May 2010

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DEMONSTRATION Katherine Ellison prepared for a test of attention deficit hyperactivity disorder with help from Dr. M. Randall Bloch in California.

WALNUT CREEK, Calif. — I’m sitting in front of a gray plastic console that resembles an airplane cockpit. Each time I move, a small reflector on a makeshift tiara resting on my forehead alerts an infrared tracking device pointing down at me from above a computer monitor.

TASK ORIENTED Katherine Ellison using the Quotient A.D.H.D. System

Watching the screen, I’m supposed to click a mouse each time I see a star with five or eight points, but not for stars with only four points.

It’s a truly simple task, and I’m a college-educated professional.

So why do I keep getting it wrong?

Halfway into the 20-minute session, I find myself clicking at a lot of four-point stars, while sighing and cursing with each new mistake and stamping my feet, sending further unflattering information to the contraption via tracking straps taped to my legs.

Dr. Martin H. Teicher, the Harvard psychiatrist who invented the test, has an explanation for my predicament.

“You have some objective evidence for an impairment in attention,” he said — in other words, a “very subtle” case of attention deficit hyperactivity disorder. (Indeed, I had already received a diagnosis three years earlier.) Not only did I click too many times when I shouldn’t have, and occasionally vice versa, but subtle shifts in my head movements, tracked by the device’s motion detector, suggested that I tended to shift attention states, from on-task to impulsive to distracted and back.

Dr. Teicher’s invention, the Quotient A.D.H.D. System, is only one of several continuing efforts to find a biomarker — i.e., distinctive biological evidence — for this elusive disorder.

Most mainstream researchers consider A.D.H.D. to be an authentic neurological deficit that, left untreated, can ruin not only school report cards, but lives. Nonetheless the quest for objective evidence has gained new urgency in recent years.

Many critics say the disorder is being rampantly overdiagnosed by pill-pushing doctors in league with the drug industry, abetted by a culture of overanxious parents and compliant educators.

These critics say that the standard treatment — stimulant medications like Ritalin and Adderall — carries a high risk for side effects and abuse in children whose attention problems might have no biological cause.

Yet despite the perils of faulty diagnosis, the most common way of detecting the disorder has nothing directly to do with biology. Instead, patients — along with their parents and teachers, in the case of children — are asked to respond to a checklist of questions about symptoms that most mortals suffer at one time or another. Do you (or your child) often make careless mistakes? Do you often seem not to listen when spoken to directly? Do you often not follow through on instructions?

This method, similar to the way doctors diagnose most mental illnesses, is so subjective that the answers, and the diagnosis, may depend on how distressed a patient, a parent or a teacher is feeling on a given day. Moreover, parents and teachers, and indeed mothers and fathers, can disagree, obliging a doctor to choose whom to believe.

All this helps explain why an objective test has become “the holy grail” for many researchers, said Stephen Hinshaw, chairman of the psychology department at the University of California, Berkeley. Still, he and other experts are not convinced that any one test developed so far has proved better than the prevailing checklist method.

Many psychologists who offer comprehensive testing of children with undiagnosed learning problems include some variation of the Continuous Performance Test, a computerized assessment that measures distractibility; it is similar to Dr. Teicher’s invention, but without the motion detector.

In Southern California, meanwhile, Dr. Daniel G. Amen has built a business empire on his assertion that he can detect A.D.H.D. with a brain scan using a technology called Spect, for single photon emission computed tomography — a claim still unestablished in peer-reviewed reports of clinical trials.

In contrast, Dr. Teicher has reported on trials of his test’s efficacy in the Journal of the American Academy of Child and Adolescent Psychiatry. The Food and Drug Administration approved sales of the device in 2002, and several insurers, including Aetna and Blue Cross, now cover the test, according to Carrie Mulherin, a vice president at BioBehavioral Diagnostics, a startup company in Westford, Mass., that is marketing Dr. Teicher’s system (and paying him royalties; the list price is $19,500).

