Synapse On-Line

November-December 1998

Identity Crisis or Disorder?

First, there is the changing identity of a modern psychiatrist. Is the psychiatrist of the twenty-first century someone who does psychotherapy as well as prescribe medication? Five years ago, even posing this question would have been absurd. But residents are now being less well trained to do it, insurance companies are creating economic disincentives to engage in it and even hospitals will often make a double referral when they discharge a patient to the community; one to the psychiatrist for medication and another to a social worker for therapy. The popular image of the psychiatrist with his notepad and couch is quickly becoming an anachronism. In the age of managed care, some have handled this issue by developing small "boutique" practices where insurance is not accepted and that cater to patients who can pay out of pocket. But are these practitioners avoiding the mainstream patient who lives from one paycheck to another and cannot afford to go outside the restrictions of their insurance for treatment. Whose responsibility will these individuals become? Conversely, some have developed psychopharmacology megapractices where patients are seen briefly and therapy is done by a non-medical practitioner or not at all. Is the traditional role of the practitioner being diluted in this setting, even if the pharmacological care is good; the loss of the very soul of psychiatry. Perhaps this issue will become more inflamed when the politicians who write the laws finally ask us what organized psychiatry's vision of parity specifically entails; is it the right to see a patient with a major mental illness frequently enough to stabilize their condition medically, or is it the right to treat an anxious or dysthymic patient in psychotherapy with as many sessions per week and for as many years as the psychiatrist deems is necessary.

Secondly, there are questions as to how far a psychiatrist can go in terms of commingling their clinical practice with a nonmedical therapist. If one looks to the public mental health system in Rockland County for an answer, there appears to be no limits. Non-psychiatrists are performing the initial diagnostic evaluations at the Assessment Center when the patients first come into the system, and psychiatrists are essentially relegated to medication management services. This trend is also reflected in a managed care private practice setting, where psychiatrists are generally asked to see patients for medication who are already in therapy with a nonmedical practitioner. If the two major "players" in mental health referrals support this type of practice, it can be assumed that a substantial number (if not a majority) of patients who are taking psychotropic medication are in multiple practitioner arrangements.

Unfortunately, there are no clear guidelines for the psychiatrist on how to conduct this sort of treatment relationship; frequency of visits, contact between the clinicians and the thorny issue of how much responsibility the psychiatrist should delegate to the therapist to monitor changes in the patient's mental state. A number of psychiatrists have opted out of these arrangements altogether, in spite of the growing trend, describing them as potentially dangerous to patient care, as well as being a malpractice risk. It is my impression that this issue may not pose as much of a dilemma for newer doctors who have "grown up" under this type of system and are more comfortable with it.

A third area of uncertainty involves the demanding and sometimes even bizarre practice parameters set by large institutions, both public and private. This might include arbitrary drug formulary exclusions by insurance companies, in an age where virtually nothing useful is on generic and there is fierce pressure to cut costs. Or there may be changes brought about by the political will of a single individual, such as Mayor Guilliani's thought about shutting down the methadone clinics in NYC. What should the response of a psychiatrist be to these arbitrary changes? Will it become a stark choice of staying with a particular system, no matter how flawed, or choosing to opt out and practice elsewhere.

Hopefully, with all of these issues, we can sustain the professional ties that bind us together and support each other in these difficult decisions, rather than develop an "every man for himself mentality" where our unique sense of comradeship is lost.

Marc Tarle, MD

Psychiatry and the Law: Child Murder

While "infanticide" is the term most commonly used to describe child murder, it is only a general term. Filicide is the murder of a child by a parent, and neonaticide is the murder of a newborn, within 24 hours of birth. Recent cases, some seemingly inexplicable to us, raised my interest enough to decide to clarify some of the issues in these cases.

Ancient civilizations considered children omens from the gods. Those born with deformities were routinely sacrificed. Asian cultures routinely killed female infants, Roman fathers had the right to murder their children, and Japanese fathers could also have their newborns killed to keep family size down. The slaying of children is an international phenomenon. In certain Eskimo tribes, Indian cultures and Chinese cultures there is evidence that female children are still killed at birth.

