Gaps Seen in Therapy for Suicidal Teenagers

Most adolescents who plan or attempt suicide have already received at least some mental health treatment, raising questions about the effectiveness of current approaches to helping troubled youths, according to the largest in-depth analysis to date of suicidal behaviors in American teenagers.

The study, in the journal JAMA Psychiatry, found that 55 percent of suicidal teenagers had received some therapy before they thought about suicide, planned it or tried to kill themselves, contradicting the widely held belief that suicide is due in part to a lack of access to treatment.

The findings, based on interviews with a nationwide sample of more than 6,000 teenagers and at least one parent of each, linked suicidal behavior to complex combinations of mood disorders like depression and behavior problems like attention-deficit and eating disorders, as well as alcohol and drug abuse.

The study found that about one in eight teenagers had persistent suicidal thoughts at some point, and that about a third of those who had suicidal thoughts had made an attempt, usually within a year of having the idea.

Previous studies have had similar findings, based on smaller, regional samples. But the new study is the first to suggest, in a large nationwide sample, that access to treatment does not make a big difference.

The study suggests that effective treatment for severely suicidal teenagers must address not just mood disorders, but also behavior problems that can lead to impulsive acts, experts said. According to the Centers for Disease Control and Prevention, 1,386 people between the ages of 13 and 18 committed suicide in 2010, the latest year for which numbers are available.

“I think one of the take-aways here is that treatment for depression may be necessary but not sufficient to prevent kids from attempting suicide,” said Dr. David Brent, a professor of psychiatry at the University of Pittsburgh, who was not involved in the study. “We simply do not have empirically validated treatments for recurrent suicidal behavior.”

The report said nothing about whether the therapies given were state of the art or carefully done, said Matt Nock, a professor of psychology at Harvard and the lead author, and it is possible that some of the treatments prevented suicide attempts. “But it’s telling us we’ve got a long way to go to do this right,” Dr. Nock said. His co-authors included Ronald C. Kessler of Harvard and researchers from Boston University and Children’s Hospital Boston.

Margaret McConnell, a consultant in Alexandria, Va., said her daughter Alice, who killed herself in 2006 at the age of 17, was getting treatment at the time. “I think there might have been some carelessness in the way the treatment was done,” Ms. McConnell said, “and I was trusting a 17-year-old to manage her own medication. We found out after we lost her that she wasn’t taking it regularly.”

In the study, researchers surveyed 6,483 adolescents from the ages of 13 to 18 and found that 9 percent of male teenagers and 15 percent of female teenagers experienced some stretch of having persistent suicidal thoughts. Among girls, 5 percent made suicide plans and 6 percent made at least one attempt (some were unplanned).

Among boys, 3 percent made plans and 2 percent carried out attempts, which tended to be more lethal than girls’ attempts.

(Suicidal thinking or behavior was virtually unheard-of before age 10.)

Over all, about one-third of teenagers with persistent suicidal thoughts went on to make an attempt to take their own lives.

Almost all of the suicidal adolescents in the study qualified for some psychiatric diagnosis, whether depression, phobias or generalized anxiety disorder. Those with an added behavior problem — attention-deficit disorder, substance abuse, explosive anger — were more likely to act on thoughts of self-harm, the study found.

Doctors have tested a range of therapies to prevent or reduce recurrent suicidal behaviors, with mixed success. Medications can ease depression, but in some cases they can increase suicidal thinking. Talk therapy can contain some behavior problems, but not all.

One approach, called dialectical behavior therapy, has proved effective in reducing hospitalizations and suicide attempts in, among others, people with borderline personality disorder, who are highly prone to self-harm.

But suicidal teenagers who have a mixture of mood and behavior issues are difficult to reach. In one 2011 study, researchers at George Mason University reduced suicide attempts, hospitalizations, drinking and drug use among suicidal adolescent substance abusers. The study found that a combination of intensive treatments — talk therapy for mood problems, family-based therapy for behavior issues and patient-led reduction in drug use — was more effective than regular therapies.

