Mind: A Misguided Focus on Mental Illness in Gun Control Debate

The gunman, Adam Lanza, 20, has been described as a loner who was intelligent and socially awkward. And while no official diagnosis has been made public, armchair diagnosticians have been quick to assert that keeping guns from getting into the hands of people with mental illness would help solve the problem of gun homicides.

Arguing against stricter gun-control measures, Representative Mike Rogers, Republican of Michigan and a former F.B.I. agent, said, “What the more realistic discussion is, ‘How do we target people with mental illness who use firearms?’ ”

Robert A. Levy, chairman of the Cato Institute, told The New York Times: “To reduce the risk of multivictim violence, we would be better advised to focus on early detection and treatment of mental illness.”

But there is overwhelming epidemiological evidence that the vast majority of people with psychiatric disorders do not commit violent acts. Only about 4 percent of violence in the United States can be attributed to people with mental illness.

This does not mean that mental illness is not a risk factor for violence. It is, but the risk is actually small. Only certain serious psychiatric illnesses are linked to an increased risk of violence.

One of the largest studies, the National Institute of Mental Health’s Epidemiologic Catchment Area study, which followed nearly 18,000 subjects, found that the lifetime prevalence of violence among people with serious mental illness — like schizophrenia and bipolar disorder — was 16 percent, compared with 7 percent among people without any mental disorder. Anxiety disorders, in contrast, do not seem to increase the risk at all.

Alcohol and drug abuse are far more likely to result in violent behavior than mental illness by itself. In the National Institute of Mental Health’s E.C.A. study, for example, people with no mental disorder who abused alcohol or drugs were nearly seven times as likely as those without substance abuse to commit violent acts.

It’s possible that preventing people with schizophrenia, bipolar disorder and other serious mental illnesses from getting guns might decrease the risk of mass killings. Even the Supreme Court, which in 2008 strongly affirmed a broad right to bear arms, at the same time endorsed prohibitions on gun ownership “by felons and the mentally ill.”

But mass killings are very rare events, and because people with mentally illness contribute so little to overall violence, these measures would have little impact on everyday firearm-related killings. Consider that between 2001 and 2010, there were nearly 120,000 gun-related homicides, according to the National Center for Health Statistics. Few were perpetrated by people with mental illness.

Perhaps more significant, we are not very good at predicting who is likely to be dangerous in the future. According to Dr. Michael Stone, professor of clinical psychiatry at Columbia and an expert on mass murderers, “Most of these killers are young men who are not floridly psychotic. They tend to be paranoid loners who hold a grudge and are full of rage.”

Even though we know from large-scale epidemiologic studies like the E.C.A. study that a young psychotic male who is intoxicated with alcohol and has a history of involuntary commitment is at a high risk of violence, most individuals who fit this profile are harmless.

Jeffery Swanson, a professor of psychiatry at Duke University and a leading expert in the epidemiology of violence, said in an e-mail, “Can we reliably predict violence?  ‘No’ is the short answer. Psychiatrists, using clinical judgment, are not much better than chance at predicting which individual patients will do something violent and which will not.”

It would be even harder to predict a mass shooting, Dr. Swanson said, “You can profile the perpetrators after the fact and you’ll get a description of troubled young men, which also matches the description of thousands of other troubled young men who would never do something like this.”

Even if clinicians could predict violence perfectly, keeping guns from people with mental illness is easier said than done. Nearly five years after Congress enacted the National Instant Criminal Background Check System, only about half of the states have submitted more than a tiny proportion of their mental health records.

How effective are laws that prohibit people with mental illness from obtaining guns? According to Dr. Swanson’s recent research, these measures may prevent some violent crime. But, he added, “there are a lot of people who are undeterred by these laws.”

Adam Lanza was prohibited from purchasing a gun, because he was too young. Yet he managed to get his hands on guns — his mother’s — anyway. If we really want to stop young men like him from becoming mass murderers, and prevent the small amount of violence attributable to mental illness, we should invest our resources in better screening for, and treatment of, psychiatric illness in young people.

All the focus on the small number of people with mental illness who are violent serves to make us feel safer by displacing and limiting the threat of violence to a small, well-defined group. But the sad and frightening truth is that the vast majority of homicides are carried out by outwardly normal people in the grip of all too ordinary human aggression to whom we provide nearly unfettered access to deadly force.

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European Mobile Stocks Fall After Costly Spectrum Auction

BERLIN — Shares of four big European cellphone operators fell Monday after they paid more than twice what investors had been expecting in a spectrum auction in the Netherlands, raising concern that a damaging bidding war could sap the industry.

The Dutch auction began Oct. 31 and ended Friday, raising 3.8 billion euros, or $5 billion, for spectrum that the companies plan to use for high-speed service using Long Term Evolution, or LTE, technology. But analysts warned that the sale, to be followed next year by a much larger spectrum auction in Britain, could herald a new round of expensive infrastructure levies that might restrict operators at a time when their sales have been stagnating.

The winners were KPN, the former Dutch monopoly; Vodafone, the British mobile group; the German company T-Mobile; and the Swedish operator Tele2.

LTE supports all of the typical high-speed applications, including audio and video streaming and Internet browsing, but is much faster, cutting download times and significantly expanding the capacity of existing networks to handle increases in data traffic.

After the bidding, KPN, which is owned in part by the Mexican communications mogul Carlos Slim Helú, canceled its dividend for 2012 and lowered its projected investor payout for 2013 to cover the 1.35 billion euros the company spent in the auction.

On Monday, the first day of stock trading after the completion of the auction, shares of KPN fell nearly 15 percent in Amsterdam, the steepest drop in more than a decade. Shares of Vodafone were down 1.7 percent by the close of the day in London. Shares of Deutsche Telekom, the parent company of T-Mobile, fell 0.3 percent in Frankfurt, and shares of Tele2 declined 1 percent in Stockholm.