Researchers investigating child murder have organized classification systems in order to enhance our understanding of the events leading to the offense and the perpetrator committing the offense. A commonly used system (Resnick) includes the following:

a) Altruistic filicide - killing by parents believing the family is doomed or in conjunction with their own suicide.

b) Acutely psychotic filicide - killing while suffering severe delusions, hallucinations or delirium, with little other motive for the crime.

c) Unwanted child filicide, where the child was never or no longer wanted (often associated with illegitimacy or extramarital conception).

d) Accidental filicide - The aftermath of a battered child episode, where the death was not intentional.

e) Spouse revenge filicide - to retaliate against perceived wrongs by a spouse.

f) Mercy killing filicide - where there was intense suffering by the child, or to assist an impending death.

Perpetrator profiles have also been developed in order to assist in prevention and with treatment. We can divide the mothers who killed their infants into two groups. Neonatal killings were committed by much younger single, less depressed, less psychotic and less suicidal women, than the mothers who killed older children. They were frequently primiparas with a "primary weakness of their characterological structure" and who are much more passive in dealing with the pregnancy, with massive denial, no prenatal care and concealing the pregnancy from everyone. The massive denial may even be contagious, affecting family and friends as well.

Filicidal men had an impairment in their reality testing during the offense, were often psychotic or organically impaired, were raised with multiple develop-mental stressors themselves, including violence, parental abuse and separation from parents. Most had significant neurologic and/or psychiatric disorders earlier in life. Some had been physically and sexually abused, but most had not been abusive themselves prior to the filicide. Misinterpretation of the child’s behavior appears to be the primary motive for the killing, seeing the child as threatening, rejecting or provocative.

Interestingly, we are seeing more and more children killed by parents suffering from Munchausen By Proxy Syndrome, as well as where SIDS had been an earlier diagnosis. With our increasing suspicions of the possibility of infanticide, cases not previously considered to have been perpetrated by a troubled parent are now exposed as concealed infanticide at times, only after one or more siblings had already died and had been labeled as SIDS or unexplained deaths.

Another intriguing aspect of these cases is that there is a disproportionate gender bias in sentencing. Paternal offenders are sent to prison or executed more often than maternal offenders. Mothers who commit neonaticide are less likely to be hospitalized than those who commit filicide (corresponding to the much lower incidence of psychoses in neonaticides). Frequently, juries are very reluctant to convict a woman for neonaticide (leading to plea bargaining to very light sentences, or even probation). A mother killing a second newborn after standing trial is extremely low.

Child murder is a multifaceted phenomenon deserving a high level of professional attention to families in which serious mental illness, post-partum depression, a prior history of abuse and denial of a pregnancy may increase the risk for a future episode of filicide.

Alan J Tuckman, MD
Chairman, Ethics Committee

Johann Weyer: The First Psychiatrist

The cultural revolution of the Renaissance started in Italy during the early 1300's . From there it spread to England, France, Germany, the Netherlands, Spain and other countries of Europe. It continued into the sixteenth century ending about 1600. During this period there was an attempt to revive the artistic, literary and philosophic works of ancient Greece and Rome.

The Renaissance thinkers emphasized people's duties to the society in which they lived. There was a surge of interest in the study of Humanities and its in-finite possibilities. There was greater attention paid to other cultures of the world. The long forgotten Greek and Roman writings were acquired from the Arabs during the crusades of the 11th, 12th and 13th centuries and were retranslated into Latin.

