Tobacco use has been cited as the chief avoidable cause of illness and death in our society, responsible for more than 430,000 deaths in the United States each year (Centers for Disease Control and Prevention, 1999). Smoking is a known cause of cancer, heart disease, stroke, complications of pregnancy and chronic obstructive pulmonary disease (U.S. Department of Health and Human Services, 1990). The enormous public health implications associated with tobacco use were the impetus for last year's U.S. Public Health Service (PHS) guideline 

(Fiore et al., 2000). The guideline identified a number of effective treatments for tobacco dependence and recommended that all smokers, including those with psychiatric comorbidities, be offered appropriate treatment. 

 Smoking rates are substantially higher among individuals with a lifetime history of mental illness (35%) than among individuals without such a history (22.5%) (Lasser et al., 2000). This naturally raises the questions of whether and how to intervene with such individuals. 

The PHS guideline (Fiore et al., 2000) strongly encouraged tobacco cessation intervention in individuals with psychiatric comorbidities. Tobacco dependence is extremely common among comorbid psychiatric populations (smoking rates can exceed 70% in alcohol and other substance abuse populations) (Fiore et al., 2000), and studies show that smoking-cessation treatments can be effective with such patients (Bobo et al., 1998; Ziedonis and George, 1997). Moreover, preliminary studies have shown that smoking-cessation treatment exacerbates the underlying comorbid psychiatric conditions. Thus, while clinicians should exercise due caution, they should still treat patients for tobacco dependence. 

 In this article, we will look beyond guideline recommendations to explore issues encountered in delivering tobacco dependence treatments to three separate comorbid populations: smokers with depression, schizophrenia and non-tobacco substance abuse problems. We will then examine guideline treatment recommendations and illustrate how they are relevant to comorbid populations. Treatments that are efficacious for smokers in general are also efficacious for smokers with a psychiatric comorbidity. 

Depression is more common among smokers than non-smokers (60% versus 15%) (Borrelli et al., 1996). In addition, as many as 30% of patients seeking smoking-cessation treatment may have a history of depression (Anda et al., 1990, as cited in Fiore et al., 2000). Glassman et al. (1988) found that subjects without a history of depression are more than twice as likely to quit smoking than those with a history of depression.  

While studies show that treating tobacco dependence in patients with comorbid conditions results in little adverse effect, the exception is patients with a history of depression, for whom smoking cessation may elicit or exacerbate depression (Fiore et al., 2000). For example, patients with a history of depression are more likely to experience depressive episodes after being treated for tobacco dependence than are smokers without such a history (Covey et al., 1998; Tsoh et al., 2000). 

Patients with schizophrenia have a high rate of nicotine dependence (up to 88%) compared to the average population (about 25%) (George et al., 2000), yet few cessation programs target these smokers. This population has a particularly high risk for smoking-related death and disease because of their typically low motivation to quit smoking and their high levels of dependence (George et al., 2000). In addition, smoking cessation may affect the pharmacokinetics of certain psychiatric medications (George et al., 2000; Hughes, 1993). 

New studies have shown that it is possible to treat patients with schizophrenia for their tobacco dependence. A study by George et al. (2000) indicated that patients who were treated with atypical antipsychotic medications (clozapine [Clozaril], risperidone [Risperdal], olanzapine [Zyprexa], quetiapine [Seroquel]) versus typical antipsychotic medications (perphenazine [Etrafon], fluphenazine [Prolixin], haloperidol [Haldol], chlorpromazine [Thorazine], thiothixene [Navane]) along with the transdermal nicotine patch reported higher quit rates. One possible reason for this high quit rate is that atypical antipsychotics may mimic nicotine's effects on the central nervous system, thus minimizing withdrawal symptoms (Ziedonis and George, 1997). 

A 1997 report by Ziedonis and George on nicotine use and schizophrenia indicated that smoking-cessation treatments can be effective for psychiatric patients, but it decried the dearth of literature focusing on schizophrenia. They suggested that more extensive clinical research is needed to better define both the mechanisms of nicotine on the central nervous system of patients and the basic pathophysiological processes involved in schizophrenia. 

Among substance abusers, smoking rates are well above the population average (Budney et al., 1993; Clemmey et al., 1997; DiFranza and Guerrera, 1990). Rates of alcoholics who smoke exceed 70%; they are more likely to be highly nicotine dependent than patients without such a comorbid condition (Bobo et al., 1998, as cited in Fiore et al., 2000). 

Clinicians have been reluctant to encourage recovering alcoholics to try to quit smoking because of fears that smoking cessation may keep patients from completing their treatment for alcoholism, or that the stress of nicotine withdrawal will cause patients to relapse to drinking (Bobo et al., 1998). A study by Campbell et al. (1995), however, indicated that treatment can be provided without necessarily leading to relapse with other substances. 

Studies have shown that concurrent treatment of non-tobacco substance abuse and tobacco dependence can be successful and that patient awareness of the benefits of treating both addictions can increase abstinence rates. In one study (Bobo et al., 1998), patients who were encouraged to quit smoking remained abstinent from alcohol at a rate that was twice as high as rates achieved by patients not encouraged to quit smoking. Unfortunately, studies also illustrate that smokers with past or current alcohol problems have a more difficult time remaining abstinent from tobacco than do smokers without such a history (Hays et al., 1999). 

Smokers should be provided with practical counseling, support and pharmacotherapy, which, if delivered appropriately, can also effectively treat individuals with psychiatric comorbidities. 

For example, the guideline found that buproprion Sustained Release (Zyban) (as a first-line agent) and nortriptyline (Aventyl, Pamelor) (as a second-line agent) are efficacious treatments for tobacco dependence. These drugs have also been approved for the treatment of depressive disorders. (The brand name Wellbutrin is used for buproprion for depression.) As a result, the guideline recommended that clinicians especially consider the use of these pharmacotherapeutic agents in smokers with a current or previous depression (Fiore et al., 2000). 

The guideline also recommended that, where possible, smokers receive intensive counseling interventions, which are more effective than brief counseling. This is also consistent with evidence that intensive interventions produce higher abstinence rates in patients with psychiatric comorbidities than do less intensive interventions. 

Specifically, a 1994 study by Hall et al. on the efficacy of a more intensive cognitive-behavioral intervention and nicotine gum versus a less intensive standard treatment (group support and nicotine gum) indicated that subjects with a history of major depressive disorder had higher quit rates when they received the more intensive intervention. Additionally, a study comparing the efficacy of counseling strategies with patients having low versus high levels of negative affect indicated that subjects displaying high negative affect were more likely to benefit from support counseling as opposed to skill training (Zelman et al., 1992). Intensive counseling sessions have also been reported to increase quit rates in patients with alcoholism (Bobo et al., 1998). 

The guideline also discussed how the implementation of these strategies should not raise undue concern. Studies show that psychiatric inpatients are able to quit smoking without an increase in aggression (Smith et al., 1999). Moreover, evidence indicates that smoking-cessation interventions do not interfere with recovery from chemical dependency. Therefore, smokers receiving treatment for chemical dependency should also be provided smoking-cessation treatments, including both counseling and pharmacotherapy (Burling et al., 1997). 

The guideline does note that clinicians need to exercise caution in treating patients with psychiatric comorbidities (Fiore et al., 2000). Mental health care professionals should carefully monitor a patient's progress during a quit attempt and be prepared to intervene if necessary. 

