to determine the seizure threshold. Effective energy dosing is usefully estimated by age and seizure electroencephalogram criteria allowing therapists to avoid the loss of an effective treatment in the first session. This loss occurs when titration methods are required to estimate energy levels for RUL treatment.

Research interest was galvanized four decades ago with reports that RUL -- both electrodes on one side of the head -- reduced the adverse effects of ECT on memory. Such placement was favored by the first American Psychiatric Association ECT Task Force in 1978. However, clinicians soon found the efficacy of RUL to be considerably less than that of BT. Two new studies found that the inefficacy of RUL was due to its sensitivity to the amount of energy used to elicit the seizure, making it necessary to assess the seizure threshold by a detailed titration method. 

In one study, the authors treated four groups of 20 depressed patients each (Sackeim et al., 2000). The two groups treated with RUL at 1.5xST and 2.5xST showed unacceptable remitter rates of 35% and 30%. The group treated with energies 5xST showed a remitter rate of 60%, compared to that of 65% for those treated with BT at 2.5xST. No statistical difference in antidepressant effect was found between high-dose RUL and BT, and the authors concluded that the two treatments were equally effective. However, the samples in this study have been criticized as too small to support the conclusion (Fink et al., in press).

Sackeim et al. also examined the cognitive effects in these patients after two months. They found that in two of nine tests -- the recall of famous events and autobiographical memory -- errors were more persistent in patients treated with BT compared to those treated with RUL.

In a second study, 72 patients with major depression were treated either with titrated RUL at 2.25xST or at a fixed dose set at the 75% energy level (403 mC) of modern brief-pulse ECT devices (McCall et al., 2000). The ST was measured in all patients, permitting the researchers to report the level of energy above ST that was delivered to each. The antidepressant and cognitive effects of RUL at 2.25xST, 3.15xST to 5.04xST, and 8.4xST to 12.6xST were reported. The most effective antidepressant response occurred with energies above 8xST. As energies increased, so did global cognitive performance in an exponentially greater decrement. With the high dose required for efficacy, the advantage in memory effects of RUL over BT placement was lost.

The inefficacy of RUL placement in clinical practice has also been demonstrated in a study of continuation pharmacotherapy after ECT (Sackeim et al., 2001). Depressed patients were mainly treated with RUL placement at the low energy levels recommended in 1993 when the study began. The remission rates for the sample of 290 patients was 55%, an unusually poor rate for conventional ECT. Patients who remitted were asked to participate in a pharmacotherapy continuation treatment program of 24 weeks. The relapse rates were 84% for placebo, 60% for nortriptyline, and 39% for the combination of lithium and nortriptyline. Virtually all patients relapsed within six months.

These research findings provide guidelines clinicians can use in selecting electrode placement and energy dosing for their depressed patients. Treatment with BT electrode placement is remarkably effective. The remission rates for BT and BF ECT exceed the 50% reduction in HAM-D score that is expected for antidepressant medications marketed with approval of the U.S. Food and Drug Administration. The efficacy of BT ECT for psychotic depressed patients is another encouraging finding, exceeding the success rates reported for antidepressant and antipsychotic drugs when used alone, or in combination, for this condition (Parker et al., 1992). 

While the immediate effects on memory may be unpleasant with all electrode placements, those associated with BT are greater than those with BF and RUL. The long-term effects on memory are modest for most patients, even when BT is given at energies that are higher than necessary. Increasing energies in RUL increase efficacy but do not spare cognitive effects. Due to its efficacy and memory-sparing qualities, BF electrode placement is the leading alternative to BT electrode placement in clinical practice today. 

American Psychiatric Association (1978), Electroconvulsive Therapy: Report of the Task Force on Electroconvulsive Therapy of the American Psychiatric Association. Washington, D.C.: American Psychiatric Association.
 

Bailine SH, Rifkin A, Kayne E et al. (2000), Comparison of bifrontal and bitemporal ECT for major depression. Am J Psychiatry 157(1):121-123.
 

Delva NJ, Brunet D, Hawken ER et al. (2000), Electrical dose and seizure threshold: relations to clinical outcome and cognitive effects in bifrontal, bitemporal, and right unilateral ECT. Journal of ECT 16(4):361-369.
 

Fink M, Bailine S, Petrides G (in press), Electrode placement and ECT: a search for the chimera. Arch Gen Psychiatry.
 

Lawson JS, Inglis J, Delva NJ et al. (1990), Electrode placement in ECT: cognitive effects. Psychol Med 20(2):335-344.
 