“But that’s just one study, and it’s small,” said Dr. Brent of the University of Pittsburgh. “We can treat components of the overall problem, but that’s about all.”

Ms. McConnell said that her daughter’s depression had seemed mild and that there was no warning that she would take her life. “I think therapy does help a lot of people, if it’s handled right,” she said.

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A Financial Service for People Fed Up With Banks

Steve Dykes for The New York Times

Shamir Karkal, left, and Josh Reich, center, the founders of Simple.

Like many people, Josh Reich got fed up with his bank after it charged him overdraft fees and he endured painful customer service calls to fight them. But unlike most people, Mr. Reich, a software engineer from Australia, decided to come up with a better way to bank.

Mr. Reich and a co-founder, Shamir Karkal, created Simple, an online banking start-up company based in Portland, Ore., that offers its customers free checking accounts and data-rich analysis of their transactions and spending habits.

Few entrepreneurs dare to set their sights on industries as large and entrenched as banking and expect to flourish. But Mr. Reich, 34, a professed data nerd who has built computers and tinkered with the innards of sophisticated cameras, holds a master’s degree in business and has a robust background in financial data analysis. He is confident that Simple’s minimalist approach — it promises not to charge any fees for any services — will draw fans and customers.

“Banks make money by keeping customers confused,” Mr. Reich said. “There’s no incentives to make the experience better.”

Of course, inviting people to trust a start-up with their money is a lot to ask. The company, which began signing up customers late last year in a deliberately slow fashion, now has 20,000 and has processed transactions worth more than $200 million.

It also has the backing of prominent venture capital firms including Shasta Ventures, SV Angel and IA Ventures and has raised more than $13 million. Simple has few, if any, direct competitors, although some services like SmartyPig and Mint offer analysis of bank accounts and financial transactions.

Simple is actually not a bank. It has deals with CBW Bank and Bancorp, federally insured banks, to hold its customers’ money.

And it has built slick apps for the Web and mobile devices to give customers an overview of their accounts and transactions. But it encourages customers to treat it as a bank, closing their more traditional accounts and only using Simple.

The company’s biggest challenge, banking analysts say, will be to persuade people to give it a try.

“It is extremely difficult to get consumers to change and leave their banks,” said Jacob Jegher, an analyst at Celent, a research and consulting firm. “Plus, although they are not a bank, they still operate like a financial institution, and they will face challenges that big banks have decades of experience with.”

After the financial crisis, smaller community banks and credit unions gained customers eager for alternatives to larger corporate banks. Experts say Simple could attract those customers as well.

Early adopters are warming to the service; during a speech last fall at a conference aimed at technology enthusiasts, designers and creative people, Mr. Reich asked how many in attendance were Simple customers. A majority of the crowd raised hands.

Mr. Reich said Simple was keeping its first group of customers small to allow it to work out any kinks. (Already there have been some flaws, like one that briefly locked several users out of their accounts in November.) At this stage, those who want a Simple account have to request an invitation on its site, though these are handed out fairly liberally to those who meet the minimal qualifications of Simple and its bank partners.

Customers receive a plain white card that can be used like a debit card. The company offers most traditional banking features, like direct deposit and money transfers. But there is plenty it does not offer, like joint or business checking accounts, or paper checkbooks, which may be a deal killer for some.

The start-up does not have physical bank branches or automated teller machines, nor does it plan to build any. As a result, Simple customers cannot make cash deposits and must rely on the Internet and phone for service.

Simple tries to make up for what it does not have with modern software design and data analysis.

Each Simple transaction is tagged with detailed information that allows customers to search their accounts with plain English commands like “Show me how much I spent on meals over $30 last month,” or “Show me how much money I spent on gifts in December.”

Customers can see transactions plotted on a map or search for all transactions in a particular state or country, something that would be difficult with a traditional bank account.