To date, more than 70 clinicians in 21 states have bought or leased a Quotient system, Ms. Mulherin said.

Katherine Ellison, a journalist in California, is the author of “Buzz: A Year of Paying Attention,” to be published in October.

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Arsenic is so common in groundwater in Bangladesh, Nepal, western India, Myanmar, Cambodia and Vietnam — all heavily populated countries in the flood plains draining the Himalayas — that their drinking water has been called “the largest poisoning of a population in history.”

But a recent study in Science magazine suggests simple well-drilling techniques that could lower the risk. The arsenic comes from eroding Himalayan coal seams and rocks containing sulfides; it is released into the groundwater only under certain chemical conditions deep underground. Some of those are affected by human activities, including pumping out huge volumes of water for irrigation. Different-colored sands may indicate how likely an aquifer is to be dangerous: rusty orange sands full of iron oxides often have less dissolved arsenic in the water around them than gray-colored sands do. Any village may have many orange and gray layers at different depths underneath it, and villagers may unknowingly live near both safe and dangerous wells. But testing is usually inadequate.

Therefore, the authors — geologists from Stanford, Columbia and the University of Delaware — suggest that wells for drinking water should be drilled in deep orange sands and connected to low-pressure hand pumps, while wells connected to high-pressure pumps for crop irrigation should be kept out of those deep aquifers so they do not empty them of safe water, which would cause arsenic-laden water to migrate downward into them.

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Obesity increases the risk of Type 2 diabetes, heart disease and other illnesses, but a surprising new finding suggests it may not affect one’s health until after age 40.

The study compared medications taken by normal weight, overweight and obese Americans ages 25 to 70 who participated in National Health and Nutrition Examination Surveys from 1988-1994 and 2003-6. The surveys included 8,880 men and 9,071 women.

While obese people of all ages took slightly more medications than those of normal weight, the differences were mainly among adults 40 and older, according to the study, published in the International Journal of Obesity.

For example, 28.7 percent of obese men and 25.2 percent of normal weight men ages 25 to 39 took medications. But among those 40 to 54, 60 percent of obese men were on medication, compared with 39.3 percent of men of average weight.

The differences in medications taken by normal weight adults and those considered merely overweight were small at all ages, the researchers found.

Brant Jarrett, a graduate student who was the study’s lead author, said one message from the paper was that body mass index, the formula used to assess weight status, is an imperfect measure. “It’s not the best measure in terms of risk factors or current health,” he said.

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When J. Craig Venter announced at a news conference the other day that he and his co-workers had created the first “synthetic cell,” he displayed the savvy graciousness of an actor accepting an Academy Award.

Dr. Venter, the renowned genome wrassler and president of the J. Craig Venter Institute, praised his two dozen team members and described the long years of struggle that preceded their moment of triumph. He called out important figures in the audience: his editor, his literary agent, the celebrity diet doctor Dean Ornish. And he acknowledged that none of his group’s work would have been possible without a lot of help from the parents — Mother Nature and Father Time. After all, that stalwart pair was responsible for designing and gradually refining the real cells that brought the Venter team’s synthetic constructs to life. There is, as yet, no escaping the cell. Every past and present lodger on the twisted bristlecone tree of life is built of cells, every cell is a microcosm of life, and neither the Venter team nor anybody else has come close to recreating the cell from scratch. If anything, the new report underscores how dependent biologists remain on its encapsulated power.

As reported in the journal Science on May 20 to international attention, the Venter team managed to recreate with bottled chemicals the entire genetic code of one species of bacterium and transplant that manufactured genome into the housing of a closely related species of bacterium. Once installed, the synthetic DNA began operating like the real thing, prompting its cellular surroundings to produce a protein work force appropriate to its needs rather than that of the original bacterial host, to copy the synthetic DNA, and to do what all bacteria love to do, which is divide over and over again.