But the transition from the Dark Ages into the era of humanism was not an eventless progression. The persistence of superstitions and beliefs in demons and witches prevailed and had a dampening effect on humanistic trends. Misogyny was practiced in the form of witch hunts throughout the continent with the approval and encouragement of the church. For almost three centuries Malleus Maleficarum (The Witches' Hammer) was the official manual for the witch hunters. This was compiled by the two most famous Inquisitors of the age: Heinrich Kramer and James Sprenger. Under a Bull issued by Pope Innocent VIII on December 9th 1484 this became an authoritarian document binding on the ecclesiastical as well as the secular authorities of western Europe. A copy of the book was placed on the desk of every judge for his guidance in dealing with those accused of witchcraft.

Malleus Maleficarum gave step by step instructions on how to spot witches, how to obtain their confession and convict them. The methods of torture were elaborated to facilitate the process. Confessions resulted in punishments, the most severe of which was to be burned alive. The Malleus reminds the reader repeatedly that no one can be a witch without entering into a pact with the devil and therefore, witchcraft is a result of free choice on the part of the woman and hence, punishable. Birth deformities, miscarriages, impotence, and chronic illnesses were all attributed to their machinations. They were accused of roasting aborted fetuses to make salves and potions for their nefarious purposes.

Johannes Weyer was a man of these tumultuous times. Born in 1515 at Grave in what is now Dutch territory, he was a pupil of Cornelius Agrippa. Agrippa was a man of principles and had almost single handedly, taken upon himself to fight against the witch hunt that targeted women to men by a ratio of 19:1. One of Agrippa's writings was titled: On The Nobility and Pre-eminence of the Feminine Sex. Weyer lived for three years with Agrippa and had access to the latter's library. Weyer then went to Paris and Orleans in pursuit of medical studies, graduating from medical school at age 22 in 1537. At age thirty he found employment as the city physician of Arnheim and stayed there for five years. Following this, he was appointed the personal physician to Duke Wilhelm of Julich-Cleve-Berg. He held this position almost until his death at age 73 in 1588. During his stay at the ducal palace, he had ample opportunity to peruse the writings of the great masters of his day as well as the ancient classics and the works of Avicenna, Averroes and others of the 11th and 12th centuries. In his writings he has made references to these sources. Although this was a time of personal stability and comfort, he was tormented by what was going on in all of Western Europe. The continent was aflame with the fires of the Inquisition and he could not be indifferent to it. But his style was different from the venomous outpourings of his teacher Agrippa.

Weyer looked upon the demoniacal world as an enormous clinic full of sick persons in need of healing. He put to critical analysis the literature on the subject, including the Malleus. With characteristic courage he came out calling upon the ignorant tormentors of the so called witches to leave the management of witches and the bewitched to the physicians. He was neither abusive nor sacrilegious because he was a genuinely pious per-son. He cited a number of bishops who were opposed to the horrors of witch hunt; but he protested against the incendiary bishops. He asserted that it was wiser to let ten guilty individuals go free than to put one innocent per-son to death. The pain inflicted on witches, like pouring boiling oil on their feet or holding a lighted candle under the armpit, was a cruelty totally undeserved and inhuman.

In 1563 Weyer came out with his major work: De Praestigiis Daemonum (The Deception of The Demons). Weyer conveys the opinion that the sufferings and symptoms of the so called witches were due to the action of certain drugs or poisons like belladonna etc. or due to the disturbance of their reasoning. Weyer, thus, having reviewed all theological and philosophical arguments, turns towards clinical demonstrations and pathological physiology. Whenever he wanted to prove a point he did so after examination of the clinical facts.

Here is an example of how Weyer tried to educate not only the magic faith- healers, but the patients themselves, drawing their insights into their own troubles. This he considered as a potent therapeutic factor: "A young girl who was tormented by an evil spirit was given by a priest a piece of paper wrapped in leather to wear around her neck as a remedy. This, he said, would help her...The girl was very careful and took great pains not to lose the charm. Judith, my wife asked the girl to come to see her. She admonished the girl to place her trust only in the Lord, Protector of all sufferers, and to scorn the devil's doings. Then she gave her to eat and drink, and took the piece of paper wrapped in leather which was hanging from the girl's neck. Those present were frightened and they all ran away because they were afraid that the girl would again enter one of her states of horrible excitement. The girl was left alone with my wife and my daughter Sophie; nothing happened to the sick girl. My wife opened the leather con-tainer and found inside a piece of paper that was folded over many times; nothing was found to be written on it. In the presence of the patient she threw the piece of paper into the fire. The patient, calmed by the admonition of my wife, developed a good appetite and appeared quite cheerful and contented...and in so far as I know she remained well from that time forward."