“The money raised in the Dutch auction was a lot more than investors were expecting,” said Phil Kendall, an analyst at Strategy Analytics in Milton Keynes, England. “The concern now is that the sums will now be so great the technology will be unprofitable.”

Mr. Kendall said mobile operators were eager to obtain additional spectrum because extensive bandwidth had become increasingly critical to handle the explosion of mobile Internet data, which is testing the capacity of some carriers’ grids and causing overloading.

“Really, for many operators, the only way they will be able to differentiate themselves from other operators is by having enough spectrum to manage the demand on their services,” Mr. Kendall said. “That is why there is such intense interest in buying more frequency.”

More radio spectrum, or wireless network capacity, is crucial to delivering the high speeds advertised for LTE, which theoretically can produce download rates of up to 300 megabits per second on a wireless connection. Such speeds and the expanded capacity of the networks are considered essential to support the rapid expansion of the wireless Internet, as well as the increasing use of mobile grids for robotic communication between devices.

Speeds on the first generation of LTE networks activated in Germany, South Korea, Sweden and the United States have averaged much less, generally 10 to 25 megabits per second, in part because operators do not have enough spectrum to exploit the technology’s full potential.

The Dutch auction also raised the specter of another costly round of infrastructure fees on the cellphone industry similar to those in 1999 and 2000, when operators paid billions for the first European 3G mobile licenses.

Investors were concerned that the Dutch prices could set a precedent for auctions planned in Britain and perhaps Poland next year, as well as others that will be held across Europe over the next five years, as bandwidth is freed up and sold by national governments to wireless carriers. Germany, which held its latest spectrum auction in 2010, has indicated that it may hold another in 2016.

Those license sales in 1999 and 2000, engineered in most cases by governments to extract the maximum from mobile operators, led to large profit write-downs by operators including Vodafone and Telefónica, which owns the carrier O2.

With completion of the Dutch auction, the focus will now shift to Britain, where the sector’s regulator is planning to begin its spectrum auction in January.

All four British mobile network operators are expected to bid: Everything Everywhere, the venture of Deutsche Telekom and France Telecom; Vodafone; O2 U.K.; and 3, a unit of Hutchison Whampoa. The former landline monopoly BT has not ruled out a potential bid, which could further raise the stakes.

Matthew Howett, an analyst at Ovum, a research firm in London, said the British auction could raise £2 billion to £4 billion, or $3.2 billion to $6.5 billion.

“The £2 billion to £4 billion range that is widely touted is based on similar auctions elsewhere in Europe,” he said. “There is nothing to suggest that the U.K. should be any different. It’s possibly the most competitive market in Europe and all existing operators will want to make sure they walk away with spectrum to feed the almost insatiable appetite we in the U.K. now have for data.”

This article has been revised to reflect the following correction:

Correction: December 17, 2012

An earlier version of this article erroneously stated the amount paid by KPN for spectrum in the auction. It was 1.35 billion euros, not $1.35 billion.

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After Philippines Birth Control Law Passes, Churches Call for Resistance

MANILA — After losing a battle to stop the passage of a contentious birth control law, Roman Catholic Church officials on Tuesday dug in and instructed their millions of followers to campaign against the measure in communities, schools and homes.

“Let us intensify the moral spiritual education of our youth and children so that they can stand strong against the threats to their moral fiber,” Archbishop Socrates Villegas said in a statement. “Let us use all the means within our reach to safeguard the health of expectant mothers in our communities.”

The Philippine Congress passed legislation on Monday to help the country’s poorest women gain access to birth control. Each chamber of the national legislature passed its own version of the measure, and minor differences between the two must be reconciled before the measure goes to President Benigno S. Aquino III for his signature.

The measure had been stalled for more than a decade because of determined opposition from the church in this overwhelmingly Catholic country.

Birth control is legal and widely available in the Philippines for people who can afford it, particularly those living in cities. But condoms, birth control pills and other forms of contraception are sometimes kept out of community health centers and clinics by local government and Catholic Church officials.

The measure passed on Monday would stock government health centers, including those in remote areas, with free or subsidized birth control options for the poor. It would also require sex education in public schools and family-planning training for community health officers.

Archbishop Villegas, the vice president of the Catholic Bishops Conference of the Philippines, on Tuesday encouraged Catholics to resist the measure by disseminating information about natural family planning methods and warning people about “the hazardous effects of contraceptive pills on the health of women.”

“Let us conduct our own sex education of our children insuring that sex is always understood as a gift of God,” Archbishop Villegas stated. “Sex must never be taught separate from God and isolated from marriage.”

Bishop Gabriel V. Reyes, chairman of the conference’s Episcopal Commission on Family and Life, said after the vote Monday that “we need to explain to our fellow believers that they ought to refuse contraceptives even when they are being offered these.”

The Philippines has one of the highest birthrates in Asia, but backers of the legislation, including the Aquino administration, have said repeatedly that its purpose is not to limit population growth. Rather, they say, the bill is meant to offer poor families the same reproductive health options that wealthier people in the country enjoy.

Though lacking the numbers needed to defeat the legislation, lawmakers who opposed the measure sought to delay the vote. In one instance, an opposition senator proposed 35 amendments just before a vote was to take place.

Often the debate took bizarre turns, as when a congressman claimed that the birth control measure was a plot by the Philippine Communist Party to take over the government.

In another instance, a male senator requested removal of the phrase “satisfying sex” from a passage in the bill that referred to “safe and satisfying sex.” Several female senators opposed its removal, and the amendment was debated live on television while social media networks crackled with sarcastic commentary. “I am a Filipina,” Senator Miriam Santiago said in response to the amendment. “I am also a married woman and I insist whoever is married to me should give me safe and satisfying sex, period.”

During a vote on the measure in the House of Representatives, the boxer and congressman Manny Pacquiao linked the birth control measure to his having been knocked unconscious on Dec. 8 by Juan Manuel Marquez during their W.B.O. world welterweight fight in Las Vegas.