The researchers now have many descendants of that founding microbial construct stored in a freezer, all of them nearly indistinguishable from what you’d get if you cultivated the “donor” bacterium naturally. Only on looking carefully at the genetic sequence in each cell would you find the researchers’ distinguishing “watermarks,” brief chemical messages inserted into the otherwise plagiarized string of one million-plus letters of bacterial DNA.

The harmless nucleic interjections include encrypted versions of the researchers’ names and three apt if self-conscious quotations: “See things not as they are, but as they might be,” from a biography of the physicist Robert Oppenheimer; “What I cannot build, I cannot understand,” by Richard Feynman; and “To live, to err, to fall, to triumph, and to recreate life out of life,” by James Joyce, which, when taken together with the fact that the physicist Murray Gell-Mann named the fundamental particles of the atomic nucleus “quarks” after a line in Joyce’s “Finnegans Wake,” suggests that scientists are at least as fond of the nougaty Irish novelist as is the average English major.

Other researchers were impressed by the work but were quick to keep the feat on the ground. “There’s no doubt in my mind that this is a major achievement,” said Steen Rasmussen, a professor of physics at the University of Southern Denmark who works in the field of synthetic biology. “But is it artificial life? Of course not.”

Bonnie L. Bassler, a microbiologist at Princeton, said, “They started with a known genome, a set of genes that nature had given us, and they had to put their genome into a live cell with all the complex goo and ingredients to make the thing go.”

Dr. Venter freely admitted his indebtedness to precedence. His team, he said, was “taking advantage of three and a half billion years of evolution.” Throughout those preposterous eons, nature has had a chance to perfect the splendid entity of all earthly animation that is the living cell. And though researchers have made some tentative progress in their efforts to synthesize other essential elements of the cell apart from the genome, don’t expect even a cheap knockoff anytime soon. “I am always awed by nature,” Dr. Bassler said, “and how it manages to work so well.”

There is a reason why life is built of cells, and why most cells are too small to see without a microscope. It’s easy in a small space to keep critical components squeezed together and close at hand, the better for the right enzymes to encounter the right substrates in a timely fashion and a million tiny bonfires to burn. “Cells are not like an aquarium where a fish swims by now and again,” said Dr. Bassler. “They’re jam-packed inside. They’re teeming with stuff. They’re like a house filled with necessary clutter, or New York City, or a Thanksgiving table loaded with so many dishes you don’t know where you might put another plate.”

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SUFFERERS ALL Clockwise from top left, William James, Isaac Newton, F. Scott Fitzgerald and Gene Tierney are among the well-known people said to have had a nervous breakdown, or something like it, during their lives.

Decades ago modern medicine all but stamped out the nervous breakdown, hitting it with a combination of new diagnoses, new psychiatric drugs and a strong dose of professional scorn. The phrase was overused and near meaningless, a self-serving term from an era unwilling to talk about mental distress openly.

But like a stubborn virus, the phrase has mutated.

In recent years, psychiatrists in Europe have been diagnosing what they call “burnout syndrome,” the signs of which include “vital exhaustion.” A paper published last year defined three types: “frenetic,” “underchallenged,” and “worn out” (“exasperated” and “bitter” did not make the cut).

This is the latest umbrella term for the kind of emotional collapses that have plagued humanity for ages, stemming at times from severe mental difficulties and more often from mild ones. There have been plenty of others. In the early decades of the 20th century, many people simply referred to a crackup, including “The Crack-Up,” F. Scott Fitzgerald’s 1936 collection of essays describing his own. And before that there was neurasthenia, a widely diagnosed and undefined nerve affliction causing just about any symptom people cared to add.

Yet medical historians say that, for versatility and descriptive power, it may be hard to improve upon the “nervous breakdown.” Coined around 1900, the phrase peaked in usage during the middle of the 20th century and echoes still. One recent study found that 26 percent of respondents to a national survey in 1996 reported that they had experienced an “impending nervous breakdown,” compared with 19 percent from the same survey in 1957.