Although the studies discussed here strengthen the case for treating tobacco dependence in patients with psychiatric comorbidities, additional research is needed; the guideline highlighted several areas for future research (Fiore et al., 2000). Clinical culture and practice patterns need to change in order to ensure that all patients who use tobacco, including those with psychiatric comorbidities, are identified and offered treatment. While smokers with comorbid conditions have a greater risk of relapse, there is no evidence that patients relapse to their previous psychiatric condition while making a quit attempt. In fact, most evidence suggests that abstinence results in little adverse impact. Given the harmful nature of continued tobacco use and the existence of effective treatments, the guideline recommended treating smokers with comorbid psychiatric conditions with the same treatments identified as being efficacious for the general population (Fiore et al., 2000). 

Bobo JK, McIlvain HE, Lando HA et al. (1998), Effect of smoking cessation counseling on recovery from alcoholism: findings from a randomized community intervention trial. Addiction 93(6):877-887. 
 

Borrelli B, Bock B, King T et al. (1996), The impact of depression on smoking cessation in women. Am J Prev Med 12(5):378-387. 
 

Budney AJ, Higgins ST, Hughes JR, Bickel WK (1993), Nicotine and caffeine use in cocaine-dependent individuals. J Subst Abuse 5(2):117-130. 
 

Burling TA, Ramsey TG, Seidner AL, Kondo CS (1997), Issues related to smoking cessation among substance abusers. J Subst Abuse 9:27-40. 
 

Campbell BK, Wander N, Stark MJ, Holbert T (1995), Treating cigarette smoking in drug-abusing clients. J Subst Abuse Treat 12(2):89-94. 
 

Centers for Disease Control and Prevention (1999), Cigarette smoking among adults-United States, 1997. MMWR 48(43):993-996. 
 

Clemmey P, Brooner R, Chutuape MA et al. (1997), Smoking habits and attitudes in a methadone maintenance treatment population. Drug Alcohol Depend 44(2-3):123-132. 
 

Covey LS, Glassman AH, Stetner F (1998), Cigarette smoking and major depression. J Addict Dis 17(1):35-46. 
 

DiFranza JR, Guerrera MP (1990), Alcoholism and smoking. J Stud Alcohol 51(2):130-135.Fiore MC, Bailey WC, Cohen SJ et al. (2000), Treating Tobacco Use and Dependence. Clinical Practice Guideline. Rockville, Md.: U.S. Department of Health and Human Services, Public Health Service. 
 

George TP, Ziedonis DM, Feingold A et al. (2000), Nicotine transdermal patch and atypical antipsychotic medications for smoking cessation in schizophrenia. Am J Psychiatry 157(11):1835-1842. 
 

Glassman AH, Stetner F, Walsh BT et al. (1988), Heavy smokers, smoking cessation, and clonidine. Results of a double-blind, randomized trial. JAMA 259(19):2863-2866. 
 

Hall SM, Munoz RF, Reus VI (1994), Cognitive-behavioral intervention increases abstinence rates for depressive-history smokers. J Consult Clin Psychol 62(1):141-146. 
 

Hays JT, Schroeder DR, Offord KP et al. (1999), Response to nicotine dependence treatment in smokers with current and past alcohol problems. Ann Behav Med 21(3):244-250. 
 

Hughes JR (1993), Pharmacotherapy for smoking cessation: unvalidated assumptions, anomalies, and suggestions for future research. J Consult Clin Psychol 61(5):751-760. 
 

Lasser K, Boyd JW, Woolhandler S et al. (2000), Smoking and mental illness: a population-based prevalence study. JAMA 284(20):2606-2610. 
 

Smith CM, Pristach CA, Cartagena M (1999), Obligatory cessation of smoking by psychiatric inpatients. Psychiatr Serv 50(1):91-94. 
 

Tsoh JY, Humfleet GL, Munoz RF et al. (2000), Development of major depression after treatment for smoking cessation. Am J Psychiatry 157(3):368-374. 
 

U.S. Department of Health and Human Services (1990), The health benefits of smoking cessation: a report of the Surgeon General. HHS Publication No. (CDC) 90-8416. Atlanta: HHS. 
 

Zelman DC, Brandon TH, Jorenby DE, Baker TB (1992), Measures of affect and nicotine dependence predict differential response to smoking cessation treatments. J Consult Clin Psychol 60(6):943-952. 
 

Ziedonis DM, George TP (1997), Schizophrenia and nicotine use: report of a pilot smoking cessation program and review of neurobiological and clinical issues. Schizophr Bull 23(2):247-254.

Articles

What does the new set of U.S. Public Health Service guidelines for treating tobacco dependence say? Should everyone, regardless of mental health status, receive treatment?

Treating Tobacco Dependence in Patients With Psychiatric Comorbidities

Back then, doctors drove black Cadillacs 
and kept office hours at home. 

Role Model

Founded in 1973, The Child School is a unique learning environment that makes educational success possible for children aged 5 to 21 years with low-average to superior intelligence who are learning disabled, emotionally disturbed and/or speech impaired. 

Maari de Souza, founder and director of The Child School, started the school in a small apartment in New York City with five students. She wanted to incorporate her experience as a staff psychologist at a special-needs grammar school with what she felt was missing in the education that was provided. De Souza was aware of the students' lack of social skills, recognizing that they were unable to initiate and develop friendships among their peers. She was disappointed by the minimal academic standard for these students and the lack of an afterschool program where children could interact on a casual basis. 

The Child School has evolved into a unique therapeutic and academic facility for children with learning and developmental disabilities. Each student must succeed in satisfying the public school system's prescribed curriculum, develop the life and social skills that result in the recognition of and respect for the community, and learn to comprehend the impact of their actions and words. The ultimate goals for the students are to perform at their maximum potential and to become fully contributing members of society. 

A focus on the whole child is reflected in The Child School's education methods, therapeutic techniques and daily routines. 

The staff provides a diverse background with Ph.D., master's and bachelor's degrees. Additionally, de Souza believes it is imperative that the staff has skills and strategies not acquired in college or learned in a workshop or conference. Teachers work toward achieving their own emotional and psychological equilibrium and recognizing and eliminating negative emotional responses from their vocabulary. The staff is required to reach beyond theoretical knowledge and develop an individualized technique for each child-classes are small with approximately 62 teachers for the 161 students. 

 Parents are also required to participate in their child's education and meet with the staff regularly. The staff shares effective strategies for each step in the development that parents can adopt at home. This interaction promotes a consistent approach to each child's development. 

At the elementary school level, The Child School's sensory-motor integration teaching format emphasizes cognitive development and language skills. Music is utilized extensively to increase learning rate and retention, develop appropriate learning behaviors, and foster socialization. The curriculum treats each child as a "gifted" child, according to The Child School's mission statement. 

The middle school emphasizes preparing youth for high school. It follows the standard New York state 7th and 8th grade science and social studies curricula but regroups the children according to achievement level in reading, writing and math. However, the program recognizes that even with specialized attention, some students may not have the capacity to achieve a regents' diploma. The staff will then incorporate independent living, social skills and pre-vocational development to promote skills and behavior needed to succeed in the workforce. 

Legacy High School was established in 1996 to extend The Child School's commitment to older children with special needs. The goals of the high school program are for each student to earn their diploma, by passing all regents exams, and develop a code of ethics for themselves. It also prepares the students, whether college-bound or not, for careers. The staff achieves these goals through techniques such as "camouflaged learning," which helps students make up for extensive gaps in learning caused by their disabilities; interdisciplinary curriculum; problem solving; and real-life learning opportunities. All four students in Legacy High School's first graduating class were accepted into accredited colleges. 

