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Children, Teens and Young Adults on Antidepressants and the Risk of Suicide


2010
04.29

Posted in Psychology | No Comments »

Many mental illnesses and disorders were long thought to begin only after childhood and adolescence. However, research in recent years has revealed that half of all lifetime mental illnesses begin by age 14. Despite the high number of children and adolescents having mental illness, fewer than one in five of affected children get the help they need. Due to the small pool of child and adolescent psychiatrists, psychologists, and other mental health professionals serving the 18 and under population—especially in rural areas—pediatricians, primary health physicians, and general practitioners are frequently being called upon to assess and treat young patients with even the most serious of the mental health disorders. However, a Canadian study found that most physicians did not have enough knowledge and support to detect and manage mental health conditions in pediatric patients.

If an examination rules out a physical condition, the physician must turn his or her attention to the child’s mental state. Distinguishing between normal developmental behavior from a true mental disorder can be difficult for even the seasoned child and adolescent psychiatrist. The pediatrician or primary care provider who has no psychiatrist in the area to whom to refer the young patient may be called upon to diagnose and treat a child with a constellation of symptoms that could be diagnosed as any or a number of disorders, such as conduct disorder, bipolar disorder, oppositional defiant disorder, attention-deficit/hyperactivity disorder, panic disorder, delinquency, borderline personality, or some other psychiatric condition sharing similar symptoms, all requiring different types of treatment.

Not only are personal relationships with family and friends affected by children with mental disorders, but proper psychological development of the child, performance at school, social integration, self-esteem, and ultimately functioning as a well-adjusted adult all depend upon proper mental health care while growing up. Youths with untreated mental illness often end up in the criminal justice system. In fact, nearly 60 percent of boys and girls involved in state and local juvenile justice systems throughout the country suffer from mental disorders, at least 20 percent of whom experience symptoms so severe that their ability to function is significantly impaired.

The diagnosis of mental disorders is not an exact science; diagnosis with absolute precision and certainty is impossible. It is that much harder in patients under 25. And with restrictions on many insurance companies as to the amount of time a mental health professional may spend examining a child for the purpose of making a diagnosis, many diagnoses and subsequent treatments are wrong and do more harm than good. For instance, many managed care companies offer a single one-hour diagnostic session with a child or adolescent psychiatrist or psychologist to determine a child or adolescent’s mental status. The American Academy of Child and Adolescent Psychiatry takes the position that such restrictions “are inadequate and may lead to insufficient information, condensed evaluations, diagnostic errors, and inadequate treatment planning.”

According to the Centers for Disease Control National Vital Statistics Report, suicide is the third leading cause of death among 15- to 24-year-olds (behind only accidents and homicides), and the sixth leading cause of death for five- to 14-year-olds. Although suicides account for only about 1.4 percent of all deaths in the United States annually, they comprise 12 percent of all deaths among 15 to 24-year-olds.

In 2007, the latest year for which data is available, there were approximately 4,030 suicides in youths between the ages of 15 and 24, and 195 suicides in children ages 5 to 14. Over 150,000 trips to U.S. emergency rooms are made each year after attempted suicides or other self-harm incidents among persons aged 10 to 24 years of age. Among young people ages 15 to 24 years old, there is one successful suicide for every 100-200 attempts. The most consistently reported pattern is that the risk of first onset for suicidal behavior increases significantly at the start of adolescence (12 years), peaks at 16 years, and remains elevated into the early 20s.

In one study, the researchers found that 14.5 percent of high school students reported having contemplated suicide in the previous 12 months, 11.3 percent had made a suicide plan, 6.9 percent reported that they had actually attempted suicide one or more times during the same period, and two percent had made a suicide attempt that resulted in an injury, poisoning, or an overdose that required medical attention.

Over 90 percent of attempted or completed suicide victims under 19 years of age have at least one psychiatric disorder, untreated depression being foremost among them. As many as one in 33 children and one in eight adolescents suffer from clinical depression, known in the mental health profession as major depressive disorder (MDD). Untreated depression is generally considered the third highest risk factor for suicide among youth, behind only previous suicide attempts and a history of suicide in the family, although some experts feel that untreated depression is the most common cause of suicide.

In children and adolescents, the symptoms of major depression are often different than those of adult depression. Some of the symptoms of a depressed child or adolescent are irritability, hostility, grumpiness, an easy loss of temper, poor school performance, persistent boredom, and risk taking (especially in depressed adolescents). Unexplained aches and pains are also common symptoms of depression in young people.