Letemendia FJ, Delva NJ, Rodenburg M et al. (1993), Therapeutic advantage of bifrontal electrode placement in ECT. Psychol Med 23(2):349-360.
 

McCall WV, Reboussin DM, Weiner RD, Sackeim HA (2000),  Titrated moderately suprathreshold vs fixed high-dose right unilateral electroconvulsive therapy. Acute antidepressant and cognitive effects. Arch Gen Psychiatry 57(5):438-444 [see comment pp445-446].
 

Parker G, Roy K, Hadzi-Pavlovic D, Pedic F (1992), Psychotic (delusional) depression: a meta-analysis of physical treatments. J Affect Disord 24(1):17-24.
 

Sackeim HA, Haskett RF, Mulsant BH (2001), Continuation pharmacotherapy in the prevention of relapse following electroconvulsive therapy: a randomized controlled trial. JAMA 285(10):1299-1307.
 

Sackeim HA, Prudic J, Devanand DP et al. (2000), A prospective, randomized, double-blind comparison of bilateral and right unilateral electroconvulsive therapy at different stimulus intensities. Arch Gen Psychiatry 57:425-434 [see comment pp445-446].

Is there a difference between bifrontal, bitemporal and right unilateral? In addition to talking about other research into optimal strength and electrode placement, Max Fink, M.D., outlines some of his own ongoing research.

New Research Improves ECT Outcomes

(This is the second of a two-part series. Part one appeared in the May issue of Psychiatric Times, p20-Ed.)

At the 2000 annual meeting of the American Foundation for Suicide Prevention, Herbert Y. Meltzer, M.D., gave a special lecture on decreasing suicide in patients with schizophrenia. During the lecture, Meltzer, recent winner of the foundation's annual research award, discussed the high rate of suicide in patients with schizophrenia. 

Meltzer reported that studies have shown that the conventional neuroleptics have little, if any, effectiveness in preventing suicide, but there are data indicating that atypical antipsychotics may have a preventive effect on suicide.

Meltzer, Bixler Professor of psychiatry and pharmacology at Vanderbilt University School of Medicine and director of Vanderbilt's division of psychopharmacology, said 14 studies have found that clozapine (Clozaril) can improve cognition, particularly in verbal learning and some areas of memory (Manschreck et al., 1999; Meltzer and McGurk, 1999; Meltzer and Okayli, 1995). It may also improve insight, but take away the feeling of hopelessness (Pallanti et al., 1999). 

Meltzer continued, "That raises the question: Is there evidence that the newer antipsychotic drugs, which improve cognition, could decrease the suicide rate in schizophrenia? I will give the background about how we came to look for this with clozapine...the prototype of an atypical antipsychotic drug."

Reviewing the history of clozapine in relation to typical neuroleptics, Meltzer explained that in the 1960s the first investigators who used the drug noted its lower extrapyramidal side effects. Later, its lack of a significant effect on prolactin secretion was noted.

In 1975, however, when clozapine-induced agranulocytosis was detected, clozapine "was withdrawn completely, but then reintroduced on a compassionate need basis. Over the next decade, it became clear that it virtually never produces tardive dyskinesia, that it is efficacious in up to 60% of neuroleptic-resistant patients in terms of improving positive symptoms, and that it's efficacious in treatment-resistant bipolar disorder and major depression," he explained. 

(According to the Physicians' Desk Reference [2000], "There are no reports of tardive dyskinesia attributable to clozapine alone. Nevertheless, it cannot be concluded without more extended experience that clozapine is incapable of inducing this syndrome" -- Ed.)

Meltzer next reported that while his group was working with several hundred patients with schizophrenia in Cleveland from 1985 to 1994, he observed that the use of clozapine resulted in much improved long-term outcome. 

"For example," he said, "the part- or full-time employment rate increased from 15% to 40%, [and there was] a great deal of improvement in patients' relationships with their families, better compliance and fewer rehospitalizations. There was a perception I had, but wasn't quite sure of, that it reduced suicidality."

To answer that suicidality question, his group did a study of 88 neuroleptic-resistant patients (73 with schizophrenia and 15 with schizoaffective disorder) on whom they had very complete data. The patients had received treatment with typical neuroleptics elsewhere for at least two years. The researchers then treated them with clozapine and prospectively evaluated them for suicidality for six months to seven years (Meltzer, 1999; Meltzer and Okayli, 1995).