“ ‘Nervous breakdown’ is one of those sturdy old terms, like ‘melancholia’ and ‘nervous illness,’ that haven’t really been surpassed, although they sound antiquated,” the historian Edward Shorter, co-author with Max Fink of the book “Endocrine Psychiatry: Solving the Riddle of Melancholia,” said in an e-mail message.

Never a proper psychiatric diagnosis, the phrase always struck most doctors as inexact, pseudoscientific and often misleading. But those were precisely the qualities that gave it such a lasting place in the popular culture, some scholars say. “It had just enough medical sanction to be useful, but did not depend on medical sanction to be used,” said Peter N. Stearns, a historian at George Mason University near Washington, D.C.

A nervous breakdown was no small thing in the 1950s or ’60s, at least by the time a person arrived at a doctor’s office. Psychiatrists today say that, most often, it was code for an episode of severe depression — or psychosis, the delusions that often signal schizophrenia.

“I don’t remember people who got that label ever using it as their own complaint — it was very much stigmatized,” said Dr. Nada L. Stotland, a former president of the American Psychiatric Association and a professor at Rush Medical College in Chicago, who began practicing in the 1960s. “Whether it was ‘nervous exhaustion’ or ‘nervous breakdown,’ anything that sounded psychiatric was stigmatized at that time. It was shameful, humiliating.”

The vagueness of the phrase made it impossible to survey the prevalence of any specific mental problem: It could mean anything from depression to mania or drunkenness; it might be the cause of a bitter divorce or the result of a split. And glossing over those details left people who suffered from what are now well-known afflictions, like postpartum depression, entirely in the dark, wondering if they were alone in their misery.

But that same imprecision allowed the speaker, not medical professionals, to control its meaning. People might be on the verge of, or close to, a nervous breakdown; and it was common enough to have had “something like” a nervous breakdown, or a mild one. The phrase allowed a person to disclose as much, or as little, detail about a “crackup” as he or she saw fit. Vagueness preserves privacy.

Dr. Shorter said that the term “nervous” has traditionally been a “weasel word” for mental troubles, implying that the cause was something physical beyond the person’s control — their damaged nerves, not their mind. And a breakdown, after all, is something that happens to cars. It’s a temporary problem; or at least, not necessarily chronic.

Through the ages, every generation has attributed its own catchall diagnosis to larger cultural changes. Industrialization. Modernization. The digital age. The 19th-century philosopher William James reportedly called neurasthenia, from which he claimed to suffer himself, “Americanitis,” in part the result of the accelerating pace of American life. So it was with breakdowns. The causes were largely external — and recovery a matter of better managing life’s demands.

“People accepted the notion of nervous breakdown often because it was construed as a category that could handled without professional help,” concluded a 2000 analysis by Dr. Stearns, Megan Barke and Rebecca Fribush. The popularity of the phrase, they wrote, revealed “a longstanding need to keep some distance from purely professional diagnoses and treatments.”

Many did just that, and returned to work and family. Others did not. They needed a more specific diagnosis, and targeted treatment. By the 1970s, more psychiatric drugs were available, and doctors directly attacked the idea that people could effectively manage breakdowns on their own.

Psychiatrists proceeded to slice problems like depression and anxiety into dozens of categories, and public perceptions shifted, too. In 1976, 26 percent of people admitted seeking professional help, up from 14 percent in 1947, according to Dr. Stearns’s analysis. And “nervous breakdown” began to fade from use.

The same fate may or may not await “burnout syndrome,” which for now has backing from some doctors and medical researchers. But it has another 30 years to outlast the classic “breakdown.”

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It is inevitable. The muscles weaken. Hearing and vision fade. We get wrinkled and stooped. We can’t run, or even walk, as fast as we used to. We have aches and pains in parts of our bodies we never even noticed before. We get old.

It sounds miserable, but apparently it is not. A large Gallup poll has found that by almost any measure, people get happier as they get older, and researchers are not sure why.

