Research suggests that more than three-quarters of nursing-home residents exhibit mental health problems, including dementias such as Alzheimer's disease (AD). Yet psychiatric care in long-term care facilities is lacking. Low reimbursement rates, staffing issues and lack of attention by the facilities themselves have contributed to the problem.

Moving to an assisted-living facility or nursing home can be a distressing and disruptive experience. Patients may suffer from anxiety, depression and reactive adjustment disorders. They may experience an exacerbation of physical problems, sleep disturbances and appetite problems, all based on relocation stress.

That is the case for the average patient, Elliott M. Stein, M.D., told 

. Stein is a geriatric psychiatrist in private practice. People with cognitive disorders such as AD and dementia have additional stress when they are relocated because they have more difficulty adapting. They may have more trouble understanding what is happening to them or learning their way around. They may become more disoriented because they are in a strange location.

Medicare reimbursement inhibits psychiatrists from providing services to patients in assisted-living facilities and nursing homes, Stein said. As is the case with other outpatient settings, Medicare has a discriminatory restriction on providing services to nursing-home patients with mental illnesses. The program reimburses psychotherapy and other mental health care services at 50% of the allowed amount, compared with 80% of the allowed amount for physical illnesses. Treatments for AD and dementia are an exception to this, but only for medication management, which is reimbursed at 80%.

These restrictions on reimbursement are a limiting factor in bringing appropriate psychiatric care into long-term care settings, said Stein, former president of the American Association for Geriatric Psychiatry and the association's Clinician of the Year for 2003.

Furthermore, the rates that Medicare allows for psychiatric care in these facilities are set at a prohibitively low level compared with reimbursement rates for providing the same services in a psychiatrist's office, he said. This also erodes access to adequate care, since residents in these facilities are often unable or unwilling to make office visits.

Staffing Levels and Training Need To Be Addressed

One of the concerns of the National Citizens' Coalition for Nursing Home Reform (NCCNHR) is that nursing homes be equipped to deal with the mental health care needs of their residents. Staff training for managing behaviors associated with mental health care needs is one concern, but so are staff levels in general. If staff levels are low, supervision of patients with special needs can suffer.

According to NCCNHR Executive Director Alice H. Hedt, congressional legislation that would address staffing levels in nursing homes stood little chance of passing this year, and most laws addressing those concerns are likely to be on a state-by-state basis.

Currently, about 92% of facilities are not staffed at a level to provide adequate physical and medical care, Hedt told 

. "Then, when you compound it with complex mental health needs, you add on the issue of how well equipped the staff is in terms of training."

Nursing-home patients with AD and other dementias have different needs than do other patients in terms of supervision, Julie Meashey, ombudsman specialist at NCCNHR, told 

Patients in advanced stages of the disease sometimes need changes within their environment to make it safe. Some facilities have specialized units with higher staff levels and specialized activities, but other facilities integrate the patients within the larger population.

Patients who wander or are unsteady on their feet, or who are bed-bound, require higher levels of staffing, Meashey said. Staff members need to make sure that patients do not leave the facility or wander into other patients' rooms. If a patient needs to walk, then the staff must find a way to accommodate that.

Currently, no federal standards exist for staffing levels, Meashey explained. Minimum direct-care staffing standards developed by NCCNHR in 1998 have yet to be adopted by individual states, although Maine is the closest to meeting these standards. The standards, which were developed in consultation with long-term care experts over a number of years, call for nursing-home residents to receive at least 4.13 hours of direct nursing care each day.

Need for Services To Improve Cognition and Quality of Life

A number of these patients need more than a medication check, Stein said, and psychiatrists need to work with facility staff and the patient's family as well. He added, "Patients who have a mild cognitive decline may still benefit significantly from psychotherapeutic interventions."

Alzheimer's disease is undoubtedly a mental illness, Stein said. It affects multiple systems, such as the neurons of the brain and the body's ability to perform basic functions such as walking, eating and sleeping. "Its primary symptoms are symptoms of memory, behavior and emotion."

A study appearing in the July/August issue of the 

 found that patients who are mildly impaired by AD can improve at face-name associations, orientation, cognitive-processing speed and specific tasks, such as making change and paying bills.

Using a new cognitive-rehabilitation program that involved two 45-minute sessions a week for 12 weeks, researcher David A. Loewenstein, Ph.D., concluded that a systematic program could result in maintained improvement in performing specific tasks for mildly impaired patients.

The study found that patients with AD who participated in the cognitive-rehabilitation program for three to four months experienced a 170% improvement, on average, in the ability to recall faces and names compared with patients who did not receive the intervention. The study also found a 71% improvement in the ability of patients to make correct change for a purchase. According to the study, the improvements were still evident three months after the training ended.

A second study, published in the June issue of 

, found that older people with early-stage AD still retained functioning levels of implicit memory that were similar to levels for young adults and older adults without AD.

"Taken together, these studies introduce the exciting notion that older people who are in the early stages of AD can be taught techniques to help stay engaged in everyday life," said Neil Buckholtz, Ph.D., head of the Dementias of Aging Branch in the National Institute on Aging's neurosciences program.

Care for Institutionalized Patients With SMI

Dementia isn't the only mental health problem that seniors in long-term care facilities face. Older people have a high incidence of depression, anxiety and other emotional disorders. And although doctors are recognizing these disorders more frequently now than in the past, they are still largely underdiagnosed and undertreated, Stein said. Many patients with these disorders end up in long-term care facilities.

Also, people who have had a lifelong serious mental illness (SMI) frequently end up in long-term care. At one time, such patients would have spent their final years in a state hospital, but no longer.

According to a study appearing in the December 2003 issue of the 

Journal of the American Geriatric Society

, 89% of older people with SMI who are institutionalized reside in nursing homes. The researchers of the study reported:

Older persons with SMI who reside in nursing homes have greater functional impairment in self-care skills and community living skills, worse general health, more-severe negative (deficit) psychotic symptoms and cognitive impairment, more aggressive behaviors, and less social support than those who live in the community.

"In addition, several studies suggest that older adults with SMI are at a substantially greater risk of institutionalization than other groups of older persons," the researchers continued.

Preparedness to handle patients with SMI varies, Stein said. Overall, it appears that long-term care facilities are vastly underserved. This results from an inadequate number of psychiatrists and psychologists treating these patients and through a lack of staff awareness and training at the facilities themselves.

Some facilities train their staff well and have psychiatrists on staff to provide services, Stein said. "When it is done well and properly, it can be of great benefit, both to the facility and to the patients within the facility. But getting that staff trained and getting [psychiatrists] to come see people in a facility is not done on a systematic basis."

Some facilities do not see a need for psychiatrists, except when told by state regulators to have one check on a patient's medications, Stein explained. Ultimately, it depends on the availability of willing geriatric psychiatrists and on the willingness of facilities to have them treating their patients.