"We did as careful a retrospective and prospective data collection as we could from the patients, informants and medical records about suicidal ideation and suicide attempts, and, of course, we were seeing these patients every week during the course of treating them with clozapine to draw blood," he said, noting that it is his strategy whenever possible to use clozapine monotherapy.

The results of the comparison showed that "we went up from 45% [having] no suicidal ideation or attempts to over 75% [with clozapine]. The amount of command hallucination-induced self-harm went down dramatically."

"Most importantly," he added, "there were 22 patients in the two years on typical neuroleptics, that is, 25% of the sample, who had made either a low-lethality or high-lethality suicide attempt, and that went down to three patients, 3.4%, who made a low-lethality attempt, all within the first several months of clozapine treatment. And one of the key points about clozapine is that it can often take many months for it to work in this patient population. So overall, we saw approximately an 85% decrease in suicide attempts during the course of the two years on clozapine."

Meltzer added that the weekly contact patients were receiving as well as other nondrug factors could have contributed to the decrease in suicidality.

"It may well have been that these people didn't get optimal [psychosocial] treatment prior to study entry," he said, adding that psychosocial treatment was emphasized in his clinic.

Corroborating evidence for clozapine's role in decreasing suicidality was found when Meltzer and colleagues looked at the suicide rate in patients enrolled in the Clozaril National Registry. 

"This [registry] provided a good database about people who had suicided while on clozapine versus those who had discontinued clozapine," explained Meltzer. "The rate in terms of life years of clozapine exposure was estimated to be about 0.04% to 0.08%, roughly 40 to 80 [people] per 100,000...certainly a lot lower than the 200 to 700 per 100,000 that one expects in schizophrenia in general So I would say that [these] data [are] strongly supportive that there could be a clozapine effect. [But] it certainly doesn't rule out that it's still the weekly contact."

Other corroborating pieces of evidence of clozapine reducing suicide came from a study on a subgroup of patients with schizophrenia and schizoaffective disorder who received clozapine and other services from the Texas Department of Mental Health and Mental Retardation (Reid et al., 1998) and a Boston University epidemiologic study of suicide (Walker et al., 1997).

"It keeps coming up, a diminished rate [of 80%] in the people who are still on clozapine," said Meltzer.Meltzer also called for a re-evaluation of the risk/benefit assessment of suicide risk without clozapine versus mortality due to clozapine-related agranulocytosis.

One in 10,000 patients treated with clozapine dies due to agranulocytosis, he said, whereas approximately one in 10 patients with schizophrenia commits suicide.

Meltzer next described the two-year International Clozaril/Leponex Suicide Prevention Trial (InterSePT), which he proposed and is now conducting with funding by Novartis Pharmaceuticals Corp., the makers of branded clozapine. The study is taking place in 11 countries and involves 69 centers in the United States, Europe and the Southern Hemisphere (Meltzer, 1999).

"A 900-patient study was powered to find a 20% difference between Clozaril and olanzapine [Zyprexa] which is, along with risperidone [Risperdal], the most widely used atypical antipsychotic drug. Patients in the study had to have at least one serious suicide attempt or very serious ideation and were prevented from making an attempt during the three years prior to entry into the study. The treatment is open but raters are blinded. Clinicians are able to treat these patients with other medications if they feel they are indicated, trying to reduce the suicide rate in all groups. The olanzapine group is also seen weekly. All the patients were admitted to the study no later than 16 months ago, and hopefully in about a year, I'll be able to come back and tell you whether there was any difference between the two drugs as well as what else we found out, because there's an enormous number of additional studies going on as part of this trial. At the very least, we will learn a lot more about the epidemiology, cross-cultural issues and biological issues concerning suicide in schizophrenia."

Meltzer said there are also data on some of the other atypicals reducing suicide rate.

"I have reviewed data from the manufacturer of Seroquel [quetiapine] about the rate of suicidality during treatment with Seroquel, Haldol [haloperidol] or Risperdal. They studied a total of 2,185 patients. The [suicidality] rate on Seroquel and Risperdal was significantly lower than [on] haloperidol."

Although not discussed by Meltzer, an article examining the impact of atypical antipsychotics on suicidality in patients with schizophrenia has been published (Keck et al., 2000). The authors reviewed the available literature regarding the efficacy of clozapine, risperidone, olanzapine, quetiapine and ziprasidone (Geodon) in the treatment of depression, hostility and suicidality in patients with schizophrenia. Co-occurring depression, in particular, has been associated with suicidal ideation, suicide attempts and suicide.These studies "suggest that treatment with clozapine or olanzapine may significantly reduce suicidality in patients with schizophrenia," the authors said in their conclusion.