“It could be that there are environmental changes,” said Arthur A. Stone, the lead author of a new study based on the survey, “or it could be psychological changes about the way we view the world, or it could even be biological — for example brain chemistry or endocrine changes.”

The telephone survey, carried out in 2008, covered more than 340,000 people nationwide, ages 18 to 85, asking various questions about age and sex, current events, personal finances, health and other matters.

The survey also asked about “global well-being” by having each person rank overall life satisfaction on a 10-point scale, an assessment many people may make from time to time, if not in a strictly formalized way.

Finally, there were six yes-or-no questions: Did you experience the following feelings during a large part of the day yesterday: enjoyment, happiness, stress, worry, anger, sadness. The answers, the researchers say, reveal “hedonic well-being,” a person’s immediate experience of those psychological states, unencumbered by revised memories or subjective judgments that the query about general life satisfaction might have evoked.

The results, published online May 17 in the Proceedings of the National Academy of Sciences, were good news for old people, and for those who are getting old. On the global measure, people start out at age 18 feeling pretty good about themselves, and then, apparently, life begins to throw curve balls. They feel worse and worse until they hit 50. At that point, there is a sharp reversal, and people keep getting happier as they age. By the time they are 85, they are even more satisfied with themselves than they were at 18.

In measuring immediate well-being — yesterday’s emotional state — the researchers found that stress declines from age 22 onward, reaching its lowest point at 85. Worry stays fairly steady until 50, then sharply drops off. Anger decreases steadily from 18 on, and sadness rises to a peak at 50, declines to 73, then rises slightly again to 85. Enjoyment and happiness have similar curves: they both decrease gradually until we hit 50, rise steadily for the next 25 years, and then decline very slightly at the end, but they never again reach the low point of our early 50s.

Other experts were impressed with the work. Andrew J. Oswald, a professor of psychology at Warwick Business School in England, who has published several studies on human happiness, called the findings important and, in some ways, heartening. “It’s a very encouraging fact that we can expect to be happier in our early 80s than we were in our 20s,” he said. “And it’s not being driven predominantly by things that happen in life. It’s something very deep and quite human that seems to be driving this.”

Dr. Stone, who is a professor of psychology at the State University of New York at Stony Brook, said that the findings raised questions that needed more study. “These results say there are distinctive patterns here,” he said, “and it’s worth some research effort to try to figure out what’s going on. Why at age 50 does something seem to start to change?”

The study was not designed to figure out which factors make people happy, and the poll’s health questions were not specific enough to draw any conclusions about the effect of disease or disability on happiness in old age. But the researchers did look at four possibilities: the sex of the interviewee, whether the person had a partner, whether there were children at home and employment status. “These are four reasonable candidates,” Dr. Stone said, “but they don’t make much difference.”

For people under 50 who may sometimes feel gloomy, there may be consolation here. The view seems a bit bleak right now, but look at the bright side: you are getting old.

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Half of all Americans with high blood pressure have the condition under control, according to a new study, accomplishing one of the national objectives for improving Americans’ health set by the government public health initiative Healthy People 2010.

The accomplishment represents steady and significant progress since 1999-2000, when one-quarter of hypertensives had their condition under control, and further progress since 2003-4, when one-third had control of their high blood pressure.

“At the time the goal was set, it was seen as extremely ambitious — most experts did not see that level of progress being made,” said Dr. Brent M. Egan, professor of medicine and pharmacology at the Medical University of South Carolina in Charleston, and lead author of the study published in the May 26 issue of the Journal of the American Medical Association.

“Practicing physicians in communities across the country are doing a very good job, and awareness has improved,” Dr. Egan said.

At the same time, he said, overall prevalence of hypertension has not declined; nearly 3 of every 10 American adults has high blood pressure — and the improved control is primarily a result of improved use of medications, not changes in lifestyle.