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Record Heat Fuels Widespread Fires in Australia

Lukas Coch/European Pressphoto Agency

Firefighters battled a grass fire in Oura, near Wagga Wagga, Australia, on Tuesday. On Monday, Australia’s hottest day on record, the national average was 104.59 degrees.

SYDNEY, Australia — Australia on Wednesday was grappling with an unprecedented heat wave that has sparked raging bushfires across some of the country’s most populated regions — pushing firefighters to their limits, residents to their wits’ end and leaving meteorologists tracking the soaring temperatures into uncharted territory.

Four months of record-breaking temperatures stretching back to September of last year have combined over the past week with widespread drought conditions and high winds to create what the government had labeled “catastrophic” fire conditions along the heavily populated eastern and southeastern coasts of the country, where much of the population is centered.

Data analyzed on Wednesday by the government-run Bureau of Meteorology indicated that national heat records had again been set — Tuesday was the third hottest day on record at 40 Celsius (104 Fahrenheit) and the mean national temperature average was the highest in history, breaking a record set just the day before, on Monday. Meteorologists have taken the extraordinary step of adding two new colors to its temperature charts to extend their range to 54 degrees Celsius (129 Fahrenheit) from the previous cap of 50 degrees Celsius (122 Fahrenheit) to account for the climbing temperatures.

“If you look at yesterday, at Australia as a whole, it was the hottest day in our records going back to 1911,” said David Jones, manager of climate monitoring prediction at the Bureau of Meteorology. “From this national perspective, one might say this is the largest heat event in the country’s recorded history.”

With the record-breaking heat, firefighters were struggling to contain the huge bushfires in Australia’s most populous state, New South Wales, which have swallowed around 500 square miles of forest and farmland since they erupted on Tuesday. Fires on the island state of Tasmania off the country’s southern coast have destroyed more than 300 square miles since Friday.

No deaths have been reported in connection with the fires, although about 100 people remain unaccounted for since a fire destroyed around 90 homes in the Tasmanian town of Dunalley, east of the state capital of Hobart, last week.

Thousands of head of cattle and sheep are believed to have died already in the fires, which have torn through some of the country’s most productive agricultural and farming regions. Some 10,000 sheep alone are believed to have died in New South Wales, according to the state government’s Department of Primary Industries.

Despite a brief respite from the searing heat in some coastal areas on Wednesday, the government has warned that the hot spell was only just getting started as the so-called “Dome of Heat” began moving up the eastern seaboard away from Sydney, where it was expected to deliver more blistering weather to Brisbane, Australia’s third largest city.

NASA published alarming photographs of the enormous fires, which have grown so large that they are visible from outer space, allowing them to be photographed from the International Space Station on Tuesday. The intensity of the bushfires and the unrelenting nature of the heat have already led some climate scientists to criticize what they see as an indifference to the realities of man-made climate change, which is widely believed to be the driving factor behind these events.

“Those of us who spend our days trawling — and contributing to — the scientific literature on climate change are becoming increasingly gloomy about the future of human civilization,” Elizabeth Hanna, a researcher at the Australian National University in Canberra, told The Sydney Morning Herald. “We are well past the time of niceties, of avoiding the dire nature of what is unfolding, and politely trying not to scare the public.”

Dr. Jones, the government climate scientist, echoed that opinion.

“This event is turning out to be hotter, more spatially expansive and the duration is quite remarkable,” he said in an interview. “And that suggests climate change.”

At least 141 fires continued to rage in New South Wales on Wednesday, with 31 of those fires burning out of control. The deputy commissioner of the state’s Rural Fire Service, Rob Rogers, told reporters that it was a bad sign that the fires could not be contained during the brief drop in temperatures.

“We’ve got a huge swath of New South Wales that potentially is going to get new fires again this afternoon,” Mr. Rogers said. “It will be an absolute battle to get containment on most of those fires before the return of the hot weather on the weekend.”