The Child School also offers special services outside the academic classroom. These include speech and language therapy, counseling, occupational and music therapy, adaptive special education, and art and computer science classes. The school has two-day trips to destinations such as Washington, D.C., and Philadelphia. There is also an opportunity for students to participate in an annual seven- to 10-day spring trip designed to take the children outside New York City to explore other cultures and environments. Recent trips have been to Jamaica and Costa Rica. Numerous teachers and chaperones, including de Souza, accompany the students. 

Success stories abound: Aidan, a student who was diagnosed with severe brain damage and whose parents were told he would never learn to walk or talk, graduated from middle school, receiving the New York State Attorney General's Triple C Award honoring those whose behavior has consistently been distinguished by courage, commitment and character. Another student, Brett, who had been diagnosed as institutionable and could not carry out the most basic life skills, is now traveling to national and international destinations and receiving commendations for his deportment. He is participating in a formalized physical education program, has been termed 

 and recently carried on a lengthy conversation with his mother. 

The Child School is not the only non-public day school accredited to serve students who are legally classified as learning disabled, emotionally disturbed and/or speech impaired. However, in terms of their format, routines, structure and strategies, The Child School does not know of other schools with similar methodologies. 

When asked to summarize the teaching methods for those who may want to use them in their practice, de Souza told 

, "We work with the 'whole' child encompassing academic, social, behavioral, emotional, and moral and values-related issues. We focus on building the student's ethics, social and emotional intelligence, and their understanding of their issues and disabilities, all of which are tied into the diagnosis and unraveling of the problem. We do not compartmentalize the problems and say this is a learning disability or this is a processing problem, we look at the entire child in terms of this human being functioning as an independent person." The child does not learn how they can live with their family when they leave the school, but is intensively pushed in different directions so that they may stand independently in the world. 

De Souza added, "Without a dedicated, united team surrounding each child, a community which includes the administration, teachers, in-school therapists, outside therapists and family members, we will not be very successful in helping each child maximize their potential."  

The Child School in New York City provides a unique learning experience for children with learning and developmental disabilities. What teaching methods and curriculum are employed at the school? What is the link between parent and teacher involvement and the children's progress at The Child School?

Teaching Children With Disabilities How To Succeed

At a recent conference held in New York City, Rep. Richard A. Gephardt (D-Mo.), U.S. House Minority Leader, gave his first policy speech on mental health care in the United States. Deborah C. Peel, M.D., president of sponsoring organization the National Coalition of Mental Health Professionals and Consumers, noted that this was a historic event, adding that no elected official of his stature has spoken publicly on the importance of mental health care access and privacy. Gephardt addressed the group of clinicians, consumers and legislators as part of the coalition's conference to announce its new Inform America campaign, which will advocate for the three essential elements needed for real mental health care: real benefits (i.e., access to the right professional, at the right time, for the right treatment), real parity and real funding. 

While noting that the United States has the best health care in the world, Gephardt added that there is still a lot of room for improvement, especially in mental health care. He stated, "We have come far in raising awareness of mental health issues, but we have not come far enough. Forty years ago, mental health was simply a non-issue in our public discussions and, for the most part, in our public policies." Acknowledging the work of the Coalition and other advocacy groups in garnering attention for mental health issues, Gephardt said, "Mental health is becoming a critical issue that is part of an ongoing discussion about quality of life and quality of care issues in America and around the world." 

But he reminded attendees that such grassroots efforts were crucial to making significant changes. "You cannot expect that people in the Congress or even the President can magically turn these things around. It takes a movement. It takes citizen action to start the ball rolling down the road to...get the information out so that people feel differently about these illnesses and what can be done about them." 

Gephardt stated that the next great challenge is removing the barriers to mental health care. He explained, "I believe that the entire nation needs to be educated that mental illnesses are just that--illnesses, with effective treatments available." He added that when the American public realizes that people who suffer from mental illness no more chose to be sick than those who have diabetes, they will insist on access to treatment for mental illness, just as they would for diabetes. He added, "One of the first things we need to figure out how to do is to never say 'mental health' anymore --- it's health." 

Noting the significance of stigma as a barrier to ensuring care for all, Gephardt said that our government has already passed acts that protect against discrimination on the basis of disabilities, race or sexual orientation. "We've had a long history of being in the process of trying to think about people in the right way and change attitudes and hatreds and discriminatory behavior," he said. "We're making progress [so] don't give up, don't even be pessimistic When you look at other efforts that have fought discrimination and misunderstanding and ignorance, they are long-term efforts that have spurts of progress and then fall back and then more progress." 

In addition to raising awareness, Gephardt emphasized that the federal government has the responsibility to ensure access to real mental health care for all Americans. Another barrier to mental health care is lack of patient privacy. 

, without privacy guarantees, effective psychotherapy is simply not possible," he told attendees. "Before the privacy rule was implemented, we heard a lot of arguments against it. We heard that it would be expensive or inconvenient to safeguard the privacy of Americans' medical records. I say that privacy is so fundamental to ensuring access to medical care that it is well worth some inconvenience or expense to guarantee it to our citizens." 

He outlined what Congress is doing to address this. 

"The Senate is currently considering the Bipartisan Patient Protection Act of 2001. I am working with my colleagues in the House to ensure that we have the opportunity to vote on this important bill. I am proud that it provides protections for those with mental, as well as physical, illnesses." 

 He added that the bill requires a point-of-service option, direct access to specialty care for chronic conditions, continuity of care, access to clinical trials, age-appropriate care for children and legal remedies for those who have been injured. 

Another roadblock to access comes in the form of managed care and insurance companies that may limit or deny access to proper care for mentally ill patients. 

 Gephardt explained, "Access to care is too often limited by insurance coverage... especially in managed care plans, access to mental health care is often subject to both direct and indirect limits, making it virtually impossible for people to receive the kind of quality care they need and deserve." 

 He added that one of the issues he struggles with is whether or not health care should be for-profit. He believes that the for-profit concept is inherently going to be in conflict with what needs to be done in the health care system. 

Gephardt also addressed parity. He stressed that it is common sense that mental health care coverage should be at the same level as physical health care. "This is based on the knowledge that mental illnesses are exactly that: illnesses. And everyone must have insurance We must pass a number of bills to cover people in different circumstances." 

With effort, Gephardt believes that these barriers can be eliminated and encouraged attendees, "We can do it, and we must do it. Mental health care can improve and even transform people's lives. We can reduce suffering, increase productivity and strengthen families. But we must ensure access." 

He further acknowledged that mental health advocates have made huge steps in reaching this goal, adding, "I look forward to working with you to reach it once and for all."  

House Minority Leader, Richard Gephardt addressed the National Coalition of Mental Health Professionals and Consumers as part of their new Inform America campaign. Gephardt discussed not only what needs to happen for Americans to have good mental health care, but what Congress has already accomplished.

Congressman Gephardt Gives Historic Talk On the Future of Mental Health Care

According to the National Institute of Mental Health, anxiety disorders are the most common of childhood psychiatric conditions, affecting an estimated 13% of children during any six-month period. As with other psychiatric disorders of childhood, they tend to go untreated, and, in the absence of effective treatment, children do not simply grow out of them. On the contrary, anxious children often grow up to be adults with anxiety, depression or another affective disorder. According to Daniel Pine, M.D., chief of NIMH's section on development and affective neuroscience, "A large percentage of adult problems, anxiety as well as depression, really begin as anxiety disorders in childhood." About half of children recover, Pine explained in an interview with 

, but "those children who do continue to have problems will account for a large proportion of adults with both anxiety and mood disorders." 