Meltzer said he was optimistic about most of the atypicals, including olanzapine, risperidone, ziprasidone and quetiapine, since all have advantages over the typical neuroleptics on cognitive function (Meltzer and McGurk, 1999).

In summary, Meltzer said that when he approached the treatment of schizophrenia with the object of trying to reduce suicidality, he realized it cannot be dissociated from trying to improve outcome in general.

"All these key features of cognition, psychosis, substance abuse, etc., [are key] in order to improve quality of life. The atypical antipsychotic drugs appear to be one of the key ways that we can achieve that," he said. "Whether there is a difference between clozapine and the other atypicals remains to be determined."

Keck PE Jr, Strakowski SM, McElroy SL (2000), The efficacy of atypical antipsychotics in the treatment of depressive symptoms, hostility, and suicidality in patients with schizophrenia. J Clin Psychiatry 61(suppl 3):4-9.
 

Manschreck TC, Redmond DA, Candela SF, Maher BA (1999), Effects of clozapine on psychiatric symptoms, cognition, and functional outcome in schizophrenia. J Neuropsychiatry Clin Neurosci 11(4):481-489.
 

Meltzer HY (1999), Suicide and schizophrenia: clozapine and the InterSePT study. J Clin Psychiatry 60(suppl 12):47-50.
 

Meltzer HY, McGurk SR (1999), The effects of clozapine, risperidone, and olanzapine on cognitive function in schizophrenia. Schizophr Bull 25(2):233-255.
 

Meltzer HY, Okayli G (1995), Reduction of suicidality during clozapine treatment of neuroleptic-resistant schizophrenia: impact on risk-benefit assessment. Am J Psychiatry 152(2):183-190.
 

Pallanti S, Quercioli L, Pazzagli A (1999), Effects of clozapine on awareness of illness and cognition in schizophrenia. Psychiatry Res 86(3):239-249.
 

Physicians' Desk Reference (2000). Montvale, N.J.: Medical Economics Co.
 

Reid WH, Mason M, Hogan T (1998), Suicide prevention effects associated with clozapine therapy in schizophrenia and schizoaffective disorder. Psychiatr Serv 49(8):1029-1033.
 

Walker AM, Lanza LL, Arellano F, Rothman KJ (1997), Mortality in current and former users of clozapine. Epidemiology 8(6):671-677.

This is the second part of an article series discussing the high risk of suicide attempts in patients with schizophrenia. Herbert Y. Meltzer, M.D., continues the discussion with treatment options and efficacy.

Decreasing Suicide in Schizophrenia

(This is the first part of a series of articles addressing interdisciplinary treatment of psychiatric disorders in patients with comorbid medical illness-Ed.)

Collaboration and communication among psychiatrists, primary care doctors and other physicians are becoming increasingly critical, as both research and anecdotal data are lending empirical credibility to the interdependence of body and mind. Comorbid depression with major medical illnesses may be particularly dangerous, and evidence is accumulating that failure to address this depression can impede medical treatment and increase mortality. 

"I'm not sure that people -- meaning consumers, mental health professionals and non-mental health professionals -- realize what the numbers are," David Kupfer, M.D., explained in an interview with 

"They're epidemic and scary. We're not talking about feeling somewhat down and mildly dysphoric, we're talking about major depression."

Kupfer, chair of the University of Pittsburgh department of psychiatry, recently moderated a conference titled "The Unwanted Co-Traveler: Depression's Toll on Other Illnesses." Sponsored by the National Institute of Mental Health, the conference comprised specialists in cardiovascular disease, cancer, diabetes, HIV/AIDS, Parkinson's disease (PD) and other neurological diseases. Psychiatrists and primary care physicians "can learn a lot from each other," Kupfer continued. He believes that depression frequently is undertreated in patients with comorbid medical illness because of the mistaken belief that it is a normal response to the latter, particularly in the case of elderly patients. In fact, major depression does not occur in the majority of patients with other medical illnesses. However, when it does, neurovegetative symptoms associated with depression can substantially interfere with patients' ability to follow through with treatment recommendations. The following is a look at the latest research and treatment recommendations for depression that accompanies cardiovascular disease, stroke and PD.