“Some thought I was dead,” Mr. Pacquiao said in a speech explaining his vote against the measure. “What happened in Vegas strengthened my already firm belief in the sanctity of life.” He added: “Manny Pacquiao is pro-life. Manny Pacquiao votes no.”

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In Spain, Having a Job No Longer Guarantees a Paycheck

Samuel Aranda for The New York Times

Raul, a truck driver in Castellón, Spain, hoped last month to be paid from a government fund. Courts are jammed with requests.

VALENCIA, Spain — Over the past two years, Ana María Molina Cuevas, 36, has worked five shifts a week in a ceramics factory on the outskirts of this city, hand-rolling paint onto tiles. But at the end of the month, she often went unpaid.

Still, she kept showing up, trying to keep her frustration under control. If she quit, she reasoned, she might never get her money. And besides, where was she going to find another job? Last month, she was down to about $130 in her bank account with a mortgage payment due.

“On the days you get paid,” she said at home with her disabled husband and young daughter, “it is like the sun has risen three times. It is a day of joy.”

Mrs. Molina, who is owed about $13,000 by the factory, is hardly alone. Being paid for the work you do is no longer something that can be counted on in Spain, as this country struggles through its fourth year of an economic crisis.

With the regional and municipal governments deeply in debt, even workers like bus drivers and health care attendants, dependent on government financing for their salaries, are not always paid.

But few workers in this situation believe they have any choice but to stick it out, and none wanted to name their employers, to protect both the companies and their jobs. They try to manage their lives with occasional checks and partial payments on random dates — never sure whether they will get what they are owed in the end. Spain’s unemployment rate is the highest in the euro zone at more than 25 percent, and despite the government’s labor reforms, the rate has continued to rise month after month.

“Before the crisis, a worker might let one month go by, and then move on to another job,” said José Francisco Perez, a lawyer who represents unpaid workers in the Valencia area. “Now that just isn’t an option. People now have nowhere to go, and they are scared. They are afraid even to complain.”

No one is keeping track of workers like Mrs. Molina. But one indication of their number can be seen in the courts, which have become jammed with people trying to get back pay from a government insurance fund, aimed at giving workers something when a company does not pay them.

In Valencia, Spain’s third-largest city, the unemployment rate is 28.1 percent and the courts are so overwhelmed that processing claims, which used to take three to six months, now takes three to four years.

Since the start of the crisis in 2008, the insurance fund has paid nearly a million workers nationally back pay or severance. In 2007, it paid 70,000 workers. It is on track to pay more than 250,000 this year, and experts say the figures would be much higher if not for the logjam in the courts.

Often the unpaid workers, like Mrs. Molina, whose company is now in bankruptcy proceedings, hope their labor will keep a struggling operation afloat over the long run. Unemployment benefits last only two years, they point out, and they wonder what they would do after that. But in the meantime, they cannot even claim unemployment benefits. And no amount of budgeting can cover no payment at all.

Beatriz Morales García, 31, said she could not remember the last time she went shopping for herself. A few years ago, she and her husband, Daniel Chiva, 34, thought that they had settled into a comfortable life, he as a bus driver and she as a therapist in a rehabilitation center for people with mental disabilities. His job is financed by the City of Valencia, and hers by the regional government of Valencia.

They never expected any big money. But it seemed reasonable to expect a reliable salary, to take on a mortgage and think about children. In the past year, however, both of them have had trouble being paid. She is owed 6,000 euros, nearly $8,000. They have cut back on everything they can think of. They have given up their landline and their Internet connection. They no long park their car in a garage or pay for extra health insurance coverage. Mr. Chiva even forgoes the coffee he used to drink in a cafe before his night shifts. Still, the anxiety is constant.

“There are nights when we cannot sleep,” he said. “Moments when you talk out loud to yourself in the street. It has been terrible, terrible.”

Mrs. Morales said it was particularly hard to watch other mothers in the park with their children while she must leave her own toddler to go to work, unsure she will ever get paid.

“We are working eight hours, and we’re suffering more than people who are not working,” she said.

The couple’s pay has been so irregular that they are having a hard time even keeping track of how much they are owed, because small payments show up sporadically in their account.

Rachel Chaundler contributed reporting.

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The New Old Age Blog: In the Middle: Why Elderly Couples Fight

George and Gracie (let’s call them that because using their real names would make them even unhappier than they already appear to be) are in their 80s and married for more than 65 years. Until recently they seemed to ride the waves that are inevitable in any marriage that spans nearly seven decades; through good and bad, they were partners and best friends.

But lately — ever since her hospitalization and his fall — they have been arguing more bitterly than usual (“Do you have to make such a mess in the kitchen?”), criticizing each other (“Why haven’t you dealt with the insurance company yet?”), withdrawing from each other, and generally making each other more miserable, more often than ever before.

This kind of degenerative relationship is not uncommon among the elderly in even the happiest marriages, marriage therapists and geriatricians said. But that is small comfort to either the couple in the middle of the maelstrom, or the children who care for them, as evidenced by a number postings on caregiver blogs. As some of the children have wondered there: “Why can’t we all just get along?”

Therapists and others who work with the elderly said the first step to addressing the problem is understanding where it came from.

“A key question is whether the marital bickering is part of a lifelong marital style or a change,” said Dr. Linda Waite, director of the Center on Aging at NORC/University of Chicago. Is it new behavior – or just new to the grown children who are suddenly so deeply enmeshed in their parents’ lives that they are only now noticing that something is amiss?

How much of the problem is really just the marriage style? “Some couples like to fight and argue – it keeps their adrenaline going,” said Dr. Nancy K. Schlossberg, professor emerita of counseling psychology at the University of Maryland and author of “Overwhelmed: Coping with Life’s Ups and Downs.”