A 2001 report by the Office of Inspector General at the U.S. Department of Health and Human Services found little evidence of compliance with required screenings for mental illness in nursing-home patients, which are supposed to be conducted through the Preadmission Screening and Resident Review (PASRR) system. The report found that only 47% of sampled residents had a Level 1 PASRR screen in their nursing-home records. And only 41% had any evidence of a Level II PASRR, which screens for SMIs.

Level II PASRR reviews, which are supposed to occur with any significant change in a resident's mental health condition, rarely occurred, the report said. Of the cases reviewed, only 29% of patients who had an initial Level II PASRR screening also had a review, and all those were conducted before the annual reassessment requirement was repealed in 1996.

One of the difficulties that nursing homes face is making sure that caregivers recognize the types of behaviors that could be addressed by mental health care practitioners, Meashey said. Staff training is sometimes lacking in that area, especially as it involves patients who have behavioral symptoms.

Staff members who are poorly trained may not recognize that certain behaviors are communication attempts by the patient. This can lead to abuse or neglect if the caregiver loses patience with the individual. A patient may hit a staff member as a way of communicating that they do not want to do something. This can cause the staff member to strike back in self-defense or out of frustration.

A patient with AD or dementia may need assistance with bathing or going to the bathroom, which brings up issues of dignity and privacy, Meashey said. Depending on the staff member's approach, a patient who feels vulnerable may become violent or defensive. However, a staff member who is trained to recognize violent or defensive behavior as fear or concern may use a different strategy to prevent the situation from escalating.

Behavior changes may also indicate that a disease is progressing or that the medication mix is a problem. A patient with dementia might also act out to signal pain, Meashey said. It could be an indication of a new condition, such as a sprained ankle, or even a broken hip, if the patient fell without being noticed. Staff members need to be trained to consider pain. "These are the things that if somebody's trained to think about, they might be assessing for," she said.

Articles

Despite the increasing number of elderly nursing home patients with dementia or Alzheimer's disease, there are problems providing appropriate care. Two of the major difficulties are lack of Medicare reimbursement and poor staff training. How can we better care for these elderly patients?

Many Needs But Few Psychiatric Services for Seniors in Long-Term Care

The occurrence of neuropsychiatric symptoms in dementia patients has been well established (Rovner et al., 1990). Of patients with Alzheimer's disease (AD), 78% suffer depressive symptoms, 77% have agitation and 69% have psychotic symptoms, with over half experiencing all three symptoms (Tractenberg et al., 2003). The diagnosis and treatment of mood symptoms in this population remains a challenge for physicians (Harman et al., 2002). It is important to recognize and treat these neuropsychiatric symptoms, as they result in increased morbidity, mortality and health care costs (Janzing et al., 1999). Mandatory depression screening in nursing homes can improve treatment rates (Cohen et al., 2003). 

Major depression and other, less severe forms of depression frequently form part of the clinical presentation of dementia. Depression with reversible cognitive impairment may be a prodrome for dementia rather than a separate and distinct disorder (Janzing et al., 1999).

Depression may be challenging to assess in a patient with dementia. In patients with AD, the presence of depression may range from 6% to 30%, depending on the diagnostic criteria employed (Cummings et al., 1995). The prevalence and course of depression in dementia are controversial, due to several confounding factors. Family members tend to report much greater levels of depression in patients than do clinicians.

Caregiver mood, patient's self-awareness of illness and dementia severity appear unrelated to the prevalence of depression in dementia, but the presence of delusions is positively correlated with worse mood scores (Cummings et al., 1995). Clinically significant depression in dementia may be less common than previously reported, tending to remit within a year (Copeland et al., 2003).

In one study of seniors with dementia, 11.8% had major depression, compared to only 3.9% of nondemented seniors (Forsell and Winblad, 1998). Symptoms such as lack of energy, thinking/concentration difficulties, loss of interest and psychomotor disturbance were found more commonly in people who were demented than in those who were not. 

 shows various neuropsychiatric clusters in dementia. High level of disability is associated with major depression, in both demented and nondemented people.

Depressive symptoms can be present in AD in the absence of major depression. Symptoms of sadness, diurnal mood variation and insomnia present in depression alone differentiates from depression in dementia with almost 90% accuracy (Purandare et al., 2001). Symptoms such as irritability, retardation and weight loss were common to both depression and depression in dementia. A three-year study of seniors showed that those who converted to meet clinical criteria for AD had more symptoms of personality change, such as agitation, passivity, and mild symptoms of baseline depression, than those who did not progress to AD (Copeland et al., 2003). Personality changes, but not depressive symptoms, were associated with a more rapid increase in functional difficulty over time.

Major depressive disorder can be reliably diagnosed in patients with mild-to-moderate levels of cognitive impairment (Katz, 1998). Self-ratings of symptoms with the Geriatric Depression Scale (GDS) remain valid in patients with Mini-Mental State Examination (MMSE) scores of at least 15. Some rating scales are more inclusive than others for symptoms of depression in dementia (Schaub et al., 2003). Diagnostic dilemmas are more common in patients with intermediate symptom severity, rather than mild or severe cases. Interviewer scales such as the Hamilton Rating Scale for Depression (HAM-D) and the Cornell Scale for Dementia in Depression (CSDD) are the best established (Vida et al., 1994). The CSDD is the best diagnostic scale for detecting depression in dementia. Its optimal cutoff score in a recent study was 6/7 (sensitivity=91.7%, specificity=80%) in the mild dementia group and 12/13 (sensitivity=70%, specificity=87%) in the more advanced dementia group (Lam et al., 2004). 

The clock-drawing test may be a useful way to identify depressed patients with underlying AD (Herrmann et al., 1998). They typically have significantly lower scores on clock drawing, copying and reading than either patients without underlying AD or controls. Patients with depression do not differ significantly from controls on quantitative scores or qualitative errors on clock drawing. 

In one study, approximately 25% of patients with dementia suffered from major depression and another 27% from minor depression (Ballard et al., 1996). Major depression was more common and severe in patients with vascular dementia than in patients with AD. In another study of 288 outpatients with dementia, a prevalence of 7.4% was found with HAM-D, 8% prevalence with the GDS and 6.3% with 

 criteria (Brodaty and Luscombe, 1996). Clinically significant depression in dementia did not persist over 12-month follow-up. Depressive symptoms without depressed mood were common in patients with AD and multi-infarct dementia in another study (Reichman and Coyne, 1995). Major depression was found in 10.5% of patients with AD, in contrast to 29% of those with multi-infarct dementia. Rates of vegetative or subjective symptoms of depression were the same between AD patients with or without depressed mood or anhedonia. Presence of depression, lack of insight and personality changes do not seem to differ between vascular dementia and AD (Verhey et al., 1995).