Tuesday’s new high adds to a growing list of records the Bureau of Meteorology has recorded during this extended heat wave: the first time the country has recorded seven consecutive days of temperatures above 39 degrees Celsius (102 degrees Fahrenheit); the year with the most record hot days in Australia since national records began in 1910, and nationwide average temperatures on each of the first eight days of 2013 that were among the top 20 hottest days on record here.

Dr. Jones warned that there was no sign that temperatures would stay down even as the heat wave appeared to slightly recede in Sydney on Wednesday.

“We expect it to stay very hot across inland Australia for the next week,” he said. “Beyond that it’s hard to say.”

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Wall Street Trades Lower as Earnings Reports Begin

Stocks trading on Wall Street ticked lower on Tuesday as an earnings season that is expected to show sluggish corporate growth got under way.

The Standard & Poor’s 500-stock index fell 0.4 percent in morning trading, the Dow Jones industrial average lost 0.4 percent and the Nasdaq composite index fell 0.2 percent.

Over the next couple of weeks, quarterly reports on fourth-quarter profits are expected to come in above the previous quarter’s lackluster results, but analysts’ current estimates are down sharply from where they were in October. Quarterly earnings are expected to grow by 2.8 percent, according to Thomson Reuters data.

German data showed industrial orders fell more than forecast in November because of a sharp drop in demand from abroad, reinforcing concerns that Europe’s largest economy may have contracted in the fourth quarter of 2012.

“I’m surprised futures are holding up, given the relative disappointment that German data showed, but I think all eyes are on the beginning of earnings season,” said Kim Forrest, senior equity research analyst at Fort Pitt Capital Group in Pittsburgh.

European shares were mixed after the German report, with the DAX index in Frankfurt down 0.1 percent and the CAC 40 in Paris up 0.5 percent in afternoon trading.

Monsanto shares rose 3.5 percent after the world’s largest seed company raised its earnings outlook for fiscal 2013 and posted strong first-quarter results.

Shares of the restaurant-chain operator Yum Brands fell 4.6 percent. On Monday the company, which owns KFC, warned that sales in China, its largest market, shrank more than expected in the fourth quarter.

Vodafone shares rose almost 3 percent in London after its American partner in the joint venture Verizon Wireless said it would be “feasible” to buy out the British group.

Sears Holdings shares were 1.9 percent lower a day after the company said its chief executive would step down for family health reasons.

GameStop shares fell 6.8 percent after it reported sales for the holiday season and cut its guidance.

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The New Old Age Blog: Who Should Receive Organ Transplants?

Joe Gammalo had been contending with pulmonary fibrosis, a scarring of the lungs, for more than a decade when he came to the Cleveland Clinic in 2008 seeking a lung transplant.

“It had gotten to the point where I was on oxygen all the time and in a wheelchair,” he told me in an interview. “I didn’t expect to live.”

Lung transplants are a dicey proposition, involving a huge surgical procedure, arduous follow-up, the lifelong use of potent immunosuppressive drugs and high rates of serious side effects. “It’s not like taking out an appendix,” said Dr. Marie Budev, the medical director of the clinic’s lung transplant program.

Only 50 to 57 percent of all recipients live for five years, she noted, and they will still die of their disease. But there’s no other treatment for pulmonary fibrosis.

Some medical centers would have turned Mr. Gammalo away. Because survival rates are even lower for older patients, guidelines from the International Society for Heart and Lung Transplantation caution against lung transplants for those over 65, though they set no age limit.

But “we are known as an aggressive, high-risk center,” said Dr. Budev. So Mr. Gammalo was 66 when he received a lung; his newly found buddy, Clyde Conn, who received the other lung from the same donor, was 69.

You can’t mistake the trend: A graying population and revised policies determining who gets priority for donated organs, have led to a rising proportion of older adults receiving transplants.

My colleague Judith Graham has reported on the increase in heart transplants, but the pattern extends to other organs, too.