Sometimes the best judges of whether there is a problem are outsiders, said Dr. William Dale, chief of geriatrics at the University of Chicago Geriatrics Medicine. Pay attention if someone says, “‘Gee, Mom seems more argumentative or withdrawn than the last time I saw her,’” Dr. Dale advised.

If the tone or severity of the marital tensions seem new, then it is important to find out why. The causes could be mental or physical, doctors say.

On the mental front, increased anger and fighting could be one of the first signs of mild cognitive impairment, a precursor of dementia or Alzheimer’s, in one or both of the spouses, said Dr. Lisa Gwyther, director of the Duke Center for Aging Family Support Program and Associate Professor in the Department of Psychiatry and Behavioral Sciences.

Dr. Dale concurs: “There is good evidence that the earliest signs of cognitive impairment are often emotional changes” — anger, anxiety, depression — “rather than cognitive ones” — memory, abstract thought.

But these early signs of cognitive decline can be so subtle that neither the spouses themselves, or their grown children, recognize them for what they are, Dr. Gwyther said. So husband and wife blame each other for the changes and allow feelings of hurt and resentment to grow.

Withdrawing from activities that used to give them pleasure can be a telltale sign of mild cognitive impairment – and can trigger anger and arguments.

“In one couple, the husband just didn’t want to participate in the holidays — the wife got angry and said he was being lazy and stubborn,” said Dr. Gwyther. But the truth was that his cognitive decline made all the activity overwhelming, and he didn’t want anyone to know that he was anxious about not remembering everyone’s names and embarrassing himself.

Suspicion and paranoia can also accompany mild cognitive decline and precipitate distrust and hurtful accusations. Dr. Gwyther recalled another woman who “called her daughter frantic because she said her husband dropped her at her chemo appointment, went to park the car, and didn’t return to get her.” The woman couldn’t imagine that her husband could possibly have lost his sense of time and direction, Dr. Gwyther added. She took it personally, complaining to her daughter that “your father doesn’t seem to care any more.”

Dr. Dale told of a spouse who accused her mate of infidelity because “she was convinced that when he was out grocery shopping he was really having an affair.”

Hoarding, an early symptom of mild cognitive impairment, can also create tension in a marriage. (For new treatments, see this recent post by my colleague Paula Span.)

When one couple came to a counseling session with Dr. Norman Abeles, emeritus professor of psychology and former director of psychological clinic at Michigan State University, the hoarding spouse finally said, “she did it because she thought that they would run out of money, even though there was enough money to go around.” Dr. Abeles said that incident led to her diagnosis of mild cognitive impairment.

Adding to the confusion, mild cognitive impairment (M.C.I.) comes and goes. “There are good days and bad days, good hours and bad hours,” said Dr. Gwyther. “Alzheimer’s and dementia don’t start on Tuesday — it’s a slow insidious onset.” But the diagnosis is becoming more common: The Institute for Dementia Research and Prevention predicts that 1 in 6 women, and 1 in 10 men, who live past the age of 55 will develop dementia in their lifetime.

“Spouses find it difficult to know when their partner with M.C.I. is acting differently (usually badly) due to the advancing illness or due to ‘willful’ personality issues,” said Dr. Dale, citing a 2007 study in the journal Family Relations exploring the problems this can create for couples.

Blaming is often easier than understanding. Another of Dr. Gwyther’s patients was furious at her husband for not filing their taxes. “He’s a C.P.A.,” she said. “How could we owe back taxes?” It did not occur to her that he might be unable to handle that task — and was too frightened about his deteriorating mental focus to let her know.

But as harmful as mental decline can be for a marriage, it is just part of the equation. Physical ailments – even those that seem completely unrelated to marital relations – “can upset the equilibrium of the marriage,” according to a study in the Canadian Medical Association Journal.

“Most men get angry at what’s happened to them when they get ill, women get angry and scared when he’s not what he used to be — so they fight,” said Dr. Schlossberg.

Chronic illnesses, like diabetes, arthritis and heart disease, can have a strong negative effect on mood, said Dr. Waite, who will soon be publishing a study on the subject. Diabetes is so often accompanied by depression that, Dr. Waite said, “one of my colleagues argues that that it is even part of the disease.”

And ailments can have an effect on a couple’s sex life — which can compound the marital problems, doctors said.

“Diabetes brings on neuropathy,” said Dr. Waite. “That means touching and feeling in sex is not as rewarding.” Without the pleasures of affectionate touching — whether a passing hug at the sink, or more — tensions can build. That’s why, if a couple is having problems with sex, they are more likely to have problems in the relationship — and vice versa, according to a 2007 New England Journal of Medicine study of sex and health among older adults.

Other changes in circumstances — retirement, shifting roles, the loss of autonomy, disparities in health and abilities — can wreak havoc. Losing independence can feel like losing oneself — and if you don’t know who you are any more, how can you know how to relate to your spouse?

“Fighting may come from a misguided notion that you can regain power by asserting it over your spouse,” said Dr. Schlossberg, whose observations are echoed in a 1984 study in the Canadian Journal of Medicine. “It doesn’t work, it’s false power – but they’ll try anything.”

The sheer exhaustion that can come from being the caregiving spouse is also bound to “make them stressed and angry,” said Dr. Waite. Not to mention guilty and resentful — never a prescription for happy marital relations.

“Part of the trap for the caregiver is the idea that you have to do it all, and the guilt you feel when you cannot live up to it,” said Dr. Gordon Herz, a psychologist in private practice in Madison, Wisc. Not surprisingly, resentment can soon follow, Dr. Herz added, because it’s hard to admit to anyone that, “‘this is too much for me.’”

What can outside caregivers — children or other loved ones — do about these golden marriages on the rocks? Should they intervene — or butt out? And can marital therapy help — or is it too late to change?

Share your thoughts and experiences — and tomorrow we’ll try to provide some advice from experts.