Mass neurosis was prevalent through out the Middle Ages and into the 16th and 17th centuries. Weyer treated these outbreaks, which appeared to be in the nature of epidemics, in his usual practical manner. The epidemics were most frequent in monasteries and convents. They presented many complex problems and endless theological hair-splitting. As usual, Weyer standing apart from the theological controversies, kept in touch with various institutions like monasteries, orphanages and convents, in order to find out what specific types of mental disturbances were prevalent among congregations of individuals living restricted and well-regulated lives. The history of the nuns of the convent of Nazareth at Cologne who were afflicted by the 'devil' is quoted here in some detail:

For some years these nuns had been intermittently disturbed by hysterical seizures; when the trouble climaxed in 1564 Weyer organized an investigation. The nuns were subject to frequent attacks of peculiar convulsions during which they closed their eyes lay on their backs with their abdomens elevated. Weyer recognized the obvious erotic nature of the convulsions observing that the nuns when they opened their eyes had an apparent expression of shame and pain.

A girl named Gertrude, who was 14 years old and lived in this convent was the first cause for all this hysteria. She often suffered from visions of apparitions while in bed. She was first discovered by the noises she made when trying to chase away her imaginary lover. One of her companions came to sleep near her room to defend her against the apparition, but became very frightened as she began to hear the usual noise and herself had a break-down. During the attacks Gertrude appeared as if she was unable to see, while at other times she appeared visually normal. Soon others joined her in these bizarre seizures.

Weyer observed that when there was an epidemic of (?Typhoid) fever the mental condition of the nuns would clear up, but that no sooner they recovered from the fever the convulsive states and the mental confusion would return. The investigation made by Weyer disclosed the following realistic pathogenesis: The episodes started when a few young men of the neighborhood, probably drunk, became acquainted with one or two of the nuns and repeated their visits by climbing the wall and indulging in a love affair with them. When this was stopped the fantasy of the girls was aroused and they got in imagination what they missed in reality. Weyer kept in touch with the nuns, specially those who were the original source of the trouble.

Weyer comments: "If one finds several bewitched or demonical persons at one and the same place, as ordinarily happens in monasteries and convents, particularly in the latter...it is necessary to separate them from each other and to see to it that they be sent back to their respective parents or relatives, in whose homes they could more conveniently be cured; however, this should be done always taking into consideration the individual needs of each person; one should avoid, as the expression goes, molding them all in accordance with one definite model...the young nuns should be spared from seeing such spectacles because they are very susceptible to such things and they might catch the same illness."

Based on his extensive clinical observations Weyer firmly believed that "those illnesses whose origins are attributed to witches come from natural causes." He was well aware that all mental illness could not as yet be explained but he knew that witches can harm no one. The imaginations (hallucinations and delusions?) of the 'witches' inflamed by the torture of melancholy makes them only fancy that they have caused all sorts of evil. To this they confessed and for this they went to the stakes. Weyer asserted, after Hippocrates, that mental diseases are neither supernatural nor sacred and that it was his duty as a physician to treat people so afflicted. He was the first physician who made mental illness his major area of concern. He can, therefore, be justifiably called the first psychiatrist.

Weyer could not escape the scorn of the people of his age, he was called "Weirus heriticus" or "Weirus insanus". It was rumored that he himself was a wizard, otherwise why would he defend the witches. His writings, proscribed and banned by the church, remained unnoticed by medical men until he was only recently discovered as an early psychiatrist. Others who participated in constructing a humanistic image of man included, besides Weyer, Paracelsus, Vives, Agrippa, Erasmus and Thomas More. Weyer's greatest accomplishment was the introduction of a scientific, descriptive, observational method to clinical psychopathology thereby he reclaimed the field from the hands of clergymen and restored it to medicine.