The number of kidney transplants performed annually on adults over 65 tripled between 1998 and last year, according to data from the Scientific Registry of Transplant Recipients. In 2001, 7.4 percent of liver transplant recipients were over 65; last year, that rose to 13 percent.

The rise in elderly lung transplant candidates is particularly dramatic because, since 2005, a “lung allocation score” puts those at the highest mortality risk, rather than those who’ve waited longest, at the top of the list.

In 2001, about 3 percent of those on the wait list and of those transplanted were over 65; last year, older patients represented almost 18 percent of wait-listed candidates and more than a quarter of transplant recipients. (Medicare pays for the surgery, though patients face co-pays and considerable out-of-pocket costs, including for drugs and travel.)

The debate has grown, too: When the number of adults awaiting transplants keeps growing, but organ donations stay flat, is it desirable or even ethical that an increasing proportion of recipients are elderly?

Dr. Budev, who estimated that a third of her program’s patients are over 65, votes yes. As long as a program selects candidates carefully, “how can you deny them a therapy?” she asked. So the Cleveland Clinic has no age limit. “We feel that everyone should have a chance.”

At the University of Michigan, by contrast, the age limit remains 65, though Dr. Kevin Chan, the transplant program’s medical director, acknowledged that some fit older patients get transplanted.

“You can talk about this all day — it’s a tough one,” Dr. Chan said. Younger recipients have greater physiologic reserve to aid in the arduous recovery; older ones face higher risk of subsequent kidney failure, stroke, diabetes and other diseases, and, of course, their lifespans are shorter to begin with.

Donated lungs, fragile and prone to injury, are a particularly scarce commodity. Last year, surgeons performed 16,055 kidney transplants, 5,805 liver transplants and 1,949 heart transplants. Only1,830 patients received lung transplants.

“What if there’s a 35-year-old on a ventilator who needs the lung just as much?” Dr. Chan said. “Why should a 72-year-old possibly take away a lung from a 35-year-old?” Yet, he acknowledged, “it’s easy to look at the statistics and say, ‘Give the lungs to younger patients.’ At the bedside, when you meet this patient and family, it’s a lot different.”

These questions about who deserves scarce resources — those most likely to die without them? or those most likely to live longer with them? — will persist as the population ages. They’re also likely to arise when the International Society for Heart and Lung Transplantation begins working towards revised guidelines this spring. (I’d also like to hear your take, below.)

Lots of 65- and 75-year-olds are very healthy. Yet transplants themselves can cause harm and there’s no backup, like dialysis. Without the transplant, they die. But when the transplant goes wrong, they also die.

More than four years post-transplant, the Cleveland Clinic’s “lung brothers” are success stories. Mr. Conn, who lives near Dayton, Ohio, can’t walk very far or lift more than 10 pounds, but he works part time as a real-estate appraiser and enjoys cruises with his wife.

Mr. Gammalo, a onetime musician, has developed diabetes, like nearly half of all lung recipients. But he went onstage a few weeks back to sing “Don’t Be Cruel” with his son’s rock band, “a highlight of both our lives,” he said.

Yet when I asked Mr. Conn, now 73, how he felt about having priority over a younger but healthier person, he paused. “It’s a good question,” he said, to which he had no answer.

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Paula Span is the author of “When the Time Comes: Families With Aging Parents Share Their Struggles and Solutions.”

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The New Old Age Blog: Who Should Receive Organ Transplants?

Joe Gammalo had been contending with pulmonary fibrosis, a scarring of the lungs, for more than a decade when he came to the Cleveland Clinic in 2008 seeking a lung transplant.

“It had gotten to the point where I was on oxygen all the time and in a wheelchair,” he told me in an interview. “I didn’t expect to live.”

Lung transplants are a dicey proposition, involving a huge surgical procedure, arduous follow-up, the lifelong use of potent immunosuppressive drugs and high rates of serious side effects. “It’s not like taking out an appendix,” said Dr. Marie Budev, the medical director of the clinic’s lung transplant program.