Depressed mood has been reported to lead to a two- to threefold increased incidence of dementia, particularly AD. In a study of 1,070 elderly people living in the community, depressed mood at baseline was associated with an increased risk of incident dementia (relative risk=2.94) (Devanand et al., 1996).

In contrast, a comprehensive study of 140 patients older than 60 with depression showed that depression alone does not cause cognitive impairment (Butters et al., 2004). Half of the participants showed significant cognitive problems while depressed, but the other half did not. If significant cognitive problems exist in an elderly depressed person, they are likely permanent and may worsen over time. 

Slowed information processing affecting all realms of cognition was a key finding supporting the notion that fronto-striatal dysfunction plays a key role in late-life depression. Risk factors include advanced age, low education, ventricular atrophy and depression severity. The vascular disease burden, age at onset of first depressive episode, apolipoprotein E genotype and serum anticholinergicity did not correlate (Butters et al., 2004).

In addition to pharmacological treatments (

) and electroconvulsive therapy for more severe depression, a treatment plan for depression in dementia includes nonpharmacological therapies (

) (Teri and Wagner, 1991; Teri et al., 1997). These are patient-focused interventions, as well as family or caregiver support. These interventions are very effective in milder depressions or when caregivers are depressed and should be considered first. Cognitive-behavioral therapy and pure behavior therapy for both patients and caregivers can be useful (Teri and Wagner, 1991; Teri et al., 1997). Pharmacological or nonpharmacological interventions do not totally eliminate depression in dementia symptoms, but they do decrease the symptom severity (Snowden et al., 2003). 

 lists an algorithmic approach to treatment.

Relatively few controlled studies have been done due to limitations of sample size and different defining criteria for depression in dementia and efficacy. Few placebo-controlled antidepressant trials have been conducted. Antidepressants are effective for major depression, but data for mild depression are limited. High placebo response rates are seen particularly with milder depression, but more efficacy is noted with higher drug-placebo differences in trials with more severe forms of depression (Lyketsos et al., 2003).

Only one placebo-controlled trial has been reported with a tricyclic antidepressant. There was significant benefit for both imipramine (Tofranil) and placebo in the treatment of major depression in AD, with no difference observed between the medication and placebo groups (Reifler et al., 1989). Two placebo-controlled trials of the selective serotonin reuptake inhibitor citalopram (Celexa) in elderly patients, with or without dementia, found significant improvements in depression and decreases in mood lability on citalopram (Gottfries et al., 1992; Nyth and Gottfries, 1990). Fluoxetine (Prozac) treatment did not differ significantly from placebo (Petracca et al., 2001). This study also confirmed the presence of a placebo effect in the treatment of depression in AD. Sertraline (Zoloft) showed improvement in the CSDD scores and clinical global score in some studies (Lyketsos et al., 2003, 2000). Although moclobemide (Aurorix) has been shown to be safe, well tolerated and effective, it has limited clinical usefulness (Roth et al., 1996). 

Antidepressant treatment often produces clinical improvement in 50% to 60% of patients with depression (Schneider and Olin, 1995), and side effects, particularly cardiovascular and anticholinergic, may be limiting (Moskowitz and Burns, 1986). Less improvement is noted with antidepressants in patients with white matter hyperlucencies and lacunar infarcts (Simpson et al., 1998, 1997). The efficacy of ECT appears particularly high in late-life depression (Flint and Rifat, 1998) and is safe for cardiac patients (Rice et al., 1994). No brain damage has been shown with ECT, but temporary cognitive problems can be frequent (Devanand et al., 1994; Scott, 1995).

A case series of 31 patients showed that ECT is effective, leading to improvements in both mood and cognition (Rao and Lyketsos, 2000). Multiple ECT treatments may be necessary before a significant improvement is achieved. Electroconvulsive therapy appears to be acceptable in terms of safety, but may need to be administered in lower doses and frequency than in nondemented patients.

In summary, depression in dementia is a common condition with a great impact on the quality of life of both patients and caregivers. It must be identified and treated promptly. Nonpharmacological and pharmacological therapies are helpful, but ECT may be needed in some cases. Depression in dementia is poorly understood in terms of prevalence and etiology, making it a challenge to conduct clinical trials and treat effectively.

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It has been well established that there is a high incidence of depression in conjunction with Alzheimer's disease and other forms of dementia. What are the best assessment and diagnostic methods, and which treatments will produce the best results?

Depression in Dementia: Diagnosis and Treatment

Multiple epidemiological studies have shown that depression is the most frequent comorbid psychiatric disorder in patients with epilepsy (Kanner and Balabanov, 2002). Prevalence rates range from 20% to 55% in patents with recurrent seizures and 6% to 8% in patients with well-controlled seizures (Hauser and Kurland, 1975; Kogeorgos et al., 1982; Mendez et al., 1986; Mungas, 1982; Robertson et al., 1987). In addition, suicide is one of the most common causes of death in patients with epilepsy (Barraclough, 1987; Robertson et al., 1987); it was found to be almost 10 times more frequent in these patients than in the general population (Robertson et al., 1987). In a study carried out in a group of patients with refractory epilepsy admitted to a video-electroencephalogram monitoring unit, Boylan and colleagues (2004) found 50% of the patients were depressed, 19% had suicidal ideation, and only 17% were being treated with antidepressant medications. Despite the high prevalence of depression and suicide risk, depression often goes unrecognized and untreated in these patients. Reasons for this include: 

Treating physicians pay attention only to seizure control and fail to inquire about the presence of psychiatric symptoms;

Patients are hesitant to report mood changes, and when they do, they tend to minimize them out of fear of being thought of as crazy;

Physicians and patients often consider symptoms of depression to be a normal adaptation process to epilepsy and its associated problems; and

A fear among clinicians that antidepressant drugs can exacerbate the underlying seizure disorder prevents many patients from receiving treatment even when the need for antidepressant treatment is recognized.

The goal of this article is to highlight the importance of recognizing, preventing and treating depression in patients with epilepsy.

. Many investigators have tried to find an association between depression and epilepsy with respect to age of onset and seizure type, frequency, and duration (Indaco et al., 1992; Kogeorgos et al., 1982). Depression has been identified more frequently in patients with seizures involving limbic structures (predominantly temporal and frontal lobes) and less often in patients with generalized seizure disorders. Laterality of seizure focus also has been considered as a possible risk factor, with seizure disorders of left hemispheric origin being more likely to be associated with depression (Mendez et al., 1986). This association has been questioned by several investigators, however. There is evidence that seizures originating in or propagating to the frontal lobes increase risk of depression. For instance, patients with left temporal focus and depression have been found to display bilateral inferior frontal hypometabolism on both positron emission tomography (PET) and single proton emission computed tomography (SPECT) studies (Bromfield et al., 1992). In fact, decreased frontal metabolism on PET and SPECT has been found in primary depression (Musselman et al., 1998).