In a recent prospective study that followed 776 adolescents into adulthood, Pine et al. (1998) found that adolescent anxiety or depressive disorders predicted an approximate two- to threefold increased risk for adulthood anxiety or depressive disorders. 

Researchers and clinicians are hoping that a better understanding of children's anxiety disorders and more effective treatments will not only alleviate children's suffering but also prevent the development of affective disorders later on. "We'd like to believe that early intervention will reduce downstream morbidity," John March, M.D., M.P.H., told 

. Only large-scale prospective studies will be able to show if this is the case. 

Pharmacologic Treatment of Anxiety Disorders 

The first large, randomized, controlled study of the pharmacologic treatment of anxiety disorders in children was published in spring of this year (The Research Unit on Pediatric Psychopharmacology [RUPP] Anxiety Study Group, 2001). In this multisite NIMH-funded trial, 128 children between the ages of 6 and 17 who met the criteria for social phobia, separation anxiety disorder or generalized anxiety disorder were randomly assigned to receive either fluvoxamine (Luvox) (maximum dose: 300 mg per day in adolescents; 250 mg per day in children less than 12 years of age) or placebo for eight weeks. By week 3 of the trial, significant differences between the treated and untreated groups were evident on the Pediatric Anxiety Rating Scale. Symptoms continued to improve through week 6, with little change during the final two weeks of the trial. 

At the end of the study, patients in the fluvoxamine group had a mean decrease of 9.76.9 points and an average rating below 10-a score reflective of mild anxiety. In the placebo group, patients had a decrease of 3.14.8 points and an average rating of 14 or higher-indicative of high anxiety. On the Clinical Global Impressions (CGI)-Improvement scale, 48 of 63 children in the fluvoxamine group (76%), compared to only 19 of 65 children in the placebo group (29%) responded well to the treatment and had scores of less than 4. 

Five children dropped out of the fluvoxamine group, and one child in the placebo group, because of adverse events. Abdominal discomfort was the only adverse event that was significantly more prevalent in the fluvoxamine group. There was also a trend toward a greater frequency of increased motor activity in the fluvoxamine group, an observation that has been found inconsistently in previous trials of selective serotonin reuptake inhibitors in children. When found,  this increase seems to occur most often in younger children (Lalellarte et al., 1999, as cited in RUPP, 2001). 

Asked to comment on the significance of the study, Pine, one of the study's authors, said, "The magnitude of the effect was dramatic, and even more impressive because it was largely the same across the five study sites." 

This study suggested that fluvoxamine is an effective treatment for acute anxiety disorders in childhood, although it leaves many questions about the proper use of pharmacotherapy in treating children with anxiety disorders. The American Academy of Child and Adolescent Psychiatry's Practice Parameters for the Assessment and Treatment of Children and Adolescents with Anxiety Disorders, which have not been revised since 1997, recommend that medication be used only as an adjunct or after a behavioral or psychotherapeutic intervention trial has failed, not as a stand-alone treatment (Bernstein and Shaw, 1997). This philosophy is advocated by the experts interviewed for this story, most of whom would use cognitive-behavioral therapy (CBT) first whenever possible. 

The fluvoxamine trial continued for only eight weeks and could not address the questions of optimal duration of treatment in those children for whom pharmacotherapy is warranted, likelihood of relapse when treatment is discontinued or the benefit-risk of ongoing treatment in children. "We don't have randomized evidence for how long to continue this treatment or for how and when to discontinue it," said March, a member of the RUPP study and director of the program in child and adolescent anxiety disorders at Duke University. "We do have a pretty good understanding of what to do now for initial treatment with single agents, either SSRIs or cognitive-behavioral therapy." 

In 1994, Philip Kendall, Ph.D., director of the child and adolescent anxiety disorder clinic at Temple University, reported on the first randomized clinical trial of CBT for anxiety-disordered children. Forty-seven children between the ages of 9 and 13 who met DSM-III-R criteria for overanxious disorder, separation anxiety or avoidant disorder received a 16-session treatment (Kendall, 1994). Post-treatment, 64% of the children were free of the diagnosis for which they were treated. Kendall later replicated these findings with a similar group of 94 patients (Kendall et al., 1997). Follow-up with the first group at 3.35 years showed that about two-thirds of the treated children maintained their treatment gains (Kendall and Southam-Gerow, 1996). The follow-up did not allow for comparison with an untreated control group since the original wait-listed group had gone on to receive therapy. Kendall and his team are now in the process of conducting an eight-year follow-up of the subjects in the 1997 study. 

An Australian group led by Paula Barrett, Ph.D., has had similar results using a manualized form of Kendall's therapy (Barrett et al., 1996). They recently published the longest follow-up to date of CBT in anxious children, with an analysis of the clients six-years post-treatment (Barrett et al., 2001). The 52 clients, aged 14 to 21 years (out of an original study group of 79), had received CBT for overanxious disorder, separation anxiety or social phobia. Of these subjects, 42 (85.7%) no longer met the diagnostic criteria for any anxiety disorder. Long-term outcomes did not differ significantly on the basis of either the initial diagnosis or the presence of comorbidity. There was no follow-up control. 

 to summarize the findings to date on cognitive behavioral therapy and anxiety disorders in children, Kendall said, "In children with separation anxiety, generalized anxiety disorder and social phobia, CBT is effective in 66% to 72% of the patients. On follow-up of a year or more, about two-thirds of the responders maintain their gains." 

What are the unique features of CBT that have been shown to be effective with anxious children? According to Kendall, there is an emphasis on exposure tasks during which the child is asked to do what they are most afraid of. There are also systematic attempts to change the child's internal dialogue or "self-talk." "Depending on the child's developmental level, instead of talking about self-talk, we might look at a cartoon with a blank thought bubble and fill it in," he said, adding, "There are lots of role plays, a lot of practice opportunities shaped and guided by the therapist." 

 For example, in the case of a child who worries a lot about "their mother forgetting and not picking them up on time at school," Kendall would "organize multiple opportunities for the kid to have to wait for mom to pick them up" in the context of the therapy. While waiting with the child, the therapist would help them to list all the potential reasons why the parent could be late (e.g., traffic, last-minute phone call). The dreaded "being forgotten about" becomes only one among many far more likely possibilities. 

Anne Marie Albano, Ph.D., also considers a critical element of the treatment its "normalizing of the experience of anxiety" itself. Although research has yet to clarify whether, and in exactly what ways, anxiety-disordered children's arousal, neurochemistry or brain function is actually different from normal children in the face of anxiety-provoking situations, it is clear that these children find their own experience of being anxious as less tolerable. 

"Part of what you do with exposure therapy is to help them to feel their anxiety," said Albano, who is director of the anxiety and mood disorders clinical research service in New York University's child study center. "Let them feel their heart rates go up, while you stay in and manage the situation." The more exposure they have to their own anxiety, Albano explained, the less they focus on their heart rate racing or the butterflies in their stomach. After successfully completing the exposure tasks, "All the children say, 'I didn't even notice I was nervous anymore,'" she said. 

Although it is common for practitioners to utilize some form of CBT as part of an eclectic package of therapy techniques, what is being offered may not provide the essential components of Kendall's protocol. "My concern," said Pine, "is that there aren't very many true experts in cognitive-behavioral therapy with children out there in the community." 