Estimates indicate that roughly one-fifth of post-myocardial infarction patients meet diagnostic criteria for major depression. Research indicates that the prevalence of depression among patients who have not had heart attacks but have angiographically documented coronary artery disease runs around 18% (Carney et al., 1987, as cited in Robinson and Krishnan, in press), compared to about 10% in the general American population. The risk of dying within six months is three to four times greater for depressed survivors of myocardial infarction (MI), compared to their nondepressed peers (NIMH, 1999).

In another study, Canadian researchers found that the significantly higher risk of cardiac mortality at the one-year mark among depressed patients was largely independent of the severity of cardiac disease (Frasure-Smith et al., 1999). Equally, if not more, concerning are recent findings indicating that depression can actually foreshadow the development of heart disease (Moon, 2001).

"Depression is a chronic illness and contributes to chronic stress," Lawson Wulsin, M.D., coordinator of the family medicine and psychiatry residency training program at the University of Cincinnati, told 

"We know that stress is taxing to the cardiovascular system in particular, because it can increase blood pressure, decrease heart rate variability and may suppress immune function in subtle ways that contribute to inflammatory processes, and cardiovascular disease is an inflammatory disease."

In addition, higher smoking rates among depressed individuals put them at higher risk of developing heart disease, said Wulsin, who presented findings suggesting the link between depression and subsequent heart disease at the American Psychiatric Association's 2000 annual meeting (Wulsin and Singal, 2000). In a recent interview, Wulsin reiterated his recommendation that depressed patients over the age of 40 be referred for a full medical checkup to screen for potential cardiovascular problems: "Psychiatrists should be taking better cardiovascular histories of their depressed patients, and primary care [doctors] and cardiologists should be taking good histories of depression in their patients with heart disease."

Wulsin said that prophylactic use of antidepressants may be justified in patients with cardiovascular disease who have a history of major depression or a strong family history of the mood disorder. He added, however, that too many questions remain regarding the treatment of depression, and its effect on cardiovascular outcomes, to recommend that all patients with cardiovascular disease receive prophylactic antidepressant treatment.

Despite the high incidence of depression among patients with cardiovascular disease, information on how to safely and effectively treat such patients remains limited. Tricyclic antidepressants generally are not used, due to documented side effects that include cardiac conduction delays and orthostatic hypotension. To date, sertraline (Zoloft) has been shown safest and most effective in post-MI patients (Goodnick and Hernandez, 2000; Robinson and Krishnan, in press).

A number of studies have shown that the selective serotonin reuptake inhibitors are safe and effective for depressed patients with ischemic heart disease, and this class of antidepressants is generally preferred by clinicians due to its more favorable side-effect profile. Still, when choosing an SSRI -- particularly for post-MI patients -- psychiatrists should take into account factors such as platelet activation, as well as the usual drug interaction caveats. Concerning the latter, University of Miami mood disorders director Paul J. Goodnick, M.D., clearly remembers hearing about a patient who was put on paroxetine (Paxil), along with a ß-blocker, digoxin and other medications by cardiac care unit staff after being hospitalized for chest pain. The patient, who was not being treated for depression, was released and then emergently re-hospitalized after an interaction between the paroxetine (a potent 2D6 inhibitor) and the ß-blocker significantly lowered his heart rate.

An estimated 10% to 27% of American stroke patients experience major depression each year. That translates to between 60,000 and 162,000 people, three-quarters of whom are over the age of 65. An additional 15% to 40% will suffer depressive symptoms within two months of suffering a stroke.

If the emotional suffering inherent in depression were not incentive enough to treat the disorder, researchers have discovered that untreated depression in this population can seriously impede patients' chances of recovery. A growing body of research strongly indicates that depression in stroke patients leads to poorer outcomes, both in cognitive functioning (Kimura et al., 2000) and in the recovery of the ability to perform activities of daily living (ADLs) (Chemerinski et al., 2001).

"Patients tend to report that they're depressed because they've had a stroke," Robert Robinson, M.D., head of the psychiatry department at the University of Iowa College of Medicine, explained to

"Physicians in those circumstances will often just regard it as an understandable, reactive depression and not realize what a profound effect this depression has on [the patients'] recovery and survival."

Assessing depression in a stroke patient can present unique clinical challenges. Stroke can cause apathy and/or crying spells, interfere with a patient's awareness of objectively observable neurovegetative signs, and impair their ability to express or describe emotion (Black, 1995). 

Evidence is accumulating that untreated depression can impede comorbid medical treatment and increase mortality. The author reports on the latest research and treatment recommendations for depression that accompanies cardiovascular disease, stroke and Parkinson's disease.

Psychiatric Times Vol 18 No 6