Since untreated depression is one of the leading causes of suicide in children, adolescents, and young adults, and depression is thought to be largely due to a “chemical imbalance” involving certain neurotransmitters in the brain (serotonin, norepinephrine, and dopamine), it is only natural that physicians would prescribe antidepressants to their depressed young patients as an integral part of their overall mental and physical health treatment plan, in addition to a course of psychotherapy and other treatments. In recognition of the fact that many attempted and completed child and adolescent suicides are due to underlying depression, from 1990 through 2003 the prescriptions for and use of antidepressants—in particular the “new” generation of antidepressants, “selective serotonin reuptake inhibitors” (SSRIs) such as Prozac, Paxil, and Zoloft, and the SSRI/norepinephrine reuptake inhibitor drug Effexor—by children, adolescents, and young adults had been rising significantly each year. During those years, the number of attempted and completed suicides in these age groups went down.

In October 2003, the FDA issued a Public Health Advisory warning that there is twice the risk (from 2 percent to 4 percent) in suicidal ideation and behavior in children under the age of 19 who were not actively suicidal when they are starting treatment with one of the newer antidepressants (sometimes as soon as 10 days after starting the antidepressant or when the dosage of the antidepressant is increased or decreased.)

A year later, in October 2004, the FDA issued another public health advisory requiring antidepressant manufacturers to include a “black box” warning in its prescribing information—the most serious action the FDA can take short of withdrawing approval of the drug (i.e., taking the drug off the market). The black box warning is required for all antidepressants—not just the SSRIs—regarding the risk of suicidality at certain times in pediatric patients being treated for depression. In May 2007, the FDA extended the warning to include the risk to young adults under 25.

After the FDA’s October 2003 Public Health Advisory, the overall rate of new depression diagnoses in patients 18 and under declined and the number of patients in this age group who were being prescribed the newer antidepressants decreased. The exception to this trend involved the number of patients in this age group who were prescribed fluoxetine (generic Prozac), the only antidepressant approved by the FDA for pediatric use.

Before 2003, SSRI prescriptions had steadily increased since 1987. Aside from minor fluctuations in 1993 (a one percent increase) and in 2000 (a three percent increase), the child and adolescent suicide rate consistently declined for the 15 years from 1988 to 2003. However, after the FDA’s 2003 public health advisory regarding several reports of children and adolescents taking antidepressants who attempted or committed suicide, the number of depressed youths being prescribed an antidepressant declined by some 20 percent, and in 2004 the suicide rate in U.S. adolescents increased by a record 14 percent from 2003. These increases in completed suicide occurred despite decreasing overall SSRI prescriptions among these age groups. Other countries, such as Canada and the Netherlands, reported similar increases in suicide among children, adolescents, and young adults when the number of prescriptions for SSRIs decreased.

The number of attempted and completed suicides among children and adolescents in the United States has increased since the black box warning was required. However, most completed suicides have no trace of an antidepressant in their system. In Canada, a similar lack of antidepressants in the systems of the “vast majority” of children and adolescents who had successfully completed suicide was found. As two psychiatrists pondered, “If SSRIs increase the risk of suicide, it is unclear why these drugs are so rarely found on toxicological examinations of youth after suicide.” Another study stated that if the FDA’s conclusion that there may be a causal link between suicide and antidepressants were correct, “we would have expected to see decreases in the suicide rate during the period of declining SSRI prescription rates, but instead we saw an increase in suicide rates, and the increase was greatest in the age range most affected by the decline in SSRI prescription rates. This finding suggests that SSRIs confer a protective effect.”

The new warning balances the efficacy of antidepressants in youthful patient against the risk of drug-induced-suicide. According to the black-box warning, such monitoring should include at least weekly face-to-face contact with patients or their family members or caregivers during the first four weeks of treatment, then biweekly visits for the next four weeks, then at 12 weeks, and as clinically indicated beyond 12 weeks. Additional contact by telephone may be appropriate between face-to-face visits. Clinical evidence, however, reveals that this observation regimen is not being adhered to.

During the 12-month period from August 2006 to July 2007, 62 percent of the total number of antidepressant prescriptions during the year were written by general practitioners, not psychiatrists. While pediatricians (who were included in the general practitioners category) prescribed 25 percent of all stimulants, they wrote prescriptions for only 21 percent of antidepressants during that time frame. The authors of one article concluded that, “[g]iven the large role of primary care providers in psychotropic drug prescribing, additional efforts may be needed to enhance the quality of psychiatric treatment in general practice settings across a range of psychiatric conditions.”

Because untreated depression is a leading cause of suicide in youth, pediatricians and other physicians who treat patients under 25 should routinely screen their young patients for this debilitating, life-threatening condition. The health care provider should also inquire into the medical and psychiatric history of the patient’s parents, specifically asking about whether a parent suffered from depression, committed suicide, or sexually abused the patient, as these are increased markers for a suicide attempt by the young patient.