Only 50 to 57 percent of all recipients live for five years, she noted, and they will still die of their disease. But there’s no other treatment for pulmonary fibrosis.

Some medical centers would have turned Mr. Gammalo away. Because survival rates are even lower for older patients, guidelines from the International Society for Heart and Lung Transplantation caution against lung transplants for those over 65, though they set no age limit.

But “we are known as an aggressive, high-risk center,” said Dr. Budev. So Mr. Gammalo was 66 when he received a lung; his newly found buddy, Clyde Conn, who received the other lung from the same donor, was 69.

You can’t mistake the trend: A graying population and revised policies determining who gets priority for donated organs, have led to a rising proportion of older adults receiving transplants.

My colleague Judith Graham has reported on the increase in heart transplants, but the pattern extends to other organs, too.

The number of kidney transplants performed annually on adults over 65 tripled between 1998 and last year, according to data from the Scientific Registry of Transplant Recipients. In 2001, 7.4 percent of liver transplant recipients were over 65; last year, that rose to 13 percent.

The rise in elderly lung transplant candidates is particularly dramatic because, since 2005, a “lung allocation score” puts those at the highest mortality risk, rather than those who’ve waited longest, at the top of the list.

In 2001, about 3 percent of those on the wait list and of those transplanted were over 65; last year, older patients represented almost 18 percent of wait-listed candidates and more than a quarter of transplant recipients. (Medicare pays for the surgery, though patients face co-pays and considerable out-of-pocket costs, including for drugs and travel.)

The debate has grown, too: When the number of adults awaiting transplants keeps growing, but organ donations stay flat, is it desirable or even ethical that an increasing proportion of recipients are elderly?

Dr. Budev, who estimated that a third of her program’s patients are over 65, votes yes. As long as a program selects candidates carefully, “how can you deny them a therapy?” she asked. So the Cleveland Clinic has no age limit. “We feel that everyone should have a chance.”

At the University of Michigan, by contrast, the age limit remains 65, though Dr. Kevin Chan, the transplant program’s medical director, acknowledged that some fit older patients get transplanted.

“You can talk about this all day — it’s a tough one,” Dr. Chan said. Younger recipients have greater physiologic reserve to aid in the arduous recovery; older ones face higher risk of subsequent kidney failure, stroke, diabetes and other diseases, and, of course, their lifespans are shorter to begin with.

Donated lungs, fragile and prone to injury, are a particularly scarce commodity. Last year, surgeons performed 16,055 kidney transplants, 5,805 liver transplants and 1,949 heart transplants. Only1,830 patients received lung transplants.

“What if there’s a 35-year-old on a ventilator who needs the lung just as much?” Dr. Chan said. “Why should a 72-year-old possibly take away a lung from a 35-year-old?” Yet, he acknowledged, “it’s easy to look at the statistics and say, ‘Give the lungs to younger patients.’ At the bedside, when you meet this patient and family, it’s a lot different.”

These questions about who deserves scarce resources — those most likely to die without them? or those most likely to live longer with them? — will persist as the population ages. They’re also likely to arise when the International Society for Heart and Lung Transplantation begins working towards revised guidelines this spring. (I’d also like to hear your take, below.)

Lots of 65- and 75-year-olds are very healthy. Yet transplants themselves can cause harm and there’s no backup, like dialysis. Without the transplant, they die. But when the transplant goes wrong, they also die.

More than four years post-transplant, the Cleveland Clinic’s “lung brothers” are success stories. Mr. Conn, who lives near Dayton, Ohio, can’t walk very far or lift more than 10 pounds, but he works part time as a real-estate appraiser and enjoys cruises with his wife.

Mr. Gammalo, a onetime musician, has developed diabetes, like nearly half of all lung recipients. But he went onstage a few weeks back to sing “Don’t Be Cruel” with his son’s rock band, “a highlight of both our lives,” he said.