Acknowledgments: My grateful thanks are due to Mr. Stuart Moss, Chief Librarian at the Nathan Kline Institute. He provided invaluable help with the source materials for this article. (Bibliography available on request)

Syed Abdullah, MD

Private Practice: Getting Out of Managed Care

I had an interesting conversation with a social worker colleague recently. She, like so many of us, had eagerly signed up several years ago with every managed care firm that offered her a contract. That was about 5 years ago when we all were hearing about the demise of private practice, of the need to join this new form of insurance to keep our income, and our patients, coming; when we feared being frozen out of the marketplace, pushed out by our competitors who had gotten their foot in the door with the right company who had more "managed lives" and would woo our patients to their doors with the lure of lower co- pays. Now she had a dilemma. She was spending inordinate time in frustrating conversations with reviewers from the managed care firms she belonged to, hours at her desk filing lengthy reports about her patients and caught in ethical dilemmas about truncated care and denied coverage. She was being paid less per hour for the time she spent with her patients and spending inordinate uncompensated time with all the administrative tasks. Unfortunately, about 80% of her practice was people referred by managed care. If she terminated her contracts with these managed care firms, most of these individuals would go elsewhere, unable to afford the increased cost of their care. Who would be able to assess the competence of the new therapist compared to my friend or the impact upon the therapeutic process of changing therapists in the middle due to administrative reasons? She could not quit for fear she would see a huge decrease in her practice and her income, even after ac-counting for increased per session income from those few who might remain with her. SHE WAS ADDICTED TO MANAGED CARE.

During Depression Screening Day I took advantage of the event to poll many of my colleagues who reiterated similar dilemmas. Those who kept managed care to a small percentage of their practice were not unhappy. They had a few referrals to help fill in those unfilled hours all of us have from time to time. They had kept contracts only with the companies whose paperwork and review requirements were easy and whose fees were close to the fees allowed by Medicare. Many were in the process of terminating contracts with those firms which displeased them in one way or another. Those who had a large percentage of practice income from managed care felt caught in the same bind my social worker friend is in; unable to leave and hating to stay. All felt there were plenty of patients willing to seek therapy out-of-network and to self-pay. All noted the pleasure of treating patients without the intrusion of managed care, whose presence so often complicates therapy.

We all commiserated about the dilemma patients are in whose insurance is through a mental health managed care plan. So often they are constrained by the plan to choosing from among a few psychiatrists who participate. With fewer psychiatrists participating, the choices for the patient are dwindling. We all shared stories of patients calling multiple providers, only to be told there were no openings for many weeks. I am left wondering if there would be openings if the patient was paying full-fee and the psychiatrist did not have to comply with oversight requirements by the insurance company. Many patients have to split treatment, seeing a therapist for the psychotherapy and a psychiatrist for medication. While some of us felt this could be a workable arrangement, depending upon the skill of the therapist; all of us felt it was a second choice to seeing a psychiatrist for all of the care.

My own experience parallels that of my colleagues who are getting out of managed care. I quit Blue Cross/Blue Shield in 1995 and Oxford last year. My egress from these contracts has been complicated by the bureaucratic fumbling one might expect from a large organization. Oxford failed to register my retirement and kept referring prospective patients to me long after my departure, wasting my time and that of the referred patients. The Blues had no record of my having quit in 1995 and insisted as recently as a few months ago that I refund monies paid to me by patients covered by them; apparently they saw this as breaking the contract stipulating I accept only the co-pay and bill BC/BS for the balance of the fee determined by them (considerably below my usual fee). Only after repeated correspondence(certified, return receipt) with copies of the original letters indicating my desire to depart our relationship did they finally acknowledge that we were no longer in contract. This only reinforced my impression that participating in these managed care contracts is time consuming, inefficient, clinically complicates an already difficult endeavor, can be unethical, is bureaucratic and is best left to large organizations with staff dedicated to managing these relationships.