If a child or adolescent patient is diagnosed with major depression, and the health care provider is reluctant to prescribe antidepressants for fear of the increase in suicidal thinking and behavior, the health care provider must provide alternative and approved methods of treatment or refer the patient to another health care provider who will provide appropriate treatment, whether it be in the form of prescribing psychotropic medication or employing regular psychotherapy sessions. Two particular forms of psychotherapy have been shown to be helpful in treating depressed patients. One is cognitive behavioral therapy, which helps the patient learn new ways of thinking and behaving. The other is interpersonal therapy, which helps patients understand and work through troubled personal relationships. Some health care providers are prescribing newer atypical antipsychotics (e.g., Abilify, Risperdal, and Seroquel) and other non-antidepressant psychoactive drugs in place of antidepressants, often with a less than efficacious result and a higher risk of side effects than the newer generation of antidepressants.

In seriously depressed youths, a major study sponsored by the National Institute of Mental Health involving adolescents having a mean age of 15 found that, after 12 weeks, the most effective treatment for adolescents with major depression was a combination of fluoxetine (Prozac) and Cognitive-Behavioral Therapy (CBT), rather than either one alone or placebo.

It is clear that compared to placebo the overall benefits of the newer antidepressants are successful in treating major depression in children, adolescents, and young adults and in reducing the risk of completed suicide. Although there may be a higher risk of suicidal thoughts and behavior at certain times, the health care provider can minimize the risk with proper monitoring of the patient. Deliberately not diagnosing major depression in pediatric patients to avoid the antidepressant-suicide issue can only lead to untreated depression and a much higher risk of completed suicides.

As two psychiatrists wrote, two facts are undisputed: (1) pediatric suicide is most common in children with untreated major depression, and (2) SSRIs are rarely found to be present at the time of death in suicide victims, suggesting that SSRIs are not likely to be a causal factor in a substantial proportion of child and adolescent suicide. These writers further state:

If the intent of the pediatric black box warning was to save lives, the warning failed, and in fact may have had the opposite effect; more children and adolescents have committed suicide since it was introduced. If the FDA’s goal is to ensure that children and adults treated with antidepressants receive adequate follow-up care to better detect and treat emergent suicidal thoughts, the current black box warning is not a useful approach; what should be considered instead is better education and training of physicians.

Major depression in a child, teenager, or young adult is a serious mental health disorder that if left untreated or inadequately treated can lead to the youth’s isolation, anhedonia, risk taking, change in personality, inability to tend to his or her basic personal hygiene, suicidal thoughts and attempts, and, in the worst cases, completed suicide. Mental health care providers who diagnose (or should have diagnosed) a child, adolescent, or young adult patient with major depressive disorder must weigh the pros of prescribing antidepressants and their attendant risks against the cons of not prescribing such drugs and using other forms of treatment. However, health care providers cannot simply ignore major depression in a young patient and do nothing because of the increased risk of suicide inherent in untreated depression.

If your child has been acting strangely lately—e.g., an outgoing child becoming more introverted and keeping to himself, getting into trouble at school, grades dropping, listening to songs about death, suicide, or there being “only one way out,” or repeatedly playing songs by rock stars such as Kurt Cobain (the leader of the band Nirvana, who killed himself with a shotgun while at the top of his popularity)—you should immediately get the child to a mental health professional for an examination and evaluation.

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SING! Live the Life You Dream of


2010
04.26

Posted in Self-Help | No Comments »

Most men lead lives of quiet desperation
and go to the grave with the song still in them.

- Henry David Thoreau

When she was five years old, Melanie Kinchen knew she wanted to be a doctor. When she was ten, an acquaintance of her mother asked Melanie if she knew what she wanted to do when she grew up. Melanie replied that she was going to go to an Ivy League university, become a doctor, and be the head of a clinic with “lots of people” working for her.

Twenty-five years later, Melanie’s mother ran into her old acquaintance, who cynically asked, “Whatever became of that odd child of yours?” Her mother stated that her “odd child” had gone to Yale, graduated from Harvard Medical School, did her residency and fellowship at Johns Hopkins Hospital, and now was a respected back surgeon and Director of the Spine Center at a highly regarded regional hospital. Melanie is singing her song just as she had laid it out years before. Thoreau would be proud of her.

Singing one’s song means being true to oneself, living a full, passionate, and authentic life. The philosopher Soren Kierkegaard said the goal of life is “to be that self which one truly is.” Finding your true song can be like peeling away the layers of an artichoke until the heart reveals itself. Your song may be buried deep under layers of pain, sorrow, discouragement, depression, anxiety, abuse, failure in the face of heightened (and unrealistic) expectations, lack of affection and support, or conditional or withheld love. As a person becomes clearer about who he or she really is, that person will be in a better position to decide what he or she wants out of life, what his or her song is and to begin singing it.

Often people follow their parents’ or someone else’s expectations as to their education and occupation, rather than discovering for themselves what really turns them on. The late psychologist Carl Rogers stated that people must move away from the person or direction they were told they ought to be or should go. Rogers found that many people put on a facade to try to please others, but when they were free, they moved away from being that person.