March agreed, "There's so much heterogeneity of practice, and that directly predicts heterogeneity in quality of care." 

The parents of Albano's New York City patients often claim their children have already "failed cognitive-behavioral therapy." What Albano finds with further investigation is that the previous practitioners may have done "something CBT-like" but without the systematic thought and planning that goes into gearing the exposure to the specific child and their disorder. 

A number of variables may be important in determining the success or failure of CBT, according to Kendall. In at least one study (Treadwell and Kendall, 1996), the reduction in the child's negative self-talk was very significant. "We measured positive and negative self-talk at the beginning of treatment, at its end and one year later. Positive self-talk did not change but there was a significant reduction in the negative self-talk, and this reduction was a significant mediator of therapeutic change," he said. Gender, age, ethnicity and socioeconomic status were not significant variables in success or failure, and there were no differences in outcome on the basis of individual diagnosis or comorbidity. 

Other forms of psychotherapy to treat anxiety disorders in children have not been subjected to randomized controlled trials. Psychoanalyst Peter Fonagy, Ph.D., is developing a study that will compare CBT and a manualized form of psychodynamic therapy for "severely disordered anxious children" in the United Kingdom. Fonagy, director of research at London's Anna Freud Centre, contended that psychodynamic therapy may have broader and more long-lasting developmental effects than CBT. 

Comparison of CBT, SSRIs and Combination Therapy

In a press release commenting on the fluvoxamine trial, NIMH director Steven E. Hyman, M.D., called for the need to "compare the efficacy of existing therapies, including cognitive-behavior therapy to, or in combination with, medication." An ambitious multisite, randomized, controlled trial to evaluate SSRIs, CBT and combination therapy is currently awaiting NIMH funding. The study will enroll children between the ages of 7 and 14. By standardizing the diagnostic criteria, the study will ensure that the patients receiving CBT and those receiving pharmacotherapy are truly comparable. Outcome measures, which have varied from study to study, will also be rigorous and standardized, ensuring that success will be measured in the same way across treatments. Kendall's manualized CBT will be used (Kendall, 2000), with all practitioners overseen by Kendall's group to ensure consistency and treatment integrity. The trial will probably continue for 12 weeks with a six-month follow-up, enough time to allow researchers to measure relapse if it occurs. 

If all goes well, the study may help clinicians to determine if combination therapy has advantages over monotherapies, or if it works for patients who have failed other treatments. Based on his own clinical experience, March suspects that combined treatment may confer "an advantage for the sickest, most comorbid children." He anticipated that this trial and others like it will resolve at least some of the open questions in the treatment of children with anxiety disorders. 

He said, "Five to seven years from now, we're going to have a much better idea of which treatments work best for which kids with which problems across the range of internalizing disorders." 

Barrett PM, Dadds MR, Rapee RM (1996), Family treatment of childhood anxiety: a controlled trial. J Consult Clin Psychol 64(2):333-342.


Barrett PM, Duffy AL, Dadds MR, Rapee RM (2001), Cognitive-behavioral treatment of anxiety disorders in children: long-term (6-year) follow-up. J Consult Clin Psychol 69(1):135-141. 


Bernstein GA, Shaw K (1997), Practice Parameters for the Assessment and Treatment of Children and Adolescents with Anxiety Disorders. American Academy of Child and Adolescent Psychiatry. J Am Acad Child Adolesc Psychiatry 36(10 suppl):69S-84S. 


Kendall PC (1994), Treating anxiety disorders in children: results of a randomized clinical trial. J Consult Clin Psychol 62(1):100-110.


Kendall PC (2000) Cognitive-Behavioral Treatment for Anxious Children: Therapist's Manual, 2nd Edition. Ardmore, Pa.: Workbook Publishing Co. 


Kendall PC, Flannery-Schroeder E, Panichelli-Mindel SM et al. (1997), Therapy for youths with anxiety disorders: a second randomized clinical trial. J Consult Clin Psychol 65(3):366-380. 


Kendall PC, Southam-Gerow MA (1996), Long-term follow-up of a cognitive-behavioral therapy for anxiety-disordered youth. J Consult Clin Psychol 64(4):724-730. 


Pine DS, Cohen P, Gurley D et al. (1998), The risk for early-adulthood anxiety and depressive disorders in adolescents with anxiety and depressive disorders. Arch Gen Psychiatry 55(1):56-64. 


Research Unit on Pediatric Psychopharmacology Anxiety Study Group (2001), Fluvoxamine for the treatment of anxiety disorders in children and adolescents. N Engl J Med 344(17):1279-1285. 


Treadwell KR, Kendall PC (1996), Self-talk in youth with anxiety disorders: states of mind, content specificity, and treatment outcome. J Consult Clin Psychol 64(5):941-950.

A recent large, randomized, controlled trial showed fluvoxamine to be effective in treating anxiety disorders in children. The eight-week trial raises many questions about anxiety, the most common psychiatric disorder in children. A panel of experts looks at past and future research.

New Developments in Treating Anxiety Disorders

According to the 1990 U.S. census, approximately 2 million children and adolescents under the age of 18 (over 2%) have experienced the death of a parent. In contrast to the emphasis of earlier psychoanalytic interpretations on children's inability to mourn parent death (Freud, 1917; Wolfenstein, 1966), there is now general agreement that children as young as 3 years old do indeed grieve, that their mourning is different from that of adults, and that supporting children's bereavement may help to prevent later adverse psychological consequences (Bowlby, 1980; Furman, 1983; Weller et al., 1991).But systematic descriptions of how children's responses vary by their developmental status have been limited. This has led to confusion and uncertainty about how professionals, parents and other supporting adults can understand children's grief, distinguish normative from more pathological responses, and mediate the more stressful aspects of the experience.

Healing Children's Grief: Surviving a Parent's Death from Cancer 

 (Christ, 2000) reports the findings from a qualitative analysis of a parent guidance intervention study that began about six months before and ended 14 months after the death of one parent from cancer. The findings presented in this book emphasize the changing manifestations of mourning in 157 3- to 17-year-old children from 88 families. 

There were several unique features of the parent guidance intervention research we conducted from 1988 to 1994 at Memorial Sloan-Kettering Cancer Center. First, rather than beginning after the death as did previous studies, families were identified in which the ill parent had an estimated survival time of three to six months. This permitted exploration of anticipatory responses of both children and adults. Secondly, only families where the parent had cancer were studied. Sudden or traumatic deaths such as homicide or suicide that may elicit traumatic stress responses, in addition to grief reactions, were not included. Finally, data were collected for both a quantitative and qualitative arm of the study, which permitted a more in-depth understanding of the phenomena. An expanded account of the qualitative methodology is available at 

The first aim of the quantitative arm was to determine whether depression, anxiety and self-esteem scores of bereaved children were different from those of a non-bereaved community sample before and after the death of a parent. The non-bereaved control sample was selected because the parents had similar education and family incomes to those of the study sample and they were matched with the study children on age, gender and number of children in the family. The scores of children in the study sample were significantly worse (by about half the standard deviation) during the pre-death evaluation but were no longer different from those of the community sample at eight and 14 months after the death (Siegel et al., 1996a, 1996b). 

A second aim for the quantitative analyses was to determine whether children whose parents participated in the more intensive parent-guidance intervention had better scores on three standardized measures after the intervention than those that participated in an alternative intervention. Although the scores of children in the experimental group were better than those in the control group, the differences did not reach significance except for greater improvement in trait anxiety of children in the experimental group. An assessment of the children's rating of their parent's parenting skills and communication by a measure developed for this study (Siegel et al., 1996a, 1996b) showed that the children who participated in the experimental intervention rated their parents as more skillful and more communicative than those who participated in the alternative telephone monitoring one. 