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The New Old Age Blog: In the Middle: Why Elderly Couples Fight

George and Gracie (let’s call them that because using their real names would make them even unhappier than they already appear to be) are in their 80s and married for more than 65 years. Until recently they seemed to ride the waves that are inevitable in any marriage that spans nearly seven decades; through good and bad, they were partners and best friends.

But lately — ever since her hospitalization and his fall — they have been arguing more bitterly than usual (“Do you have to make such a mess in the kitchen?”), criticizing each other (“Why haven’t you dealt with the insurance company yet?”), withdrawing from each other, and generally making each other more miserable, more often than ever before.

This kind of degenerative relationship is not uncommon among the elderly in even the happiest marriages, marriage therapists and geriatricians said. But that is small comfort to either the couple in the middle of the maelstrom, or the children who care for them, as evidenced by a number postings on caregiver blogs. As some of the children have wondered there: “Why can’t we all just get along?”

Therapists and others who work with the elderly said the first step to addressing the problem is understanding where it came from.

“A key question is whether the marital bickering is part of a lifelong marital style or a change,” said Dr. Linda Waite, director of the Center on Aging at NORC/University of Chicago. Is it new behavior – or just new to the grown children who are suddenly so deeply enmeshed in their parents’ lives that they are only now noticing that something is amiss?

How much of the problem is really just the marriage style? “Some couples like to fight and argue – it keeps their adrenaline going,” said Dr. Nancy K. Schlossberg, professor emerita of counseling psychology at the University of Maryland and author of “Overwhelmed: Coping with Life’s Ups and Downs.”

Sometimes the best judges of whether there is a problem are outsiders, said Dr. William Dale, chief of geriatrics at the University of Chicago Geriatrics Medicine. Pay attention if someone says, “‘Gee, Mom seems more argumentative or withdrawn than the last time I saw her,’” Dr. Dale advised.

If the tone or severity of the marital tensions seem new, then it is important to find out why. The causes could be mental or physical, doctors say.

On the mental front, increased anger and fighting could be one of the first signs of mild cognitive impairment, a precursor of dementia or Alzheimer’s, in one or both of the spouses, said Dr. Lisa Gwyther, director of the Duke Center for Aging Family Support Program and Associate Professor in the Department of Psychiatry and Behavioral Sciences.

Dr. Dale concurs: “There is good evidence that the earliest signs of cognitive impairment are often emotional changes” — anger, anxiety, depression — “rather than cognitive ones” — memory, abstract thought.

But these early signs of cognitive decline can be so subtle that neither the spouses themselves, or their grown children, recognize them for what they are, Dr. Gwyther said. So husband and wife blame each other for the changes and allow feelings of hurt and resentment to grow.

Withdrawing from activities that used to give them pleasure can be a telltale sign of mild cognitive impairment – and can trigger anger and arguments.

“In one couple, the husband just didn’t want to participate in the holidays — the wife got angry and said he was being lazy and stubborn,” said Dr. Gwyther. But the truth was that his cognitive decline made all the activity overwhelming, and he didn’t want anyone to know that he was anxious about not remembering everyone’s names and embarrassing himself.

Suspicion and paranoia can also accompany mild cognitive decline and precipitate distrust and hurtful accusations. Dr. Gwyther recalled another woman who “called her daughter frantic because she said her husband dropped her at her chemo appointment, went to park the car, and didn’t return to get her.” The woman couldn’t imagine that her husband could possibly have lost his sense of time and direction, Dr. Gwyther added. She took it personally, complaining to her daughter that “your father doesn’t seem to care any more.”

Dr. Dale told of a spouse who accused her mate of infidelity because “she was convinced that when he was out grocery shopping he was really having an affair.”

Hoarding, an early symptom of mild cognitive impairment, can also create tension in a marriage. (For new treatments, see this recent post by my colleague Paula Span.)

When one couple came to a counseling session with Dr. Norman Abeles, emeritus professor of psychology and former director of psychological clinic at Michigan State University, the hoarding spouse finally said, “she did it because she thought that they would run out of money, even though there was enough money to go around.” Dr. Abeles said that incident led to her diagnosis of mild cognitive impairment.

Adding to the confusion, mild cognitive impairment (M.C.I.) comes and goes. “There are good days and bad days, good hours and bad hours,” said Dr. Gwyther. “Alzheimer’s and dementia don’t start on Tuesday — it’s a slow insidious onset.” But the diagnosis is becoming more common: The Institute for Dementia Research and Prevention predicts that 1 in 6 women, and 1 in 10 men, who live past the age of 55 will develop dementia in their lifetime.

“Spouses find it difficult to know when their partner with M.C.I. is acting differently (usually badly) due to the advancing illness or due to ‘willful’ personality issues,” said Dr. Dale, citing a 2007 study in the journal Family Relations exploring the problems this can create for couples.

Blaming is often easier than understanding. Another of Dr. Gwyther’s patients was furious at her husband for not filing their taxes. “He’s a C.P.A.,” she said. “How could we owe back taxes?” It did not occur to her that he might be unable to handle that task — and was too frightened about his deteriorating mental focus to let her know.

But as harmful as mental decline can be for a marriage, it is just part of the equation. Physical ailments – even those that seem completely unrelated to marital relations – “can upset the equilibrium of the marriage,” according to a study in the Canadian Medical Association Journal.

“Most men get angry at what’s happened to them when they get ill, women get angry and scared when he’s not what he used to be — so they fight,” said Dr. Schlossberg.

Chronic illnesses, like diabetes, arthritis and heart disease, can have a strong negative effect on mood, said Dr. Waite, who will soon be publishing a study on the subject. Diabetes is so often accompanied by depression that, Dr. Waite said, “one of my colleagues argues that that it is even part of the disease.”

And ailments can have an effect on a couple’s sex life — which can compound the marital problems, doctors said.