One of Rogers’s clients, looking back at some of the process he had been through, wrote, toward the end of therapy: “I finally felt that I simply had to begin doing what I wanted to do, not what I thought I should do, and regardless of what other people feel I should do. This is a complete reversal of my whole life. I’ve always felt I had to do things because they were expected of me, or more important, to make people like me. The hell with it! I think from now on I’m just going to be me — rich or poor, good or bad, rational or irrational, logical or illogical, famous or infamous.’”

Oprah Winfrey says that, “Your job is not just to do what your parents say, what your teachers say, what society says, but to figure out what your heart calling is and to be led by that.” Winfrey tells people to “[u]nderstand that the right to choose your own path is a sacred privilege.” Meditation teacher and former Buddhist monk Jason Siff says, “You can’t really tell someone that this or that is something they should really do. It’s for each person to find his way to something that really suits and fulfills him.”

Singing your song is not about the amount of money you make or the material things you accumulate, the size of the house you buy with its Olympic-size swimming pool, tennis court, and horse stables, the price and speed capabilities of the car you drive, the make and vintage of the wine you drink, or the number of lovers you have had. The British philosopher Bertrand Russell said: “The most valuable things in life are not measured in monetary terms. The really important things are not houses and lands, stocks and bonds, automobiles and real estate, but friendships, trust, confidence, empathy, mercy, love and faith.”

Singing your song can mean giving up a lavish lifestyle in favor of a lower paying yet emotionally satisfying life. Former President Jimmy Carter has dedicated his life to public service, and with every nail he pounds in building a new home for an underprivileged family through Habitat for Humanity, he is truly singing his song.

Few have overcome as much adversity to sing her song as loud and clear as Oprah Winfrey. She was born to a poor single teenage mother in Mississippi and lived with her grandmother on a farm with no indoor plumbing. When she was 6, she moved to her mother’s home in Milwaukee, and a few years later to her father’s in Nashville. She was physically abused as a child and was raped when she was 9 years old. She gave birth to a son at 14, but he died a short time later. A voracious reader as a child—she started reading the Bible at 3— she wrote a note to her kindergarten teacher that she didn’t belong there, and was quickly put in the first grade. After the first grade, she was advanced to the third grade. A seventh-grade teacher noticed Oprah reading during lunch and managed to get her a scholarship to a better school.

With her winning personality and good looks, Oprah managed to win several beauty contests. But it was being crowned “Miss Fire Prevention” at 17 in Nashville that the tide turned. She was interviewed on a local radio show and for a lark was invited to read copy on the air and was hired to read the news. And the rest, as the saying goes, is history. Oprah says that she always knew that she was destined for success. And of singing one’s song, she says, “The biggest adventure you can take is to live the life of your dreams.”

Many people are afraid of singing their song out of a fear of failure. Dr. Wayne Dyer observes in his book The Sky’s the Limit that when we are young children we are not intimidated by making mistakes. Failure was nothing to be avoided or ashamed of, he states, but rather something to be welcomed because “you instinctively knew that you couldn’t learn anything unless you were willing to fail at it first. . . . If children were made in such a way that they were afraid to try new things because they feared failure, they would never get out of their cribs! Likewise, adults who fear failure simply vegetate.”

On the other hand, some people don’t risk singing their song out of the fear of success. In her book Overcoming the Fear of Success, Dr. Martha Friedman talks about the difference between external and internal success. External success consists of all the trappings of fortune, fame, power, prestige, and possessions. But without internal success, external success is hollow, leaving us unfulfilled and asking, “Is that all there is?” In Dr. Friedman’s words, “The sort of success I mean consists of this: getting to do what you really want to do in your work life and in your love life, doing it very well, and feeling good about yourself doing it. The fear of success is not getting what you really want because you unconsciously feel you don’t deserve it.”

Dr. Friedman sees the fear of success as a paradox: “On a conscious level, everyone wants to be successful. But on an unconscious level, it’s quite a different story. There, in the unconscious, is where many of us do our best, without realizing it, to ensure that success is never reached and, if it is, that it doesn’t last.” This concept is not new. Freud found that people occasionally fell ill precisely because a deeply seated and long cherished wish had been fulfilled. According to Freud, apparently “they could not endure their bliss, for the causative connection between this fulfillment and the falling ill there can be no question.”

One person who has had more than his share of success and failure is British billionaire entrepreneur and adventurer Sir Richard Branson. The “rebel billionaire” has been called the closest thing there is to a real James Bond. He presides over more than 200 companies and 50,000 employees, and now is working on Virgin Galactic, an airplane/spaceship that will take people into suborbital space, where they will experience weightlessness and see the curvature of the earth. Yet Branson has had to overcome his own difficulties, including mild dyslexia and a poor academic record. In fact, he dropped out of high school to start publishing a magazine, and the seeds of success were planted when he began a business of selling records.