Do depression and epilepsy share common pathogenic mechanisms? Twenty-six centuries ago, Hippocrates was the first to suggest a bidirectional relationship between epilepsy and depression when he wrote (Lewis, 1934):

Melancholics ordinarily become epileptics, and epileptics melancholics: what determines the preference is the direction the malady takes; if it bears upon the body, epilepsy, if upon the intelligence, melancholy.

This observation has been supported by population-based, controlled studies published in the past 10 years. Forsgren and Nystrom (1990) conducted a population-based, case-controlled study of patients with newly diagnosed epilepsy in Sweden. They discovered that patients with epilepsy were six times more likely than controls to have experienced a history of depression prior to the onset of the seizure disorder. In a separate study, Hesdorffer et al. (2000) conducted a population-based, case-controlled investigation of the prevalence of new-onset epilepsy among adults ages 55 and older and showed that compared to controls, patients were 3.7 times more likely to have had a history of depression prior to the onset of their seizure disorder. These researchers controlled for the impact of medical therapies for depression on seizure occurrence.

These data do not suggest that depression causes epilepsy or vice versa, but they do suggest that the two disorders may share common pathogenic mechanisms. Indeed, epilepsy and depression may share common pathogenic mechanisms mediated by abnormal serotonergic, noradrenergic, 

-aminobutyric acid (GABA)-ergic and dopaminergic secretion in the central nervous system (Jobe et al., 1999; Ronald and Duman, 1999; Schildkraut, 1973, 1965). In primary depression, decreased activity of these neurotransmitters has been identified as one of the pivotal pathogenic mechanisms and the basis for antidepressant pharmacologic treatment (Garlow et al., 1999; Maes and Meltzer, 1995; Richelson, 1991). In animal models of epilepsy using the genetically epilepsy-prone rat, decreased activities of serotonin and norepinephrine have been shown to facilitate the kindling process (Jobe et al., 1999, 1995; Lehmann, 1967; Meldrum et al., 1982), exacerbate the seizure severity and intensify seizure predisposition. Other common pathogenic mechanisms for primary depression and epilepsy include disturbance of mesial temporal structures, particularly amygdala and hippocampal formation, which have been found to be atrophic in both disorders (Mathern et al., 1997; Sheline, 2003).

. Patients with epilepsy are subjected to discrimination and lack of acceptance. Significant risk factors for the development of depression include the stigma of having epilepsy; the lack of social support; the need to make significant adjustments in lifestyle, such as giving up driving privileges or having to change jobs; and the limited educational and employment opportunities. The individual's sense of lack of control over their life may result in overall fear of seizures and agoraphobic behavior that may not correlate with the actual severity of seizure activity. In addition, sexual dysfunction has been a very prevalent problem among patients with epilepsy, with rates ranging from 14% to 66% (Morrell, 1991). Although biologic and medication factors are largely causative, they clearly facilitate the development of decreased self-esteem and depression.

. Antiepileptic drugs can cause psychiatric symptoms, especially depression. Phenobarbital (Luminal), felbamate (Felbatol), primidone (Mysoline), tiagabine (Gabitril), vigabatrin (Sabril), topiramate (Topamax) and levetiracetam (Keppra) are known to cause depressive episodes (Barabas and Matthews, 1988; Brent et al., 1987; Collaborative Group for Epidemiology of Epilepsy, 1986; Ferrari et al., 1983; McConnell and Duncan, 1998; Ring and Reynolds, 1990; Smith and Collins, 1987). In addition, cognitive side effects associated with some of these drugs (e.g., topiramate) are closely associated with previous or current history of depression (Kanner et al., 2000a). Carbamazepine (Tegretol) and valproic acid (Depakene) are anti-epileptic drugs with mood-stabilizing effects, but can occasionally cause depressive symptoms as well (Smith and Collins, 1987).

Depression and other psychiatric complications have been seen after epilepsy surgery and especially following an anterior temporal lobectomy for the treatment of pharmacoresistant temporal lobe epilepsy (Savard et al., 1998). It is actually not unusual to see mood lability within the initial six weeks after the surgery. Most of the time these symptoms subside, but in up to 30% of the patients, overt symptoms of depression become evident within the first six months. Patients with prior history of depression are at greater risk. The development of this depression is independent of the postsurgical seizure control.

Depression in patients with epilepsy can be the expression of a relatively rare phenomenon known as 

. It consists of the development of psychiatric symptoms following the cessation of seizures in patients whose seizures had failed to be controlled for a long time. Worsening of interictal depression in patients when seizure control is achieved may also be an expression of this phenomenon (Robertson, 1998).

Depressive symptoms and disorders can be classified according to their temporal relation to seizure occurrence. Depressive symptoms can present during the 48 to 72 hours preceding a seizure (pre-ictal symptoms of depression), they can be an expression of an actual seizure (ictal symptoms of depression) or can occur within 120 hours after a seizure (postictal symptoms of depression). Symptoms that precede or follow are referred to as 

. Depression can also occur unrelated to the seizure occurrence (interictal depression). Often, patients experience symptoms of depression during both peri-ictal and interictal periods with an exacerbation in severity of symptoms during the postictal period.

. There are a few reports in the literature of pre-ictal depression, which typically presents as a cluster of dysphoric symptoms for hours or up to three days before the onset of seizures. Blanchet and Frommer (1986) studied mood changes over 56 days in 27 patients who were asked to rate their mood daily. Mood ratings pointed to symptoms of dysphoria, anxiety and irritability three days before a seizure in 22 patients. This change in mood was more accentuated during the 24 hours preceding the seizure. It should be noted that in children, these dysphoric moods take the form of irritability, poor frustration tolerance, motor hyperactivity and aggressive behavior.

. Ictal symptoms of depression are the expressions of a simple partial seizure (aura) in which the symptoms of depression are its sole (or predominant) semiology. It has been estimated that psychiatric symptoms occur in 25% of auras; 15% of these involve affect or mood changes (Daly, 1958; Mulder and Daly, 1952; Weil, 1959, 1955). Ictal depression ranked second after anxiety/fear as the most common type of ictal affect in one study (Weil, 1959). When mood changes represent the only clinical expression of simple partial seizures, it may be difficult to recognize them as epileptic phenomena. Typically, they are brief, are stereotypical, occur out of context with the patient's activity and are associated with other ictal phenomena. The most common symptoms include feelings of anhedonia (inability to experience pleasure in anything), guilt and suicidal ideation. More typically ictal symptoms of depression are followed by alteration of consciousness as the ictus evolves from a simple to a complex partial seizure.