The qualitative arm of this study had a broader aim: to deepen our understanding of the bereavement process in children and adolescents, to understand the role of development in the children's mourning, to understand how positive and negative mediators and moderators impacted on bereaved children, and to develop a baseline that would permit longer term prospective follow-up. Of the 137 families who participated in the parent-guidance intervention, 88 were selected who completed most of the six pre- and post-death therapeutic interviews and the pre- and post-death assessments so that extensive therapy notes and audiotaped therapeutic interviews were available (Christ, 2000). 

The sample included 51 surviving mothers and 37 fathers and their 3- to 17-year-old children (78 sons and 79 daughters). Since an arbitrary age category is not a good indicator of development (Rutter, 1989), grouping children by several developmental attributes rather than arbitrary age groups has been recommended, but it remains a challenge to implement. For this analysis, three developmental areas (cognitive, psychodynamic and ecological) were found to be most pertinent in this particular sample. Grouping children by these developmental attributes yielded five age groups with the most developmental similarities. 

The 3- to 5-year-old children, even when well-prepared by parents during the terminal illness, did not understand that death was permanent and irreversible. It was often three to six months after the death before they understood the parent would never return. Cognitively, they were pre-operational (Ginsberg and Opper, 1997); emotionally, they were intolerant of separations from primary caregivers but adjusted well to surrogates; and ecologically, the family microsystem was paramount (Bronfenbrenner, 1989). Their mourning was nonspecific and included temporary irritability, toileting regression, sleeping with the surviving parent, somatic symptoms, nightmares and increased separation anxiety. They wanted an intact family--one 5-year-old girl asked her mother to get two daddies in case one died. Anxiety was apparent during parental separation, especially during the terminal illness period. Parents found that play bereavement groups helped improve communication and decrease symptoms. 

The 6- to 8-year-old children were in transition. Cognitively, they were late pre-operational with some early concrete operational attributes. They struggled most with misunderstandings of the situation based on magical thinking and their focus on themselves as the cause when bad things happened. Emotionally, they tolerated separations better, but needed clear preparation for emergency separations. Although the school microsystem became important, self-esteem remained predominantly dependent on parental approbation. When informed of their parent's death, they immediately understood its finality. Their mourning included joyful reminiscences. They displayed pictures of the parent, liked and wore deceased parental belongings, and many spoke of wanting to die to be with the deceased parent but, when evaluated by a psychiatrist, had no suicidal intent. 

Most felt comforted by "speaking" with the dead parent, whom they located in a place (usually heaven), and most were convinced the parent watched and cared for them from there. Crying and sadness were sporadic--they quickly returned to play and activities. Play bereavement groups or contacts with peers with similar loss experiences could be helpful, as were reminiscences and rituals like going to the cemetery, observing Father's/Mother's day and others. It was harder for fathers to understand and be supportive of children in these first two groups because of the children's extensive cognitive, emotional and caregiving needs. 

The 9- to 11-year-old children were in developmental equilibrium. They were solidly concrete operational. Their self-esteem was enhanced by parental and other adult approbation and by their own experience of competence. They left home to be with peers rather than to distance themselves from family, as did the next two groups. Ecologically, school, home, and peer and group activities (sports) were important. Intellectualization was an important defense, and they were able to compartmentalize their feelings. Although intolerant of strong emotions, their mourning included a strong need for intellectual understanding. In school, they wrote reports about cancer, its treatments and even about euthanasia. They often looked for ways to be helpful with caretaking, benefitting from active mastery. 

It was vitally important that parents provide clear, detailed, concrete information and balance the children's intolerance of strong emotion with encouragement of appropriate reminiscences. More structured rituals seemed to help children in this age group overcome their fears of speaking informally about the parent who died. Like their younger peers, they mourned the parent's caretaking role, but more so their teaching and supportive attributes. Both mothers and fathers found boys and girls in this group easier to understand and support than younger and older children. 

The 12- to 14-year old group was characterized by marked egocentrism and emotional and physiological disequilibrium. Inconsistent fluctuations in emotional responses and needs, such as dependence-independence, were common and, for parents, confusing. Formal operational attributes began to emerge. Emotionally, boys began to distance from parents (Blos, 1962); girls also began to change their relationship, especially with mothers, and started to enjoy talking about relationships, sharing shopping ideas and so on (Jordan et al., 1991). Both boys and girls seemed to need to be in control of their withdrawal, shown by assertions of independence and fury when their dependent needs were not met. Paradoxically, they also reacted strongly to the emotional and physical withdrawal of both parents during the terminal illness period. Boys and girls were intolerant of strong emotions, but they were also avoidant of information about the illness and death. 

The peer microsystem not only included peers to do things with, as did the younger group, but also close friendships. Unlike the 15- to 17-year-old group, sharing personal grief with peers was very unusual. Grief was very private: "I cry in my room, alone" was their mantra. Surprisingly, they generally felt free to talk about dreams after the parent died, describing a strong sense of their continuing presence. Many said they spoke with the dead parent and generally felt a connection with them. Obvious identification with the parent who died, e.g., wearing their clothes, becoming interested in their vocations and avocations was most frequent in this age group. A marked contrast grief expression occurred with the few 12- to 14-year-old adolescents whose parents were recent immigrants. These adolescents more openly shared their grief with parents and interviewers suggesting the important role of culture in shaping grief responses. 

Setting appropriate limits and providing formal family reminiscence experiences was important for this early adolescent group, as it was for the 9- to 11-year-old children. These rituals also helped them express feelings in formal ways that they avoided in more informal discussions. 

The 15- to 17-year-old group showed more consistent pervasive formal operational attributes. Their anticipatory grief during the terminal illness included clear recognition that their family's future would be changed. Many experienced the full weight of adult grief shortly after the death, although its duration was generally shorter than their parents'. Where parents were concerned that 9- to 11-year-old and 12- to 14-year-old children were not grieving, parents of the 15- to 17-year-old children were more likely to be concerned about the intensity of the grief. The anhedonia was pervasive, including sleeping problems, waking early and inability to concentrate in school, even in sports. 

Emotionally, their peer involvement was more intense, and it often included sharing grief experiences with others their age who had lost parents to death or divorce. They were more accepting of family responsibility, including that of caring for younger siblings. They mourned more complex attributes of the parent than did younger peers and thought in more specific ways about what the parent who died expected of them and how they might fulfill their dreams. As with the 12- to 14-year-olds, the challenge to the parent was setting appropriate limits and staying out of or getting out of spiraling conflicts. An additional task was to encourage confidence in independent functioning. 

 What was impressive was that 83.5% of the children had returned to previous levels of functioning as measured by a qualitative assessment of psychological evaluations. This compares with 12% who had high depression scores both before and after the death (Siegel et al., 1996a, 1996b). As described in the book 

(Christ, 2000), most mothers and fathers succeeded in their struggle to balance their own powerful grief and their children's emotional needs. Most of these parents made excellent use of help offered by the intervention, but also outside that domain. They appropriately enlisted school personnel, family and neighbors. Surviving mothers were generally more psychologically attuned to their children, especially younger children, while fathers were more comfortable setting limits and allowing adolescents their independence. 