My advice is to sign contracts only after careful consideration of all the ramifications, to keep copies of everything, to exit contracts when they no longer work for you and to keep all the correspondence related to this business for at least five years.

My advice for a newcomer to our field hoping to establish a practice in Rockland County was to avoid managed care contracts even though they hold out the promise of a rapidly filled practice. Find a niche you are good at, that distinguishes you from others, market yourself well, strive for absolute excellence and treat your patients well. You will likely be busy enough very soon.

For those of you addicted to managed care - my condolences. Try to wean yourself off slowly or look at going cold turkey; which could be a painful and costly experience.

James Flax, MD, MPH

Private Practice: Depression Screening

The Private Practice Committee sponsored its' seventh "Depression Screening" at both the Palisades Center and the Nanuet Mall on Thursday, October 8 as part of National Mental Illness Awareness Week. Three to four psychiatrists manned the tables at the Palisades Mall from 10 AM to 9 PM and at the second level Community Service Booth of the Nanuet Mall from 5 PM to 9 PM. They spoke with passersby, answered questions, distributed volumes of literature including our private practice referral guide, and conducted individual depression screenings for those who wished it. It was once again a resounding success!

The thousands of shoppers passing by saw individuals openly talking with us about mental illness in a setting de-signed to eliminate stigma and fear. Seventy-nine individuals took the HAND depression screening (compared to 75 last year). Forty-eight scored at or above the minimal to mild depression category (60%) and were urged to seek psychiatric consultation. This is about the same number as those who have participated in our previous depression screenings and continues to be an enormous number of people, averaging more than any other site. Compared to the hundreds we had expected and prepared for, all of us felt it was a poor turn-out. This was probably attributable to few people at the mall due to the atrociously rainy weather.

Those of us who participated were again very pleasantly surprised by the openness of the passersby who spoke with us in the public setting of the mall. Your colleagues who volunteered reiterated the refreshing change this professional activity is from the usual clinical settings in which we all work. I think all of us enjoyed the screening task and the opportunity to kibbutz with colleagues. I overheard conversations ranging from managed care, to district branch business, to medications, to case discussions, to vacation destinations, to how our children are doing.

I wish to thank all of the participants including Drs. Syed Abdullah, Mona Begum, Lina Haber, Roger Harris, Joan Berson, Dave Brody, Les Citrome, Peter Ferber, Andy Hornstein, Lois Kroplick, John Lucas, Mary Mavromatis, Barti Pakhiwala, Bert Pepper, Norm Scher, Alan Tuckman, & Denny Walters. I want to thank newcomers to our screening - Biman Roy, Meryl Rome, Pablo Sadler & Elizabeth VonZamensky who I think enjoyed their participation. I know Dr. Rome stayed for nearly two hours longer than she agreed to; which I assume was because she was learning from and enjoying the experience. Dista, the makers of Prozac, again provided substantial financial support for this event; for which we are grateful. I especially want to thank our President, Dr. Marc Tarle, who volunteered to manage the Palisades Mall during the hours I was at the Nanuet Mall, so that we could run two sites simultaneously.

I invite all of these individuals and others who were not able to make it this year, to volunteer for next years' Depression Screening in October, 1999. It is a rewarding experience and a chance to share notes during free time with your colleagues manning the booth. James Flax, M.D.