. Recognized for a very long time, postictal symptoms of depression have been recently studied in systematic matter in a study completed in our center, where we investigated the presence of postictal psychiatric symptoms in 100 consecutive patients with poorly controlled partial seizure disorders (Kanner and Balabanov, 2002; Kanner et al., 2004). Patients were given a 42-item questionnaire designed to identify psychiatric symptoms occurring in the postictal period, defined as 72 hours following recovery of consciousness from the last seizure. The following symptoms of depression were investigated: anhedonia, irritability, poor frustration tolerance, feelings of hopelessness and hopelessness, suicidal ideation, feelings of guilt and self-deprecation, and crying bouts. Five neuro-vegetative symptoms (changes in pattern of sleep, appetite and sexual drive) were analyzed separately, as they are common postictal symptoms not associated with symptoms of depression.

A total of 43 patients (43%) experienced a median of five postictal symptoms of depression after more than 50% of their seizures. Patients estimated a median duration of 24 hours in two-thirds of the symptoms they experienced. Thirty-five patients experienced at least two postictal symptoms, with a minimum duration of 24 hours; in 13 of these patients, at least seven symptoms clustered to mimic symptoms of a major depression lasting 24 hours or longer. Thirteen patients reported habitual postictal suicidal ideations. Thirteen patients exclusively experienced symptoms of depression, whereas in the other 30 patients, we identified concurrent postictal symptoms of anxiety and a combination of depression, psychosis and anxiety. It should be noted that postictal symptoms of depression were significantly associated with more postictal cognitive deficits.

Clearly, these data show that postictal symptoms of depression are relatively common in a sample of patients with poorly controlled epilepsy. It remains to be investigated whether this observation applies to patients with rare seizures. It should be kept in mind that the symptoms of postictal depression can last up to two weeks after the seizure occurrence. At times, this can lead to suicide attempts; therefore, close follow up of patients with known postictal depression is necessary.

. Interictal depression is the most commonly recognized presentation of affective disorders among patients with epilepsy (Altshuler et al., 1990; Blumer and Altshuler, 1998; Blumer and Zielinski, 1988; Blumer et al., 1995; Kanner and Palac, 2000). Interictal depression can present as major depressive disorder or any of the other mood disorders included in the 

 classification. In our opinion, however, a large number of patients with epilepsy do not meet 

 criteria for these mood disorders, rather they have pleomorphic cluster of symptoms of depression with a chronic course that is interrupted by recurrent symptom-free periods of hours to several days duration. This clinical presentation closely resembles a dysthymic disorder. Blumer et al. (1995) referred to this atypical form of depression as interictal dysphoric disorder. According to Blumer (1991), almost one-third to one-half of patients with epilepsy suffer from interictal dysphoric disorder of sufficient severity to require pharmacologic treatment. Blumer described the interictal dysphoric disorder as a chronic dysthymic state in which symptoms tend to occur intermittently and are intermixed with brief euphoric moods, explosive irritability, anxiety and somatoform symptoms (e.g., anergia, atypical pain and insomnia), which have been considered as depressive equivalents (Blumer, 1991; Blumer and Zielinski, 1988; Blumer et al., 1995). Despite the fact that interictal depression presenting as interictal dysphoric disorder is so prevalent among our patients, it usually goes unreported by patients and unrecognized by clinicians. Patients eventually assume that their symptoms reflect a natural state that is part of their epilepsy. Physicians overwhelmed with the goal to achieve seizure control very often miss detecting symptoms of depression, even in patients they have followed for a long time. Clinicians should carefully inquire about symptoms of depression as an integral part of their evaluation of seizure disorder.

Many clinicians are reluctant to use antidepressant medications in patients with known seizure disorder because of fear that the antidepressant drugs can worsen the seizure disorder. However, is that a legitimate concern? Antidepressants have been associated with increased risk of seizure in nonepileptic patients at high plasma serum concentrations or when given at rapid dose increments (Preskorn and Fast, 1992). Other risk factors include known CNS pathology, abnormal EEG, and personal and family history of epilepsy (Curran and de Pauw, 1998; Swinkels and de Jonghe, 1995). If this is the case, then do antiepileptic drugs protect patients with epilepsy from the proconvulsant properties of these drugs?

Blumer and colleagues (1995) have reported using tricyclic antidepressants in combination with selective serotonin reuptake inhibitors in patients with epilepsy, without seizure exacerbation. In a study done in our center by Kanner et al. (2000b), only one of 100 patients had worsening of seizures when treated with sertraline (Zoloft). In our opinion, SSRIs should be considered drugs of first choice for treatment of depression in patients with epilepsy (Kanner and Balabanov, 2002). Being inhibitors of the enzymes of the cytochrome P450 system, some SSRIs, such as fluoxetine (Prozac), fluvoxamine (Luvox) and to some degree paroxetine (Paxil), have pharmacokinetic interaction with antiepileptic drugs (Fritze et al., 1991; Grimsley et al., 1991; Pearson, 1990). Of note, citalopram (Celexa) does not have any pharmacokinetic impact on the metabolism of the antiepileptic drugs (Kanner and Balabanov, 2002). Selective serotonin reuptake inhibitors also have more favorable adverse-effect profiles and are less likely to result in fatalities after an overdose. They have good efficacy in the treatment of symptoms of irritability and poor frustration tolerance, which are symptoms often seen in patients with epilepsy. Venlafaxine (Effexor), a reuptake inhibitor of norepinephrine and serotonin, is a drug of choice for patients who failed to respond to SSRIs. Monoamine oxidase inhibitors are not known to cause seizures in nonepileptic patients (Schiwy et al., 1989). Bupropion (Wellbutrin), maprotiline (Ludiomil), amoxapine (Asendin) and clomipramine (Anafranil) are the antidepressant drugs with the strongest proconvulsant properties and should be avoided in patients with epilepsy. Neurotoxicity of lithium (Eskalith, Lithobid) can cause a change of EEG recordings and has been reported to increase seizure frequency; therefore, it should be used with caution (Bell et al., 1993). Finally, it should be noted that electroconvulsive therapy is not contraindicated in depressed patients with epilepsy (Coffey et al., 1995; Regenold et al., 1998; Sackheim, 1999; Sackheim et al., 1983).

Psychotherapy is an important addition to pharmacological treatment. Counseling and psychotherapy can be very useful in helping the patient deal with the stressors and limitations of living with epilepsy. Patients involved in psychotherapy not only improve in scales of depression and anxiety but also show a decline in seizure frequency (Gillham, 1990).

Clinicians should keep in mind that in patients with refractory epilepsy, mood disorders and adverse events have a greater impact on patients' quality of life than the actual seizure frequency or severity (Boylan et al., 2004). Therefore, treatment of the seizure disorder without treating the eventual comorbid depression is incomplete and inappropriate.