“Diabetes brings on neuropathy,” said Dr. Waite. “That means touching and feeling in sex is not as rewarding.” Without the pleasures of affectionate touching — whether a passing hug at the sink, or more — tensions can build. That’s why, if a couple is having problems with sex, they are more likely to have problems in the relationship — and vice versa, according to a 2007 New England Journal of Medicine study of sex and health among older adults.

Other changes in circumstances — retirement, shifting roles, the loss of autonomy, disparities in health and abilities — can wreak havoc. Losing independence can feel like losing oneself — and if you don’t know who you are any more, how can you know how to relate to your spouse?

“Fighting may come from a misguided notion that you can regain power by asserting it over your spouse,” said Dr. Schlossberg, whose observations are echoed in a 1984 study in the Canadian Journal of Medicine. “It doesn’t work, it’s false power – but they’ll try anything.”

The sheer exhaustion that can come from being the caregiving spouse is also bound to “make them stressed and angry,” said Dr. Waite. Not to mention guilty and resentful — never a prescription for happy marital relations.

“Part of the trap for the caregiver is the idea that you have to do it all, and the guilt you feel when you cannot live up to it,” said Dr. Gordon Herz, a psychologist in private practice in Madison, Wisc. Not surprisingly, resentment can soon follow, Dr. Herz added, because it’s hard to admit to anyone that, “‘this is too much for me.’”

What can outside caregivers — children or other loved ones — do about these golden marriages on the rocks? Should they intervene — or butt out? And can marital therapy help — or is it too late to change?

Share your thoughts and experiences — and tomorrow we’ll try to provide some advice from experts.

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In Europe, a Push for Higher Phone Fees

BERLIN — When the authorities have tinkered with European telecommunications rules, it has usually been to lower prices for consumers, whether through retail price controls on mobile roaming fees or mandatory cuts in regulated interconnection charges.

But this year, to encourage more investment in high-speed broadband networks, regulators are considering helping the biggest operators increase a main source of income: the rent they receive from rivals that lease their landline grids.

The architect of the plan, Neelie Kroes, the European Union’s digital agenda commissioner, has pitched the increases as part of a broader package to stimulate spending while preserving competition and consumer choice.

The plan, however, has alarmed operators that would have to pay the higher charges, like the British mobile operator Vodafone. Vittorio Colao, chief executive of Vodafone, said that the plan to increase the fees collected by former monopolies, including BT, Deutsche Telekom, France Télécom, KPN, Telecom Italia and Telefónica, could lead to a “re-monopolization” of the business.

Mr. Colao said he was worried that landline operators would use the additional revenue to lower their own prices and try to squeeze competitors like Vodafone.

“Increasing the incentive to invest is a good thing,” Mr. Colao said. But now Ms. Kroes must “demonstrate that these new criteria won’t contaminate the competitive arena in Europe,” he said.

Under the plan, the European Commission, the executive arm of the European Union, would begin regulating the fees that mobile operators routinely pay to lease the grids of landline operators.

In much of the world, running telecommunications lines to homes and businesses has traditionally been the domain of a local monopoly, or sometimes a duopoly in the case of telephones and cable television in the United States. Until 1998, countries in the European Union were allowed to maintain national monopolies for this “local loop” to the consumer.

With deregulation, however, the former monopolies were required to unbundle the cost of the local loop and offer it to competitors, thus allowing companies like Vodafone to enter the market.

Despite 14 years of deregulation, and the addition of more than 100 mobile operators in Europe, the former monopolies still supply the majority of fixed-line services in their home countries. In Spain, Telefónica has more than 70 percent of this business.

Until now, these unbundling rates have been set by national regulators, and the average monthly cost per customer in the European Union stands at €8.62, or $11.35. The fee typically makes up a third or more of monthly landline phone bills in Europe and also influences wireless prices because it affects mobile operator costs. The fee ranges from €4.20 in Slovakia to €12.41 in Ireland.

Mrs. Kroes proposed to lower, not raise, unbundling fees in September 2011, to make the old landline networks less profitable for big operators and to encourage them to invest in new networks. But the former monopolies protested, and after personal appeals from executives at big operators, in some cases accompanied by their investors, she reversed course.

Ms. Kroes is proposing that each country within the European Union be required to set its fee within the range of €8 to €10 per month, according to a copy of her proposal obtained by the International Herald Tribune. The new range would most likely require 10 E.U. countries where the fee is currently below this range to raise it, in some cases only slightly, and in others, sharply.

The increases would in all likelihood be passed on to consumers. The rise in fees could be greatest in Eastern Europe, where regulators have been most aggressive in setting low leasing rates to encourage competition. The level of leasing charges could double in Estonia, Latvia, Poland and Slovakia.

Mr. Colao, the Vodafone chief executive, said Ms. Kroes needed to tighten the legal safeguards in her plan to prevent big operators from exploiting access to landline networks.

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Car Bomb Kills at Least 17 in Pakistan Tribal Region

ISLAMABAD, Pakistan — A powerful car bomb exploded near government offices in a town in the northwestern tribal belt on Monday, killing at least 17 people and wounding dozens, local officials said.

The car bomb attack in the Khyber tribal agency followed a Taliban assault on nearby Peshawar international airport over the weekend that left at least 15 people dead, 10 of them militants, underlining the continued potency of Islamist fighters in the area.

In Monday’s attack, officials said that a vehicle loaded with an estimated 90 pounds of explosives was detonated by remote control in Jamrud town, close to Peshawar, which borders the tribal belt.

Although the blast occurred near the offices of a senior government official, its immediate force ripped through the women’s waiting area of a bus stop, said Jahangir Azim, a senior official in the Khyber agency. The dead included four Afghan woman and three children, he said.

There was no immediate claim of responsibility for the blast, which damaged shops and vehicles across a wide radius. The dead and an estimated 44 wounded people were rushed to local hospitals.