A few more surprising findings that might account for the high proportion of youngsters who reconstituted well included the following: fathers fell into two groups. There were a number who could not or would not be supportive and understanding of their children, especially the younger ones. But there was a sizable group who learned these skills through different methods. Five of the 37 fathers actually did not work for three to six months after the death of their wives while they learned to understand and look after their children. A few elected to use their financial assets to hire competent caretakers and worked out realistic, though limited, times for interacting with their children. One father recognized his poor relationship with his young daughter and worked at improving it during his wife's terminal illness. When last seen, his daughter gave him high marks for improved communication. A few remarried fairly quickly, but selected a mate who was fond of the children and whom the children liked. Of interest was that these men were often still deeply mourning the death of their wives; their children and the new spouse were aware of this and responded positively. Finally, there were a few parents who dealt with psychosis or alcoholism in their background successfully by acknowledging their problem and returning for maintenance treatment. They sought clarity for those needs of their children that they were likely to be unable to meet, and they looked for people who would be able to substitute for them. 

The intent of this study was to learn about children's grief experiences in situations with limited additional stressors: i.e., families with two parents, adequate resources and opportunities for preparation for parental loss. In future research, these results can be compared with children who confront multiple stresses with fewer resources. The results of this study are also based on evaluations eight and 14 months after the death. A follow-up study is planned that will explore the longer-term outcomes. 

Blos P (1962), On Adolescence. New York: Macmillan. 
 

Bowlby J (1980), Attachment and Loss. New York: Basic Books. 
 

Bronfenbrenner U (1989), Ecological systems theory. In: Six Theories of Child Development: Annals of Child Development, Vesta A, ed. Greenwich, Conn.: JAI Press. 
 

Christ G (2000), Healing Children's Grief: Surviving a Parent's Death From Cancer. New York: Oxford University Press. 
 

Freud S (1917), Mourning and Melancholia. In: The Complete Works of Sigmund Freud, vol. 14, (1957) Strachey J et al., eds. London: Hogarth Press. 
 

 Furman E (1983), Studies in childhood bereavement. Can J Psychiatry 28(4):241-247. 
 

Ginsburg H, Opper S (1997), Piaget's Theory of Intellectual Development, 3rd ed. Englewood Cliffs, N.J.: Prentice Hall. 
 

Jordan J, Kaplan A, Miller J et al. (1991), Women's Growth in Connection: Writings from the Stone Center. New York: Guilford Press. 
 

Rutter M (1989), Age as an ambiguous variable in developmental research. Int J Behavioral Dev 12(1):1-34. 
 

Siegel K, Karus D, Raveis V (1996a), Adjustment of children facing the death of a parent due to cancer. J Am Acad Child Adolesc Psychiatry 35(4):442-450. 
 

Siegel K, Raveis V, Karus D (1996b), Patterns of communication with children when a parent has cancer. In: Cancer and the Family, Cooper C, Baider L, Kaplan De-Nour A, eds. New York: John Wiley & Sons, pp109, 128. 
 

Weller RA, Weller EB, Fristad MA, Bowes JM (1991), Depression in recently bereaved prepubertal children. Am J Psychiatry 148(11)1536-1540. 
 

Wolfenstein M (1966), How is mourning possible? Psychoanal Study Child 21:93-123.

Do children's reactions to losing a parent to cancer differ according to the child's age and mental status? What treatment options are most efficacious for each age group?

Facilitating Mourning Following Parental Death

Federal authorities are investigating whether mentally ill patients in Illinois have been inappropriately placed in geriatric nursing homes after two young patients from one nursing home were charged with murder. Meanwhile, on a national level, two recent reports from the Office of Inspector General (OIG) in the U.S. Department of Health and Human Services (HHS) faulted several states for not adequately identifying, screening or treating younger (aged 22 years old to 64 years old) mentally ill Medicaid beneficiaries who reside in nursing homes. 

In Illinois, HHS has temporarily halted Medicaid or Medicare funding for any new patients at the Hillcrest Healthcare Center nursing home, according to reports in the 

. The federal action came after Illinois' Department of Public Health recommended federal financial sanctions be imposed on Hillcrest for not properly supervising its mentally ill patients; two of its patients (aged 23 years old and 27 years old) were charged with killing a man in March after they signed themselves out of the nursing home for the day. 

If the problems at the nursing home remain unresolved by September, federal funding will be terminated permanently, Charles Bennett, Illinois branch manager of HHS' division of survey and certification, told the 

After visiting the nursing home, federal investigators stated that the facility was not equipped to handle mentally ill patients with violent backgrounds. But the investigators were equally critical of the Illinois Department of Public Aid and questioned why the department had classified Hillcrest as a nursing home rather than an institution for mental diseases (IMD). 

Well over half of the nursing home's patients are being treated primarily for mental illnesses, a Hillcrest spokesperson told the 

, and federal inspectors estimated the number at close to 80%. Inspectors added that probably more than two dozen facilities across the state are similarly misclassified. 

By classifying Hillcrest as a nursing home, the 

 pointed out, the state is able to shift part of the facility's funding burden to the federal government. Medicaid pays for the care of individuals with mental illness in nursing facilities when residents with mental illness fill 50% or less of the facility's beds. If the percentage climbs above 50%, federal law requires the facility to be designated as an IMD. In IMDs, the state mental health authorities are responsible for funding the care. 

 that the federal government is interested in assessing whether traditional nursing home patients have been neglected or put at risk because mental patients are filling more beds at places like Hillcrest. 

This is not the first time that Illinois has been under scrutiny. A three-part investigative series by the 

 in 1998 showed that, to receive federal Medicaid funds, the Illinois Department of Public Aid improperly transferred thousands of mentally ill people into nursing homes designed for older patients. The state, subsequently acknowledging that several of the nursing homes should be reclassified as psychiatric facilities, withdrew 17 nursing homes from the federal Medicaid program. In 1999, the Illinois legislature passed a bill to tighten standards for treating the mentally ill in nursing homes. The law requires the Department of Public Health to provide mentally ill nursing home residents with appropriate services and to provide training for nursing home personnel regarding the assessment, care planning and care for patients with a mental illness or developmental disability. 

Problems that surfaced in Illinois also have surfaced across the country. Issued by HHS' OIG, the report "Younger Nursing Facility Residents with Mental Illness: An Unidentified Population" (2001a) sought to determine how many younger individuals with a primary or secondary diagnosis of a severe and persistent mental illness reside in nursing homes and how much Medicaid spends on their care. One of the report's key findings is that the number of younger individuals with mental illness who reside in nursing facilities cannot be conclusively determined. 

Emily Melnick, program analyst with the OIG's Office of Evaluations and Inspections and one of the report's authors, explained to 

 that they could not establish an overall percentage. For example, the federal government's Minimum Data Set (MDS), used to aid in the administration of the survey and certification of Medicare/Medicaid long-term care facilities, found that the number of younger residents with mental illness represents an average of 1.6% of the states' nursing facility population. However, a state survey (20 states reporting) conducted by the OIG found that these younger residents represent on average 20% of the nursing facility populations. 

 Moreover, the federal government's own data sets differ: the Medicaid Statistical Information System (MSIS), which collects claims and eligibility data for medical services, shows that in 39 states there are 5,745 Medicaid beneficiaries aged 64 years and under with a primary diagnosis of mental illness who reside in nursing facilities. However, the MDS data for those same states show that 17,919 younger patients with any diagnosis of mental illness reside in nursing homes. 