Depression is a common comorbidity in patients with epilepsy. Depression is frequently unrecognized and untreated by the physicians taking care of patients with epilepsy. The depression that occurs in patients with epilepsy is not necessarily as easy to recognize when not presenting as major depression; therefore, clinicians have to inquire about symptoms of depression when evaluating patients with epilepsy. The treatment of depression is of high importance for a patient with epilepsy, since it is strongly associated with the patient's quality of life.

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The relationship between depression and epilepsy is bidirectional as not only are patients with epilepsy at higher risk of developing depression but patients with depression have a three- to sevenfold higher risk of developing epilepsy. Several studies have found that the presence of depression in patients with intractable epilepsy was a stronger predictor of poor quality of life than the frequency and severity of seizures. The principles of managing depression in epilepsy are reviewed in this article.

Unrecognized and Untreated: Preventing and Treating Depression in Patients With Epilepsy

The plight of the Falun Gong in China is no longer a front-page story in the West, but allegations that Chinese psychiatrists were involved in their persecution continues to trouble the World Psychiatric Association (WPA) (Stone, 2002b). The new China with its political and economic power on the world stage has been able to block investigations by the United Nation's Commission on Human Rights and to brush aside the many vociferous critics of its human rights record. That powerful China was on display for the millions of people who watched the splendid pageantry at the 2004 summer Olympics closing ceremonies in Athens, Greece, as a proud Chinese nation invited the citizens of the world to Beijing for the next summer Olympics in 2008. A triumphal Chinese state with a new younger regime in place and a growing sense of national pride may be more willing to acknowledge past mistakes, but it is unlikely to allow its human rights critics to rake up the many unresolved allegations: Tibetan Buddhism, suppression of the pro-democracy movement and a litany of other serious human rights complaints including the persecution of the Falun Gong (Amnesty International Testimony, 2002).

The WPA, responding to complaints and a resolution of its General Assembly members, had joined the active ranks of China's human rights critics and had been attempting to arrange for an independent investigation of the allegations of systematic political misuse of psychiatry in China. In January, after a meeting in Beijing with representatives of the Chinese Society of Psychiatrists (CSP) and a vice minister of health, the WPA leadership reported that the Chinese had acceded to the Yokohama Resolution and would permit an independent investigation (WPA, 2004). This, if true, was an astonishing achievement; such an agreement was without precedent in China's international dealings.

The WPA executive committee, meeting in Cairo, Egypt, in February 2004, appointed a task force of experts to carry out that investigation. (This writer was included on the task force.) The task force met in London in March 2004 and after reviewing the allegations that had been submitted to the WPA's Review Committee prepared a detailed agenda for its visit that was forwarded to the CSP. The investigation would have included face-to-face interviews with Falun Gong practitioners, their families, the psychiatrists who treated them and an examination of the relevant medical records at various psychiatric facilities. It should be emphasized that the WPA is not an organization with resources, procedures and technical infrastructure to carry out fact-finding investigations nor does it have the authority to subpoena witnesses, collect independent evidence or other similar activities. Nonetheless the task force made a good faith effort to prepare for the independent fact-finding investigation called for in the Yokohama Resolution. It was clear that the success of the task force would depend on the cooperation of not only the CSP but also the Chinese authorities. I must confess that I had many unresolved questions about the enterprise and was particularly concerned that the doctors, patients and families who cooperated with the investigation might suffer reprisals and that the WPA could not assure their protection.

The CSP, late in March 2004 and only days before the task force was scheduled to arrive in Beijing, rejected the proposed agenda. Their response--unlike previous communications with the WPA--took the standard hard-line position that the Chinese state had adopted in responding to all of the previous international criticisms of its persecution of the Falun Gong, namely that this was a domestic criminal matter, not an issue for outsiders. It seemed clear to me that Chinese government officials had intervened and quashed the investigation. The WPA was back to square one, in much the same position that other human rights critics of China had found themselves. The idea of an independent fact-finding investigation as planned by the task force now was out of the question.

Despite their disappointment the WPA leadership did not respond with confrontation or by threatening the CSP with expulsion as some critics might have wished. World Psychiatric Association's President Ahmed Okasha, M.D., remained calm in the eye of the storm. He maintained a cordial relationship with the CSP and was willing to consider alternative approaches. I made certain proposals to him in the hope we could get beyond the impasse. An unprecedented meeting was scheduled between the WPA and the CSP that took place in New York on May 4 (WPA, 2004). With the encouragement of Okasha, I had prepared three resolutions for that meeting in the hope that if there could be no independent investigation, a new approach based on negotiation and conflict resolution might break the stalemate in which China simply denied all allegations. If the CSP could acknowledge that there were, in fact, real clinical problems in the diagnosis and treatment of members of the Falun Gong, then I thought there might be a basis for continuing international collaboration and perhaps constructive change.

The key psychological issue from my perspective was to find a way to allow the CSP to acknowledge that there were serious problems without losing face and without risking reprisals from their own government. This, if it could be done, would provide a basis for continuing collaboration between the WPA and the CSP. Since there could be no independent fact-finding investigation as originally planned, this seemed a small step forward. The CSP--to the surprise of many--agreed in principle to the proposals. Confusing and misleading reports of the WPA and CSP agreement, however, have produced a swirl of controversy and condemnation (Hausman, 2004).

The points of greatest controversy involve the WPA's conciliatory reaction to China's decision not to permit the independent fact-finding investigation, the idea that some secret deal was made, and that language in the reported agreement between the WPA and CSP indicated that the WPA had somehow decided that there was no systematic abuse of psychiatry in China. I shall discuss these matters further but here it should be said that the language about no systematic abuse was not in my proposals. None of the evidence reviewed by the task force would justify such a finding. Okasha, in an editorial "On the China Issue" in October 2004, recently confirmed that understanding. It should be emphasized that some members of the WPA leadership believe that in some sense they are still pursuing the specific objectives of the Yokohama Resolution. My own personal opinion is that the Chinese government has made those objectives impossible and that future collaborations between the WPA and the CSP will require negotiation, not unilateral demands. In what follows, I shall describe the Falun Gong spiritual movement, review the allegations of abuse, and present my own personal views of China's rejection of the task force investigation and the results of the joint meeting with the CSP held in New York.

A chronicle of the Falun Gong's emergence and its relation to other millennial movements throughout the long history of China has now been published (Chang, 2004), and it should provide psychiatrists a more objective understanding of the broader religious cultural issues than was previously available. Chang's explanation, which is similar to that of other experts on China, is that the Falun Gong spiritual/alternative healing movement filled a vacuum that appeared in Chinese life in 1982 with the collapse of Maoism as a coherent ideology, the turn to a market economy that left behind many sectors of the population, and the growing gaps in China's provision of health care to its citizens (Forney, 2001). In less than two decades the Falun Gong movement numbered in the millions. The Internet was the "medium" that allowed the Falun Gong to recruit members across the Provinces of China.