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Amid a flurry of publicity, dozens of the nation’s insurers announced this spring that they would put into effect a popular provision of the new health law ahead of schedule. Instead of dropping young adults from their parents’ health plans when they graduated this spring, insurers said they could stay on. Early implementation was a welcome graduation gift for many families. Or so they thought.

But when parents ask for details from their employers about how to keep their children on a family plan, many are learning that their employers have said “no thank you” to their insurer’s offer to make the change early.

Instead of modifying health plans now, they plan to wait to provide the extended coverage until they are legally required to do so. For many employers, that means January 2011. The provision of the law takes effect Sept. 23, but employers don’t have to comply until the beginning of the new health plan year after the law becomes effective.

“I’m really angry,” said Allison McMaster Young, whose 22-year-old son, Alex, graduated from Fordham University on May 22 and lost his coverage under the family’s insurance plan the next day. Ms. Young, a vocal supporter of early implementation who started a Facebook page to rally interest and educate other parents, found out a week ago that her husband’s employer, a Washington, D.C.-area federal contractor, won’t let Alex re-enroll until Jan. 1.

“It doesn’t make any sense,” she said, noting that young people are generally healthy and inexpensive to insure.

The Young family’s experience is hardly unique. According to a study of nearly 800 employers released last month by the human resources consultant Mercer, only about a quarter of respondents who don’t already cover children until age 26 said they planned to put the change into effect before their annual health plan renewal date.

Typically, children lose their coverage under their parents’ plan when they leave school or reach a certain age. Under the new law, health plans will eventually be required to permit virtually all adult children to remain on their parents’ plans until age 26.

For insurance companies, early implementation means more revenue, explained Beth Umland, research director for health and benefits for Mercer, “but for the companies it just means more costs.” In addition to the unbudgeted expense of extending coverage to older children, companies must comply with the new law’s notification requirements. They will have to inform not only parents but also adult children of the option to re-enroll. That includes children who may have left the plan years ago but are under age 26, Ms. Umland said.

In the future, many employers say they are going to take steps to offset the increased costs of offering extended coverage, according to the Mercer survey. The law says that adult children who are working and have an offer of coverage from their employer can’t stay on their parents’ plan; about half of the companies said they would seriously consider requiring proof that such coverage isn’t available.

In addition, more than a third of employers surveyed said they would consider either charging more for dependent coverage in general or changing their coverage structure from simple “individual” and “family” designations to rate tiers that vary the premium based on the number of people that participate in the plan.

Insurers, for their part, aren’t throwing the gates wide open to all adult children under age 26, but generally only to those who are currently enrolled in the family plan. Grown children who have already left or been dropped before the early implementation start date — typically May or June of this year —may have to wait until the next plan year to sign back up.

That’s what the Young family expects to do. Until Alex can rejoin the family plan again as a dependent in January, they plan to pay for him to continue his current coverage under the federal law known as COBRA, which allows children who are no longer eligible for their family’s plan to extend their current coverage for up to three years.

There’s a hitch, though: the family must pay the entire premium plus a 2 percent administrative fee. In the Young family’s case, they’ll pay $510 a month for Alex’s COBRA coverage. The premium for the entire family of five, in contrast — including Allison, her husband, Alex and his two sisters — was $750 monthly.

Many companies still haven’t decided what they plan to do, leaving adult children and their parents in limbo. Brittany Luse graduated from Howard University last summer. Ms. Luse, a 22-year-old film studies graduate, has held short-term or freelance positions since then, but none offered health insurance. That hasn’t been a problem, because Ms. Luse has had insurance through her father’s employer. But that will change when she turns 23 in November and “ages out” of the policy.

Ms. Luse says the company hasn’t confirmed when it will begin extending coverage to adult children under the new law. Depending on when the new plan year begins, she could be facing several months without coverage. She doesn’t know what to do. Most of the jobs she could get in the film industry are contract jobs, without benefits, Ms. Luse said. If she has to find a job that offers insurance, “it limits my choices a lot.”

This is the eighth in a series of articles on how the health care law will affect everyday lives.

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