Besides the numerical inconsistencies, the OIG report found that Medicaid expenditures for that population could not be validated. For example, a nursing facility's claim for per diem might not identify an individual with a serious mental illness if it was not the individual's primary diagnosis. Consequently, the state and federal expenditures for this population are underestimated. The report also found that many states do not know where younger individuals with mental illness are receiving long-term care, whether it is in IMDs, state psychiatric hospitals, community-based facilities, hospital psychiatric wards or nursing homes. 

The unsuccessful attempt by the OIG to identify the younger mentally ill population in nursing homes is indicative of a larger problem with federal data sources, the OIG report authors said. 

 This examination questions the use of Federal data sources to accurately yield important demographic, utilization, and expenditures information upon which to base policy. Without reliable information that enables us to identify populations of individuals requiring particular types of services, we cannot assess appropriateness, access and quality of care, nor determine the effectiveness of Federal Medicaid and nursing facility policy. 

The OIG also produced a companion report, "Younger Nursing Home Residents with Mental Illness: Pre-Admission Screening and Resident Review (PASRR) Implementation and Oversight" (2001b) ( Table ). It evaluates the safeguards for monitoring the admission and mental health treatment of younger nursing facility residents with serious mental illness. 

According to the report, from the 1950s through 1985 state mental health hospitals began reducing their resident populations and transferring many patients to nursing facilities and other residential facilities. Thus, in 1987, the Omnibus Budget Reconciliation Act mandated preadmission screening to ensure that only individuals with serious mental illness in need of nursing facility care would be admitted to nursing facilities, that their need for specialized services would be determined and that the facilities would provide patients with mental health treatment. 

All nursing home applicants, regardless of whether they are private- or public-pay, are required to be given preadmission screening, referred to as Level I PASRR. The federal government defines a patient as having a serious mental illness if they have a major mental illness diagnosis, not including dementia or organic brain disorders; a functional limitation within the past three to six months; and psychiatric treatment more intensive than outpatient care within the past two years. States can design their own PASRR forms and may choose more inclusive criteria for identifying a serious mental illness. 

Individuals who meet the aforementioned requirements are supposed to undergo an independent physical and mental evaluation, a Level II PASRR, in part to determine whether they require specialized services. If they do, state mental health authorities must provide such services or arrange for them. Mental health services of "lesser intensity than specialized services" must be provided by the nursing home facilities. 

For their report, the OIG team collected information and data from Medicaid programs, surveys of state officials involved in mental health services and nursing home care. They also made on-site visits to 19 nursing facilities in five states--California, Florida, Kansas, Minnesota and Pennsylvania. 

 The OIG staff found that only 47% of the nursing home residents sampled in five states had received a Level 1 PASRR screen, and, of those who did, 17% of the screens were completed after the patient was admitted to the facility. "If [PASRR screens] are not being done, there is no way of insuring whether someone has a psychiatric illness or not," Melnick told 

Additionally, there was little evidence that initial Level II PASRRs or reassessments were conducted. "Of those people that the nursing home did identify as having a severe mental illness," Melnick further explained, "only 41% actually had a mental health evaluation." 

Another major problem identified in the report was that states might violate the intent of the federal requirement to provide mental health services. 

"Four of the 5 states we visited and 15 of the states responding to our survey define 'specialized services' as 24-hour psychiatric treatment. Under this definition, a nursing facility is not a 24-hour psychiatric treatment facility and residents in nursing facilities are excluded from receiving 'specialized services,'" the report authors wrote. "Limiting the definition in this way excludes the provision of certain mental health services to individuals in nursing facilities and relieves states of their responsibility to provide this care." 

Of equal concern, the report authors found that most state mental health authorities in the five states that were studied did not consider it their responsibility to monitor or provide treatment for residents of nursing facilities with mental illness. 

William C. Moran, regional inspector general of the Office of Evaluations and Inspections who directed preparation of both OIG reports, told 

 that both the Centers for Medicare & Medicaid Services and the Substance Abuse and Mental Health Services Administration have generally concurred with OIG's report findings and have laid out plans of action that are particularly important in light of the U.S. Supreme Court's Olmstead decision. 

 decision said that continued institutionalization might violate the rights of an individual with mental illness or mental retardation under Title II of the Americans with Disabilities Act. The HHS has interpreted the decision to mean that no person should have to live in a nursing home or other institution if they can live in their community. In June, President George W. Bush signed an executive order directing designated federal agencies to help states find community-based housing alternatives for such individuals. The HHS is providing $70 million in grants to help states improve their community-based services. 

 "The Center for Medicare & Medicaid Services as well as the Office of Civil Rights are very involved with the actions of the states in implementation of the Olmstead decision," Moran told 

. "A lot of actions are being taken, both specifically regarding the recommendations of the reports, as well as addressing the broader issue of ensuring that [people] with mental illness are receiving appropriate care in the least restrictive setting." 

Office of Inspector General (2001a), Younger Nursing Facility Residents with Mental Illness: An Unidentified Population. Available at: 

Office of Inspector General (2001b), Younger Nursing Facility Residents with Mental Illness: Preadmission Screening and Resident Review (PASRR) Implementation and Oversight. Available at: 

In Illinois, the Department of Public Health and a nursing home facility came under fire after two mentally ill residents were charged with murder. Two recent federal government reports look into the nature of nursing homes and their role as long-term care mental health facilities. Are nursing homes providing appropriate care for mentally ill patients or are these facilities merely being used as warehouses for mentally ill patients?

Ensuring Appropiate Treatment for Patients

In the United Kingdom, where homicide rates are lower than in the United States, 40 to 50 families each year will be devastated by the death of one parent at the hands of the other (Harris-Hendriks et al., 1993). As a result of intra-familial homicide, children lose not only both parents (one by death and the other by imprisonment) but often their homes, school, friends, possessions and self-esteem. Our interest in the plight of these children began as a result of our work with bereaved children and an increasing awareness of the lack of specialist resources for children suffering a traumatic bereavement. A specialist Children's Traumatic Stress Team was set up at the Traumatic Stress Clinic in London and has been a National Referral Centre for Post Traumatic Stress Disorder for some years. Over half the children seen at the clinic are referred as a result of intra-familial homicide. The team has now seen over 500 children where one parent has killed the other. 

Father Kills Mother: Guiding Children Through Trauma and Grief 

provides detailed documentation of cases where the father killed the mother (FKM) (Harris-Hendriks et al., 2000, 1993). Although there is a chapter within this book on the much less common phenomenon of mother kills father (MKF), a literature search did not reveal any further specific studies of the children in MKF cases. 

Women appear to be much less violent than men, as reflected in the families we studied. We found only 22 families, with 44 children altogether, where the mother killed the father (Harris-Hendriks et al., 2000). Our study of MKF cases is based on the material drawn from this clinical sample and therefore may not be representative of all cases that occur. 

The children in the study were referred to the team at different intervals after bereavement. Some children were referred for medico-legal assessment long after the critical incident and others for immediate post-trauma intervention. To obtain follow-up data, a questionnaire was administered by telephone to a social worker with current knowledge of the child's functioning. Follow-up information included questions about current and past placements, contact with the mother and relatives, contact with other mental health services and present functioning of the child with regard to health, school, and symptoms of posttraumatic stress disorder (PTSD) or other psychiatric disorders. Follow-up information was obtained on 21 of the 44 children. 

In almost all cases where the mother kills the father, the mother has endured years of abuse at the hands of the father. Unfortunately, the children also suffer. How can psychiatrists help these children heal after such a tragedy?

Psychiatric Times Vol 18 No 9