Chang describes the landmark protest of April 25, 1999, when the courageous Falun Gong "defied the state." Jiang Zemin, then president of China, was driven in his personal limousine through the crowd of 10,000 to 16,000 Falun Gong practitioners who gathered unexpectedly for a peaceful demonstration at the high-walled compound in Beijing where the leaders of China work and live. Jiang, peering through the tinted glass windows, was reportedly shocked to see members of the communist party, minor government officials, middle-aged and elderly people; these were not the young political upstarts of the pro-democracy movement who had rallied 10 years before in Tiananmen Square. What Jiang saw for himself was a well-behaved group of older Chinese citizens defying their government, holding in their hands the blue book of their leader, Master Li Hong-Zhi.

Chang has carefully worked her way through Master Li's writings and she characterizes the Falun Gong as a millennial movement, the title of her book is 

. This is not the prevailing understanding in the West, but it is central to her thesis. The respectability and decorum of the Falun Gong protesters averted an immediate repressive reaction. But in the weeks that followed it became clear to the government that the Falun Gong numbered in the millions, and they were prepared to militantly protest any public derogation of their practices or of their leader. Jiang Zemin, Chang tells us, was well aware that throughout the history of China millennial groups had toppled governments. Chang provides a brief overview extending from the 1st to the 20th century: the Yellow Turbans, the Mahayan Rebellion, the White Lotus, the Eight Trigrams, the Taiping Rebellion, the Boxers. She believes that several of the early communist leaders of the 20th century began in similar groups. Chang's account of this history and the amazingly rapid growth of the Falun Gong in China explain for the first time why Jiang Zemin and the Chinese government embarked on its cruel campaign of persecution against a non-political movement.

If Chang explains what happens, she certainly does not excuse it. With remarkable objectivity she goes through the catalogue of Falun Gong beliefs and practices. Unlike human rights advocates and most of the Western media, she has made it clear that Falun Gong is not just about people practicing a variant of traditional Chinese exercises and abiding by the moral law of Zhen, Shan and Ren (truth, benevolence and forbearance). Those little blue books the Falun Gong protesters were holding contain the revelations of Master Li Hong-Zhi. Li has proclaimed himself divine and only he can teleport the law wheel (the Falun) into the practitioner's body. The Falun with his help will restore youth and health and will get rid of the bad karma.

Li tells his followers, "If I cannot save you nobody else can" (Chang, 2004). He claims to be superior to Jesus and the Buddha Sakyamuni who appeared here on earth, while he is "not of the universe" (Chang, 2004). He has claimed that he can fly, walk through walls and has many other supernatural powers (Chang, 2004). Li's revelations about aliens here on earth and the threat they pose to humanity (e.g., their harmful science with its Western technology and medicine), their goal of obtaining our perfect human bodies and so on are carefully detailed. The dubious reader can confirm or deny Chang's evaluation by consulting the writings of Li that are available on the Web (Hong-Zhi, 1998).

For psychiatrists the crucial lesson in Chang's exposition is that Falun Gong practitioners have accepted Li's teachings as their personal and spiritual reality. For example, they believe--according to those teachings--that Li has implanted the wheel of law into their abdomens and the more advanced practitioners can actually feel it rotating. They feel this even though Li has said the Falun exists in a different dimension. (The Falun is the Buddhist symbol appropriated by the Nazis and known in the Western world as the swastika.) This implanted wheel is the Falun Gong practitioners' indoctrinated and widely shared spiritual belief, not a bizarre somatic delusion. They believe that the wheel is protecting their health and rejuvenating them. Ironically, Chinese psychiatrists unfamiliar with the Falun Gong's teachings have cited the patient's belief that he has a wheel in his abdomen as the obvious proof of their diagnosis that a practitioner was psychotic. Chinese psychiatrists who reviewed these reports failed to recognize these "proofs" as failures to understand the spiritual beliefs of their patients.

Chang identifies Li's revelations as a syncretic blending of Buddhism, Daoism, classical Chinese folk religion, magic and unidentified flying objects. However, she makes it quite clear that the Falun Gong is not the evil cult portrayed by the Chinese authorities. This is a much more balanced and contextual account than was previously available to psychiatrists and it is striking that, in her description of the persecution of the Falun Gong, Chinese psychiatrists are not at the forefront of their government's aggressive measures nor is systematic misuse of psychiatry central to the suppression of the Falun Gong. Furthermore, her account explains why an ethical psychiatrist unaware of Falun Gong beliefs might honestly, if incorrectly, think a practitioner was mentally ill.

As we know from other accounts, Jiang Zemin decided in 1999 to eradicate the Falun Gong (Ping, 2003). To that end the government created a special office, The 610, with plenipotentiary authority to root the Falun Gong out of Chinese society. Laws were passed criminalizing the Falun Gong. A propaganda campaign was initiated at home and abroad that labeled the Falun Gong an "evil cult." The founder of the Falun Gong was declared a criminal and--since he had already fled to the United States--China demanded his extradition. Chinese authorities identified "leaders" of the Falun Gong, arrested them and sent them to prison. Practitioners who nonetheless persisted in gathering and protesting were met with police brutality and sent to temporary holding areas, jails, prisons and labor camps.

China, which had abandoned Maoist ideology, imposed a new more cynical/thought reform: Work and suffer until you repent your Falun Gong practices and belief. Claims of torture by police and by guards in labor camps were widely reported (Carlyle, 2002). Thousands of Falun Gong practitioners were arrested and since the government's conservative estimate was that at least 2 million Chinese had joined the movement there were plenty of potential victims. As the government's oppression increased, Falun Gong resistance became more assertive, practitioners took over a television broadcasting system to get out their own message. The Falun Gong's access to the Internet made possible coordinated efforts with minimal organizational infrastructure. These and similar activities led to additional criminal charges and harsher measures by the government (Carlyle, 2002).

The repression of the Falun Gong in its early stages apparently did not include psychiatric intervention. Psychiatric hospitalization was not the Chinese government's first line of attack on the Falun Gong. Thus the condemnation of China's persecution of the Falun Gong began with allegations that the legislative measures openly taken by the Chinese government constituted persecution of a religion. That indictment was somewhat complicated by Li's insistence that the Falun Gong was not a religion. The Chinese government, in defending its assertion that the Falun Gong was an evil cult not a religion, relied on Li's own repeated statement. Chang's conclusion is that the Falun Gong is not an evil cult but can be considered a millennial religious sect.