But Branson is not all about business. He has risked life and limb in pursuit of various ventures, such as his several unsuccessful attempts to circumnavigate the world in a hot air balloon. Four times he has been forced to be pulled out of cold angry seas by rescue helicopters. But in the process of singing his song, Branson has set records for crossing the Atlantic in a boat in the fastest time and time and distance records for flying a hot air balloon across the Pacific. Branson says that, while the many businesses he has started play an important role in his life, “equally as important is my belief that every minute of every day should be lived as wholeheartedly as possible.” As for singing his song, Branson says: “Sometimes I wake up in the mornings and feel like I’ve just had the most incredible dream. I’ve just dreamt my life.”

Neil Young has been writing and singing songs since he was a teenager in the 1960s and has no thoughts of stopping. He doesn’t do it for the adulation of millions, once stating: “I don’t give a f*** if my audience is a hundred or a hundred million. It doesn’t make any difference to me. I’m convinced that what sells and what I do are two completely different things. If they meet, it’s a coincidence.”

Like his music, Young is always evolving. His parents divorced when he was ten, and some of the closest people to him have died from drug overdoses. Yet Young remains passionate about singing his song, metaphorically and literally. Young’s philosophy is best summed up in the name of his song Rust Never Sleeps.

Once you know your song, when are you going to start singing it? When you graduate from college? When you get married? When you have your first child? When your last child leaves home? When you turn a pivotal age, like 30, 40, or 50? When you retire? Emerson said that “we are always getting ready to live, but never living.” Dyer observes that “‘futurizing’ can become the most destructive of habits. The present is always used up in planning for the future, which never quite comes.”  As John Lennon so eloquently put it, “Life is what happens when you’re busy making other plans.”

Before you know it, there is little or no future left to sing your song. Or the unexpected gets in the way—a heart attack, a car accident, the birth of a child with a serious physical or mental defect. Life often does not turn out the way we hope or plan; every moment is precious.

The late psychologist Rollo May once had a client who stated that he knew only two things: one, that he would be dead someday, and, two, that he was not yet dead. The client said, “The only question is what shall I do between those two points.” The student would be well-advised to take author Henry James’s advice and “[l]ive all you can; it’s a mistake not to.”

8 TIPS TO LIVING YOUR DREAMS

1. Make Every Day Count. Dr. Teddy Blecher, co-founder of the Community and Individual Development Association (CIDA) City Campus in Johannesburg, South Africa, states that when you look back on your deathbed one day and ask, “Was it all worth it? Will you be able to say every day would have made it worth it?”

2 . Learn to Enjoy Life. 19th Century Baptist preacher Charles Spurgeon stated, “It is not how much we have, but how much we enjoy that makes happiness.” The Talmud states that “everyone will be called to account for all the legitimate pleasures which he or she has failed to enjoy.”

3. Don’t Worry, Be Happy. His Holiness the Dalai Lama believes that the purpose of life “is to be happy. From the core of our being, we simply desire contentment.” Gandhi said, “Happiness is when what you think, what you say, and what you do are in harmony.”

4. Stop and Smell the Roses. Famed University of Chicago psychologist Mihaly Csikszentmihalyi says that, “It really does not make sense to go through the motions of existence if one does not appreciate as much of it as possible.”

5. Live in the Moment and Be Aware. Eric Berne, M.D., the father of transactional analysis, said, “The aware person is alive because he knows how he feels, where he is and when it is. He knows that after he dies the trees will still be there, but he will not be there to look at them again, so he wants to see them now with as much poignancy as possible.”

6. Be Yourself. In Hamlet, Polonius exhorts, “This above all: to thine own self be true.”

7. Things Aren’t Important . . . Contemporary spiritual leader and author Eckhart Tolle writes in A New Earth, “Many people don’t realize until they are on their deathbed and everything external falls away that no thing ever had anything to do with who they are. In the proximity of death, the whole concept of ownership stands revealed as ultimately meaningless.”

8. . . . Relationships Are. The Dalai Lama teaches that, “The need for love lies at the very foundation of human existence. It results from the interdependence we all share with one another. However capable and skillful an individual may be, left alone he or she will not survive.”

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The King of Torts and I: Personal Reminiscences of Melvin Belli


2010
04.26

Posted in Biography/Memoir | No Comments »

On November 15, 1933, a then twenty-six year old Melvin Belli was formally sworn in as a member of the California State Bar. Sixty-three years, seven months, and twenty-four days later–nineteen days short of his 89th birthday–Melvin Belli died in the midst of bankruptcy litigation regarding his continuing ability to manage his firm.

In the interim, depending upon your point of view, Melvin Belli became a legend or an outlaw, the greatest trial lawyer of modern times or the biggest ham ever to walk into a courtroom.