Khyber is home to several Islamist militant groups, some of which are affiliated with the Pakistani Taliban, while others are fighting both the Taliban and the government.

Officials said they were unsure whether Monday’s attack was aimed at the government offices or at members of the Zakakhel sub-tribe, which has recently sided with the government against the Taliban. One bus stop in the vicinity of the blast is used by the Zakakhel to travel to their home area of Tirah Valley, which has recently seen fighting between members of a government-sponsored tribal militia and two rival Islamist groups.

“At the moment we are not in position to allege someone for the blast or to tell exactly what was the motive behind the attack by the perpetrators,” said Asmatullah Wazir, a local government official, by telephone.

The Taliban attack against the Peshawar airport saw five militants die during a failed attempt to break through the airport perimeter wall on Saturday night, while another five died during a shootout with security forces at a nearby house on Sunday morning.

At least five other people, including three civilians and two police, died in the attack, which marked the first concerted attack on the Peshawar airport. Although the Taliban claimed responsibility for that attack, officials identified several of the attackers as Uzbeks, suggesting that Al Qaeda-linked elements had also participated.

Together, the two attacks killed at least 32 people and wounded more than 80, highlighting the challenges facing the security forces in the run-up to general elections that are due in the next six months.

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As Gold Is Spirited Out of Afghanistan, Officials Wonder Why

Zalmai for The New York Times

A Kabul jewelry shop. Officials are concerned about gold being flown out of Afghanistan.

KABUL, Afghanistan — Packed into hand luggage and tucked into jacket pockets, roughly hewed bars of gold are being flown out of Kabul with increasing regularity, confounding Afghan and American officials who fear money launderers have found a new way to spirit funds from the country.

Most of the gold is being carried on commercial flights destined for Dubai, according to airport security reports and officials. The amounts carried by single couriers are often heavy enough that passengers flying from Kabul to the Persian Gulf emirate would be well advised to heed warnings about the danger of bags falling from overhead compartments. One courier, for instance, carried nearly 60 pounds of gold bars, each about the size of an iPhone, aboard an early morning flight in mid-October, according to an airport security report. The load was worth more than $1.5 million.

The gold is fully declared and legal to fly. Some, if not most, is legitimately being sent by gold dealers seeking to have old and damaged jewelry refashioned into new pieces by skilled craftsmen in the Persian Gulf, said Afghan officials and gold dealers.

But gold dealers in Kabul and current and former Kabul airport officials say there has been a surge in shipments since early summer. The talk of a growing exodus of gold from Afghanistan has been spreading among the business community here, and in recent weeks has caught the attention of Afghan and American officials. The officials are now puzzling over the origin of the gold — very little is mined in Afghanistan, although larger mines are planned — and why so much appears to be heading for Dubai.

“We are investigating it, and if we find this is a way of laundering money, we will intervene,” said Noorullah Delawari, the governor of Afghanistan’s central bank. Yet he acknowledged that there were more questions than answers at this point. “I don’t know where so much gold would come from, unless you can tell me something about it,” he said in an interview. Or, as a European official who tracks the Afghan economy put it, “new mysteries abound” as the war appears to be drawing to a close.

Figuring out what precisely is happening in the Afghan economy remains as confounding as ever. Nearly 90 percent of the financial activity takes place outside formal banks. Written contracts are the exception, receipts are rare and statistics are often unreliable. Money laundering is commonplace, say Western and Afghan officials.

As a result, with the gold, “right now you’re stuck in that situation we usually are: is there something bad going on here or is this just the Afghan way of commerce?” said a senior American official who tracks illicit financial networks.

There is reason to be suspicious: the gold shipments track with the far larger problem of cash smuggling. For years, flights have left Kabul almost every day carrying thick wads of bank notes — dollars, euros, Norwegian kroner, Saudi Arabian riyals and other currencies — stuffed into suitcases, packed into boxes and shrink-wrapped onto pallets. At one point, cash was even being hidden in food trays aboard now-defunct Pamir Airways flights to Dubai.

Last year alone, Afghanistan’s central bank says, roughly $4.5 billion in cash was spirited out through the airport. Efforts to stanch the flow have had limited impact, and concerns about money laundering persist, according to a report released last week by the United States Special Inspector General for Afghanistan Reconstruction.

The unimpeded “bulk cash flows raise the risk of money laundering and bulk cash smuggling — tools often used to finance terrorist, narcotics and other illicit operations,” the report said. The cash, and now the gold, is most often taken to Dubai, where officials are known for asking few questions. Many wealthy Afghans park their money and families in the emirate, and gold dealers say more middle-class Afghans are sending money and gold — seen as a safeguard against economic ruin — to Dubai as talk of a postwar economic collapse grows louder.

But given Dubai’s reputation as a haven for laundered money, an Afghan official said that the “obvious suspicion” is that at least some of the apparent growth in gold shipments to Dubai is tied to the myriad illicit activities — opium smuggling, corruption, Taliban taxation schemes — that have come to define Afghanistan’s economy.

There are also indications that Iran could be dipping into the Afghan gold trade. It is already buying up dollars and euros here to circumvent American and European sanctions, and it may be using gold for the same purpose.

Yahya, a dealer in Kabul, said other gold traders were helping Iran buy the precious metal here. Payment was being made in oil or with Iranian rials, which readily circulate in western Afghanistan. The Afghan dealers are then taking it to Dubai, where the gold is sold for dollars. The money is then moved to China, where it was used to buy needed goods or simply funneled back to Iran, said Yahya, who like many Afghans uses a single name.

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Dr. William F. House, Inventor of Cochlear Implant, Dies

Dr. William F. House, a medical researcher who braved skepticism to invent the cochlear implant, an electronic device considered to be the first to restore a human sense, died on Dec. 7 at his home in Aurora, Ore. He was 89.

The cause was metastatic melanoma, his daughter, Karen House, said.