But perhaps more important than China's public statements and propaganda was the reality of the new China with its economic and political power. It was that power that made it possible for China to fend off the U.N. Human Rights Commission's investigations, enlisting such unlikely voting allies as South Africa. And China has either threatened economic reprisals or simply shrugged off the repeated condemnations by the United States, many European nations and other supporters of the Falun Gong.

China's persecution of the Falun Gong was obviously not the first occasion for human rights groups to focus on China. The ruthless and bloody suppression of the pro-democracy movement after the student demonstrations in Tiananmen Square in 1989 mobilized China's human rights critics and led to the formation of dedicated organizations like Human Rights in China, who monitored and publicized China's record of human rights abuses. But the members of the pro-democracy movement lacked the solidarity, the commitment and the numbers that the Falun Gong would demonstrate 10 years later (Ping, 2003). Li has claimed 60 million followers in China and 100 million around the world, and they made their cause known around the world. The political and human rights supporters of China's pro-democracy movement, despite some misgivings about Li's belief system and his influence over his followers, rallied behind the campaign to publicize China's persecution of the resolute and highly visible Falun Gong.

One reason the WPA's effort became a focus of so much human rights attention is that more than psychiatry and the Falun Gong was at stake. The WPA was attempting to do what neither the U.N. Human Rights Commission nor any other governmental or nongovernmental human rights group had been allowed to do: conduct an independent fact-finding investigation inside China.

Some proponents of the WPA investigation--relying on an expose by Robin Munro, 

--wanted the task force investigation to go beyond the Falun Gong. They wanted to include China's political dissidents who for decades allegedly have been subjected to Soviet-style psychiatric abuse in special secure institutions known as Ankang facilities that are controlled not by psychiatrists but by China's security officials. Munro claims that psychiatrists, and particularly forensic psychiatrists, have been active since the days of Chairman Mao in the systematic misuse of psychiatry for political purposes (Munro, 2001, 2002). His supporters wanted the WPA to extend its investigative task force in that political direction using the Falun Gong as a Trojan horse for the larger agenda of alleged human rights abuse extending back to the thought reform of Mao now characterized as a form of psychiatric abuse perpetrated by forensic psychiatrists. Many psychiatrists endorse Munro's expose, as do the watchdog groups that are concerned about psychiatric abuse (Mirsky, 2003).

I confess that, in my opinion, it is an account so flawed and misleading that it cannot and should not be relied on as evidence (Stone, 2002a). But putting my personal judgment about the substance of these views aside, it is difficult to imagine how any fact-finding investigation of Munro's allegations involving political dissidents, most of which took place decades ago, could be carried out without the consent and the cooperation of the entire Chinese government, its security forces, military leaders and the major stakeholders in the Chinese Communist Party. Does anyone seriously believe the CSP, at the behest of the WPA, has the power and influence to demand that from its government?

In stark contrast to Munro's allegations about the treatment of political dissidents constructed from his layman's reading and tendentious extrapolations of Chinese psychiatric publications were the hundreds of contemporaneous reports of psychiatric abuse of the Falun Gong. These reports identified specific Falun Gong practitioners, named psychiatric hospitals, the medical personnel involved and what allegedly had been done to these people in the hospital. There were too many of these complaints and too much in them to be ignored by responsible psychiatrists concerned about the ethical standards of their profession. This must be said even if one takes into account the fact that under the law of China in force at the time, Falun Gong practitioners were criminals who insisted on continuing their criminal pursuits, that all Chinese citizens had been called on to condemn the Falun Gong as an evil cult, that the majority of Chinese psychiatrists had little or no understanding of the Falun Gong's beliefs, and that those who did know about it considered Li a madman who was leading his followers into madness.

Working with three Harvard Law student research assistants I reviewed hundreds of accounts of Falun Gong psychiatric abuse reported from all over China. (These reviews were done before I was appointed to the WPA task force.) The pattern of hospitalization differed in different provinces and did not suggest the implementation of a uniform government policy. A significant number of the reported cases were Falun Gong practitioners who had been sent on from labor camps where they had suffered terribly. They may well have been tortured and then dumped in psychiatric hospitals as an expedient disposition. The hospitalizations were initiated not by psychiatrists but by local security forces and the local authorities. There were reports of Falun Gong practitioners who were rounded up and brought in groups to psychiatric hospitals. Some were taken from protests, others from trains as they persisted in their attempts to go to Beijing to protest. Family members who felt threatened by the authorities brought others. The Falun Gong hospitalizations certainly did not follow the pattern of Soviet psychiatry portrayed by Munro in 

, no forensic psychiatrists were involved and the patients were not being sent to the special Ankang facilities. Putting Munro's claims aside, the Falun Gong reports of psychiatric abuse posted on the Web and compiled in pamphlets established a practical basis for a factual investigation. Even that proved problematic.

None of the U.S. government or academic experts on international law with whom I consulted believed that China would permit an independent fact-finding investigation even if narrowly limited to the allegations of psychiatric abuse of the Falun Gong. Letting a delegation of the WPA into their psychiatric facilities with a license to interview anyone we chose would open doors that China's government wanted to keep closed for the foreseeable future. The experts proved right, as China's rejection of the independent investigation in March 2004 demonstrated. My own opinion is that the WPA made the mistake of thinking that a vice minister of health had the authority to finally decide such an unprecedented and important political matter.

There is, however, reason to believe that in 2004 the Chinese government is easing in its repression of the Falun Gong. A leading spokesperson for the Falun Gong in the United States personally reported to me that the new Chinese leadership (Jiang Zemin is no longer in control) recognizes that the Falun Gong is not a political threat and should be distinguished from the pro-democracy movement. It is also clear that China's cruel campaign against the Falun Gong seems to have worked and therefore government concern has lessened and for a variety of reasons public opinion in China has turned against the Falun Gong. Falun Gong protest in China has decreased based on a continuing review of Internet reports and there has been a significant decline in new allegations of punitive measures and forced psychiatric hospitalizations. Furthermore, the CSP, which is controlled by the state, has for the past three years shown itself willing to investigate the alleged Falun Gong abuses. Now they are willing to work with the WPA to remedy the mistakes of the past. It may seem to be too late and too little for those who suffered, but it may now be possible for the CSP, with the help of the WPA, to protect Falun Gong practitioners from further psychiatric abuse.

Allegations of complicity by Chinese psychiatrists in abuse and persecution of members of the Falun Gong continues to trouble the World Psychiatric Association. Are the steps being taken to learn the truth enough? Dr. Stone provides a look at the events that have unfolded to date.

Psychiatric Times Vol 21 No 13

Many Needs But Few Psychiatric Services for Seniors in Long-Term Care

Depression in Dementia: Diagnosis and Treatment

Unrecognized and Untreated: Preventing and Treating Depression in Patients With Epilepsy

The Plight of the Falun Gong