To some, he was the “King of Torts,” the father of demonstrative evidence, the dean of medical malpractice, the fighter for the “little guy.” To others, he was a flamboyant, cocky, reckless lawyer who cared more about publicity and self-promotion than about his clients. I think there’s some truth to both sides. I should know. I had the rare privilege of knowing the real Melvin Belli.

In September, 1979, about six weeks after taking the California bar exam, I went to work for Melvin Belli in the historic Belli Building built in the 1840′s on the then infamous San Francisco Barbary Coast. I worked directly for Mr. Belli, not the firm. My office was in the basement, which I fondly called “the dungeon.” I didn’t mind. There was a spiral staircase connecting our two offices, and I heard everything that was said in his office. That itself was quite a learning experience.

I was hired to help him revise Modern Trials, his landmark work on tort law, trial techniques, and demonstrative evidence that was originally published in 1954, a year before I was born. During the first months of working for Mr. Belli, I kept a low profile, just doing my research and writing the best I could. After six months, Mr. Belli finally took me into his confidence. Our relationship slowly developed into one of which I have often called “father-son,” but it went much deeper than that.

When I began working for him in 1979, Melvin Belli was 72 years old. His mind was still sharp, his energy could be boundless (although he would sometimes fall asleep in his office in the afternoon, especially after a heavy lunch that included several full glasses of the best wine produced by California’s Napa and Sonoma Valleys vineyards), and his mood was unpredictable and stormy. One second he could charm the shirt off your back; the next he could turn on you like a rabid dog. I was fortunate: we always got along and never did an unkind word pass between us.

But at 72, Melvin Belli’s legendary days of hard drinking and womanizing were long gone. His life was really quite conservative when I knew him best. Some days his age would catch up with him and it was painful watching him struggle to walk. He would get angry with himself for forgetting things, for not having the same mental acuity and abilities he had had at his peak. He knew that Father Time was deteriorating his skills and ability as a lawyer, but he tried to deny it and fought it with all his might.

One of the best things about my relationship with Melvin Belli was that, at least once or twice a week when he was in town, he and I would go out for a two- or three-hour lunch by ourselves. This was quite an honor, since he usually went to lunch with a rather large entourage.

During our private lunches, Mr. Belli and I would chat about how the book, article, speech, etc., I was writing at the time was going, and how his cases were coming along. The best times, though, were when he had had a bit too much of the grape and fondly and longingly reminisced about long-ago cases and colleagues, friends, and celebrities he had known, many of whom had passed away years ago.

I remember an interview with George Burns a few years before he died, and he was asked what the worst thing about growing old was. Mr. Burns replied that it was missing all of the old friends from the early days, when everyone was struggling to make it, yet they were a close-knit family with an unbreakable bond. I knew Melvin Belli felt the same way about all of his colleagues who had died years earlier.

Melvin Belli liked to regale the media with his celebrated cases and drop names whenever he could. But when the two of us were alone at lunch, the cases he liked to talk most about–and seemed proudest of–were his earlier cases helping the average person, the “little guy” who had no money or power to fight the big corporations. Cases such as the diner waitress who picked up an unopened bottle of Coca-Cola which shattered in her hand, seriously injuring her, or the longshoreman who lost a leg because of a defective forklift. The blue-collar guy who was working long hours for small pay to put sausage or spaghetti on the table for his family; that was the person Melvin Belli loved to represent–especially if there was a large corporation or doctor on the other side.

Melvin Belli loved to talk about the early days when awards were minuscule and how he slowly got them raised. He told me about how he used demonstrative evidence to get a jury to award $5,000 for a client who had lost an arm, when the highest verdict before that was $3,000, and how in his next case he managed to obtain $7,500, then $10,000 for the same type of injury.

His whole life was based around getting his client an “adequate award.” He was not interested in the excessive award, at least not in the old days; all he wanted was that amount of money which fairly and reasonably compensated his clients for the losses they had suffered.

He told me how hard it was in the old days to win even the most obvious cases of medical malpractice, because the doctors’ “code of silence” was so strong it was nearly impossible to get a doctor to testify against a colleague. He often used a doctor he referred to variously as “sober-him-up” Smith or “clean-him-up” Smith, to whom the defense lawyer’s first question always was, “Are you still on probation, Dr. Smith?”

Another story he told me concerned a doctor he had brought into the office to interview as a potential expert witness. After explaining the case and the client’s injuries, the doctor went on a thirty-minute detailed explanation about the cause of the injuries and their severity, or rather lack thereof. After the doctor had finished, Mr. Belli said, “I’m afraid we won’t be able to use you, because that’s exactly what the insurance company is going to say.”

The doctor did a complete 180 and said, “Oh, I was just telling you what the insurance company’s doctor will testify to. Now in my opinion, . . ..” Mr. Belli used the doctor, won a large verdict, and the doctor was paid handsomely. One can’t be too critical of Melvin Belli for this episode, because, unfortunately, as we all know, this practice still occurs all too frequently today–on both sides.