James Flax, MD, MPH

WHPS Joins with Other Organizations in MIAW Activities

On October 7, 1998 Dr. Bob Sobel organized an event to mark Mental Illness Awareness Week bringing together our District Branch and Rockland Psychiatric Center. It took place at Rockland Psychiatric Center and was well attended. A breakfast was followed by opening re-marks from Dr. Hassan Dinakar (RPC Deputy Clinical Director and member of WHPS), Sandy Mauro (RPC Director of Operations) and our DB president, Marc Tarle. An academic program followed with Dr. Alan Mendelowitz (Assistant Professor of Psychiatry at the Albert Einstein College of Medicine and Unit Chief, Residency Training and Research Unit at Hillside Hospital) who spoke on the "Benefits of Early Intervention in Treating Schizophrenia." He was followed by Ken Steele, Publisher and Editor-in-chief of New York City VOICES and Consumer Journal for Mental Health Advocacy and Chair, Mental Health Voter Empowerment Project. Mr. Steele is himself a consumer. The program was supported, in part, by an unrestricted educational grant from the Eli Lilly Company.

This year Mental Illness Awareness Week has been extended by our WHPS and Mental Health Coalition to incorporate a full month of public affairs activities. On October 8,1998 our innovative annual depression screening took place at both the Nanuet and Palisades Malls. Jim Flax and Marc Tarle chaired these events. Jim has received national recognition for his out- standing work in organizing these depression screenings at Rockland's malls. I'd like to thank Jim, Marc, and all the psychiatrists who volunteered to help with these screenings. This year was our first attempt to cover two malls and it was a great success.

The Mental Health Coalition has been busy planning events for Mental Illness Awareness Week! The coalition held its first meeting of the year on September 10, 1998 in the Conference Room of the Rockland County Department of Mental Health. The meeting was well attended and the attendees were filled with enthusiasm!

The Public Forum is scheduled for October 21, 1998 at 7:30 p.m. in Clarkstown Town Hall in New City. This year is sure to be an outstanding event! The event, entitled "Breaking the Silence II" will present an inside look from the perspective of the patient, the family, and the mental health professional. The three speakers are outstanding and include the following: 1) Suzanne E. Vogel-Scibilia, MD- a Psychiatrist who suffers from bipolar disorder and recently named "Psychiatrist of the Year" by the Pennsylvania Alliance for the Mentally Ill. 2) Diane Polhemus - President of Consumers in Action, a bridger at Rockland Psychiatric Center and an active consumer advocate. 3) Mel Zalkin, MSW, Co President of NAMI FAMILYA, Clinical Social Worker and psychotherapist, who is also a family member of an individual with mental illness. I'd like to thank all three speakers and Dr. Citrome for acting as moderator of the question and answer period as well as the Co-Chairpersons of the Event - Carol Olori, CSW (Co President of the Coalition) and Rena Finkelstein (Co-President of NAMI FAMILYA). In addition, I'd like to thank Rockland County Executive Scott Vanderhoef, and Commissioner Maryann Walsh-Tozer for presenting introductory remarks.

On October 15, 1998 the coalition held its third annual elementary project. This year, George Miller Elementary School in Nanuet was visited by coalition members and by the Rockland Players. The Rockland Players, a volunteer improvisational group from the Mental Health Association per-formed 3 skits (Divorce, Depression, and Attention Deficit Disorder). Small class-room discussions and an art project followed this. Special thanks to chair- persons of this year's chairpersons - Janet Oberman, PhD and Terri Schoenfeld, who worked so hard and did an outstanding job! Our message to the children was that depression is treatable and that being depressed does not mean that someone is crazy. We also discussed that divorce is not the child's fault, and that ADHD is a treatable condition, which is not the child's fault.

I would like to share with you some of the comments of the children: "I feel different because my parents are divorced." "I felt my parents divorce was my fault, because I told my mother that my father was seeing another woman." "I take Ritalin because it helps me focus." "I got depressed when my parents got divorced." The enthusiasm of the coalition members who participated in the project, as well as the Rockland Players and the fourth grade students, was overwhelming! The openness of the students of the children was striking!

Finally, on November 1, 1998, coalition members will be doing depression screenings at the Dominican College Health Fair. Thanks to Roz Fields for coordinating this event.

The next meeting of the Coalition will be on November 5, 1998 in the Building F conference room in the Rockland County Department of Mental Health. All are welcome.

Lois Kroplick, DO
Chair, Public Affairs