Dr. House pushed against conventional thinking throughout his career. Over the objections of some, he introduced the surgical microscope to ear surgery. Tackling a form of vertigo that doctors had believed was psychosomatic, he developed a surgical procedure that enabled the first American in space to travel to the moon. Peering at the bones of the inner ear, he found enrapturing beauty.

Even after his ear-implant device had largely been supplanted by more sophisticated, and more expensive, devices, Dr. House remained convinced of his own version’s utility and advocated that it be used to help the world’s poor.

Today, more than 200,000 people in the world have inner-ear implants, a third of them in the United States. A majority of young deaf children receive them, and most people with the implants learn to understand speech with no visual help.

Hearing aids amplify sound to help the hearing-impaired. But many deaf people cannot hear at all because sound cannot be transmitted to their brains, however much it is amplified. This is because the delicate hair cells that line the cochlea, the liquid-filled spiral cavity of the inner ear, are damaged. When healthy, these hairs — more than 15,000 altogether — translate mechanical vibrations produced by sound into electrical signals and deliver them to the auditory nerve.

Dr. House’s cochlear implant electronically translated sound into mechanical vibrations. His initial device, implanted in 1961, was eventually rejected by the body. But after refining its materials, he created a long-lasting version and implanted it in 1969.

More than a decade would pass before the Food and Drug Administration approved the cochlear implant, but when it did, in 1984, Mark Novitch, the agency’s deputy commissioner, said, “For the first time a device can, to a degree, replace an organ of the human senses.”

One of Dr. House’s early implant patients, from an experimental trial, wrote to him in 1981 saying, “I no longer live in a world of soundless movement and voiceless faces.”

But for 27 years, Dr. House had faced stern opposition while he was developing the device. Doctors and scientists said it would not work, or not work very well, calling it a cruel hoax on people desperate to hear. Some said he was motivated by the prospect of financial gain. Some criticized him for experimenting on human subjects. Some advocates for the deaf said the device deprived its users of the dignity of their deafness without fully integrating them into the hearing world.

Even when the American Academy of Ophthalmology and Otolaryngology endorsed implants in 1977, it specifically denounced Dr. House’s version. It recommended more complicated versions, which were then under development and later became the standard.

But his work is broadly viewed as having sped the development of implants and enlarged understanding of the inner ear. Jack Urban, an aerospace engineer, helped develop the surgical microscope as well as mechanical and electronic aspects of the House implant.

Karl White, founding director of the National Center for Hearing Assessment and Management, said in an interview that it would have taken a decade longer to invent the cochlear implant without Dr. House’s contributions. He called him “a giant in the field.”

After embracing the use of the microscope in ear surgery, Dr. House developed procedures — radical for their time — for removing tumors from the back portion of the brain without causing facial paralysis; they cut the death rate from the surgery to less than 1 percent from 40 percent.

He also developed the first surgical treatment for Meniere’s disease, which involves debilitating vertigo and had been viewed as a psychosomatic condition. His procedure cured the astronaut Alan B. Shepard Jr. of the disease, clearing him to command the Apollo 14 mission to the moon in 1971. In 1961, Shepard had become the first American launched into space.

In presenting Dr. House with an award in 1995, the American Academy of Otolaryngology-Head and Neck Surgery Foundation said, “He has developed more new concepts in otology than almost any other single person in history.”

William Fouts House was born in Kansas City, Mo., on Dec. 1, 1923. When he was 3 his family moved to Whittier, Calif., where he grew up on a ranch. He did pre-dental studies at Whittier College and the University of Southern California, and earned a doctorate in dentistry at the University of California, Berkeley. After serving his required two years in the Navy — and filling the requisite 300 cavities a month — he went back to U.S.C. to pursue an interest in oral surgery. He earned his medical degree in 1953. After a residency at Los Angeles County Hospital, he joined the Los Angeles Foundation of Otology, a nonprofit research institution founded by his brother, Howard. Today it is called the House Research Institute.

Many at the time thought ear surgery was a declining field because of the effectiveness of antibiotics in dealing with ear maladies. But Dr. House saw antibiotics as enabling more sophisticated surgery by diminishing the threat of infection.

When his brother returned from West Germany with a surgical microscope, Dr. House saw its potential and adopted it for ear surgery; he is credited with introducing the device to the field. But again there was resistance. As Dr. House wrote in his memoir, “The Struggles of a Medical Innovator: Cochlear Implants and Other Ear Surgeries” (2011), some eye doctors initially criticized his use of a microscope in surgery as reckless and unnecessary for a surgeon with good eyesight.

Dr. House also used the microscope as a research tool. One night a week he would take one to a morgue for use in dissecting ears to gain insights that might lead to new surgical procedures. His initial reaction, he said, was how beautiful the bones seemed; he compared the experience to one’s first view of the Grand Canyon. His wife, the former June Stendhal, a nurse, often helped.

She died in 2008 after 64 years of marriage. In addition to his daughter, Dr. House is survived by a son, David; three grandchildren; and two great-grandchildren.

The implant Dr. House invented used a single channel to deliver information to the hearing system, as opposed to the multiple channels of competing models. The 3M Company, the original licensee of the House implant, sold its rights to another company, the Cochlear Corporation, in 1989. Cochlear later abandoned his design in favor of the multichannel version.

But Dr. House continued to fight for his single-electrode approach, saying it was far cheaper, and offered voluminous material as evidence of its efficacy. He had hoped to resume production of it and make it available to the poor around the world.

Neither the institute nor Dr. House made any money on the implant. He never sought a patent on any of his inventions, he said, because he did not want to restrict other researchers. A nephew, Dr. John House, the current president of the House institute, said his uncle had made the deal to license it to the 3M Company not for profit but simply to get it built by a reputable manufacturer.

Reflecting on his business decisions in his memoir, Dr. House acknowledged, “I might be a little richer today.”

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