At our luncheons, Melvin Belli would recount stories of his pioneering works in the use of demonstrative evidence, discovery procedures, and trial techniques. For instance, he told me how he was one of the first–if not in fact the first–attorneys to utilize a videotaped deposition in the case of Buehler v. Hilton in the 1950s. (In reality, it was not videotaped but recorded using the latest motion picture equipment of the day.) The plaintiff’s arm and leg had been cut off by the propeller when she was thrown out of hotel magnate Conrad Hilton’s speed boat while racing along the waters of Lake Arrowhead in the mountains east of Los Angeles. The jury awarded Ms. Buehler $265,000.00, probably the highest award to that date for the type of injuries she suffered.

As for Melvin Belli’s oratorical skills, I think the Houston Post said it best when it described his summation in the notorious case of Jack Ruby, the accused murderer of Presidential assassin Lee Harvey Oswald:

Gifted by nature with a velvety, hypnotic voice that could charm cobras out of their baskets . . . he played that voice like a symphony. It was by turns a Stradivarius, a bugle, an oboe, a snare drum racing at breakneck speed though the key pages of the trial testimony.

Besides his innovations in the use of demonstrative evidence, Melvin Belli also made important changes to the substantive law with his many books, articles, and cases. One important case in particular was Escola v. Coca Cola,1 a 1944 decision of the California Supreme Court. In that case, then Associate Justice Roger Traynor laid out in a concurring opinion the rule of strict products liability that would ultimately be adopted nearly twenty years later by the California Supreme Court in Greenman v. Yuba Power Products, Inc.2 Not long after, the drafters of the Restatement (Second) of Torts expressly adopted this rule in section 402(a).

Melvin Belli had many important victories over his lifetime, but he also had his share of losses, sometimes with devastating effects. For instance, one time he lost a wrongful death case and, after the verdict was read, the widow went home and committed suicide. Mr. Belli was devastated by this and blamed himself for her death, even though he had done everything he could to win at trial and was completely blameless.

I talked with him a few hours after he learned of the tragic news of the widow’s suicide. The depth of sorrow and guilt in his voice that day is indescribable. He cared for his clients, deeply and sincerely, as if they were members of his own family.

One day I was in Mr. Belli’s office when a reporter asked him whether he was an ambulance chaser. With his usual playfulness, Mr. Belli instantly roared: “Hell, no. I get there first! I wouldn’t be much of a lawyer if I didn’t. The next person who says I’m an ambulance chaser I’m going to sue for defamation!” The reporters, cameramen, and their assistants laughed uproariously.

Melvin Belli didn’t need to chase cases. Every day he would receive dozens of letters and the phones would ring off the hooks with calls from prospective clients wanting to be represented by the legendary lawyer. And every day attorneys from around the country would call to see if they could refer a case to Mr. Belli, or to ask Mr. Belli if he would associate in on a case with them and the two of them could try the case together.

Still that wasn’t enough to stop Melvin Belli from joining in the race for the roses in a big disaster. And he wasn’t always subtle about it, either. Probably the most obvious example was when a plane went down in Dallas, and he went so far as to rent a suite for use as an office in the same hotel the airliner was putting up the families of the dead.

But if you’re going to criticize Melvin Belli for rushing to the scene of a disaster, you’re also going to have to criticize hundreds, perhaps even thousands, of other lawyers for doing the same thing. Every time an airliner goes down or a hotel goes up in fire, or there is some other disaster, within hours lawyers from across the country are on the scene, using motor homes, folding tables and chairs, or whatever they can find as their “offices.”

Part of the game in a mass disaster is to sign up the first client and hold the first press conference, hoping that the exposure will result in other potential clients contacting you. Melvin Belli was a master of this technique, and enjoyed the added bonus of a great working relationship with the media that he had nurtured over many years. Every reporter knew that, if they were looking for a good quote, Melvin Belli was their man. So as soon as he arrived at the “scene of the crime,” reporters would scramble to get a sound bite from him to air on the evening news.

In all fairness, no matter how quickly they got there, Melvin Belli and the other plaintiffs’ lawyers still arrived on the scene hours after the insurance company’s adjusters and “grief counselors” had already visited each family, telling them that they didn’t need to hire a lawyer right away–especially not a big-time attorney–as they would help them through their grief and provide for them during this difficult period and “do right” by them.

The publicity in the last ten years of Melvin Belli’s life was more often on the negative side, focusing on Mr. Belli’s personal and professional turmoil and deteriorating skills. What gets lost is the tremendous contribution he made to the law over six decades. For the many years he was at or near his peak, he was without a doubt the best trial lawyer in the country, the Clarence Darrow of modern times, the last of a now-vanished breed.

And unlike a lot of other successful lawyers, Melvin Belli gave a lot back in return. If his schedule could accommodate it, he would rarely turn down an invitation to speak at a law school, local bar meeting, women’s garden club, or anywhere else that wanted to have him. And unlike today’s lawyers turned celebrities, he didn’t charge for his appearances. In fact, he often paid his own way. He just wanted to share his love for the law.

In the mid-1940s, Melvin Belli and a handful of other lawyers banded together and formed the National Association of Claimant and Compensation Attorneys (NACCA). This small group eventually evolved into today’s Association of Trial Lawyers of America, over 70,000 members strong but still true to the original intent of amity among plaintiffs’ lawyers, who find it much more effective to work together to fight Melvin Belli’s arch nemesis, the old “Holy Grail Insurance Company.” In 1950 and 1951, Mel even found the time to serve as President of ATLA.

Long-time members of ATLA will undoubtedly fondly recall years of attending the annual Belli Seminar, a two-day whirlwind at which top lawyers from around the country would talk ten or fifteen minutes about the latest trial victory, offering their secret strategies to a thousand or more lawyers who dared not leave their seat lest they miss the key advice that just might help them win their next case.

Every year it was chaos: Mel would always invite more speakers than could possibly be accommodated even in a week, let alone two days. Feelings were hurt, and egos were crushed of those who had been personally invited by Mel but didn’t get to speak because there simply wasn’t enough time for them. But come the next year, all would be forgotten and forgiven.

During his life, Melvin Belli did more to help the underdog and raise public awareness than anyone else. He was the original consumer protectionist. It is to him that people like Ralph Nader owe a great debt, as his efforts made their jobs much easier.

Every consumer and consumer lawyer should take a moment of silence to thank Melvin Belli for his never-ending crusade to make the world a safer–and better–place to live. I’m sure that many insurance companies, manufacturers, doctors, and their defense lawyers have already thanked God that Melvin Belli’s gone.

About 10 years before his death, I had secretly started wishing that Mr. Belli would just retire and become the elder statesman of law, making the rounds at law schools, colleges, television and radio talk shows, or become a legal analyst for a television network. Nonetheless, I always said that Mr. Belli would never retire, because law was his life, his love, his soul, indeed, his very reason for being. If he couldn’t practice law, I used to say, he would be dead the next day.

On July 3, 1996, a bankruptcy judge ruled that Melvin Belli was unfit to run his own office, and appointed a financial examiner to supervise the bankruptcy of Mr. Belli’s firm, which was allegedly heavily in debt. Six days later, Melvin Belli died.

After an autopsy amid suggestions of a “suspicious death,” the coroner listed hypertension and coronary disease as the official cause of death. Mr. Belli was also suffering from pancreatic cancer and pneumonia at the time, and had had a severe stroke a month or so earlier. But none of these killed Melvin Belli.

What killed Melvin Belli was the heartbreak of essentially being told that he was no longer competent to be a lawyer. The judge’s decision that Melvin Belli was unfit to manage his own law office was the death knell’s toll that killed him six days later.

I always thought he would die a more romantic death, in his sleep on an airliner coming home from Tibet, or at the end of an impassioned plea to save his client from the gallows–which his detractors would most likely criticize as just another gimmick to gain the jurors’ sympathy for his client.

One sad note is that Mr. Belli did not live long enough to see the tobacco industry finally brought to justice. He started battling the cigarette companies in the 1960s, claiming back then that nicotine was addictive and smoking causes lung cancer and other diseases. The day is coming closer that the tobacco industry will have to face the music. When the cases start going against the cigarette companies, I will take solace in the fact that the first refrains were written by Melvin Belli.

As for me, I found Mel to be a legal genius on one hand, and a constant attention-seeker on the other. Maybe it was the “only child” syndrome. I don’t know. Mel would sometimes resort to near buffoonery, and the media would rather write about his flamboyancies than his serious contributions to the law because it was more colorful and made better “copy.”

Mel, to me, was a dear, kind man, as loving as he could possibly be toward anyone. But deep down, Mel was an extremely lonely person with few, if any, real friends. I think that Mel may have had a deep fear of personal rejection which caused him to reject his friends and wives before, he feared, they rejected him. Yet whatever personal faults he may have had, Melvin Belli did more for tort law and consumers than any lawyer had and probably ever will single-handedly. The world is a better–and safer–place thanks to Melvin Belli, words that can be said of very few people.

Some years ago, after a particularly horrendous natural disaster had resulted in the loss of thousands of lives, one political cartoon depicted Melvin Belli, briefcase in hand, standing on the top of a mountain, with the words booming across the sky, “It’s Melvin Belli to see you, Lord.”
That’s the kind of person Melvin Belli was. He didn’t care whom he had to sue or whose feet he had to step on to get justice for the little guy. I imagine that in heaven now, he’s already got a complaint filed and depositions scheduled.

FOOTNOTES

1. 24 Cal.2d 453, 461 (1944) (Traynor, J., concurring).
2. 59 Cal.2d 57 (1983)