Yet when I asked Mr. Conn, now 73, how he felt about having priority over a younger but healthier person, he paused. “It’s a good question,” he said, to which he had no answer.

---

Paula Span is the author of “When the Time Comes: Families With Aging Parents Share Their Struggles and Solutions.”

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Mobile Apps Drive Rapid Changes in Search Technology

SAN FRANCISCO — When the Federal Trade Commission decided last week to close its antitrust investigation of Google without charges, one important factor, though hardly mentioned, was just beneath the surface: the mobile revolution.

Google has repeatedly made the argument — and the commission agreed — that the speed of change in the technology industry made it impossible for regulators to impose restrictions without stalling future innovations.

Exhibit A is the mobile device. Nowhere has technology changed as rapidly and consumer behavior as broadly. As people abandon desktop computers for mobile ones, existing tech companies’ business models are being upended and new companies are blooming.

“Mobile is very much a moving target,” said Herbert Hovenkamp, a professor of antitrust law at the University of Iowa who has been a paid adviser to Google. “This is a market in which new competitors come in a week’s time.”

When the commission began its investigation 19 months ago, for instance, the iPhone did not have the Siri voice search, Apple did not have its own mapping service and Yelp’s mobile apps had no ads. By the time the inquiry concluded, all of that had changed. Google had new competitors on all sides trying to chip away at its hold on the mobile search and advertising market.

Still, Google is even more dominant on mobile phones than on desktop computers. It has 96 percent of the world’s mobile search market, according to StatCounter, which tracks Web use. It collects 57 percent of mobile ad revenue in the United States, while Facebook, its nearest competitor, gets just 9 percent, according to eMarketer.

But, analysts say, as people change their search habits on mobile devices — bypassing Google to go straight to apps like Yelp’s, for example — that dominance could wane, or a competitor could swoop in and knock Google off its perch.

“It’s important to recognize that many mobile apps are really vertical search engines,” said Rebecca Lieb, a digital media analyst at the Altimeter Group. “It is impossible to really say anyone dominates a section of mobile in a secure way right now.”

On cellphones or tablets, for instance, people increasingly skip Google altogether in favor of apps like Flixster for movie times or Kayak for flights.

Apple is taking on mobile search with Siri on the iPhone, which can answer questions about the weather or search for nearby restaurants. With its new mapping service, Apple has also entered local search.

On Friday, Blekko, a search start-up, introduced an app called Izik for Apple and Android devices. It tries to make searching more tablet-friendly by showing images instead of just links, and making it easier to swipe through many pages of results with a finger.

On mobile devices, said Rich Skrenta, chief executive of Blekko, “the user experience is so different that we think it opens things up. On your desktop, if it doesn’t look like Google, you think that’s not a search engine. On a tablet, it’s just vastly different.”

Jon Leibowitz, chairman of the F.T.C., said at a news conference Thursday that the speed of change in the tech industry meant that “you want to be careful before you apply sanctions.”

The commission also considered Google’s partnerships with cellphone makers like Samsung and HTC that license Google search on phones, so that a search box shows up on the home screen. In the end it decided not to take action against Google.

Some Google critics said that even though the competitive landscape is different on mobile devices, it should not have influenced the government’s analysis of Google’s behavior on the desktop Web.

“There’s no doubt that mobile applications, including Yelp’s, give consumers the ability to bypass the major search engines and go directly to the best provider of the service they’re looking for,” said Vince Sollitto, vice president for government relations at Yelp. Still, he added, “I don’t see how that impacts how someone is acting anticompetitively on the desktop.”

(One of Google’s concessions to the federal agency, that it would allow other Web companies to ask Google not to show their content in its own vertical search products — a chief complaint of Yelp’s — applies to mobile as well.)

But others said antitrust enforcement in the 21st century needs to be more agile.

Nick Wingfield contributed reporting from Seattle.

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Videos of Chávez Promote Stability During Illness

Meridith Kohut for The New York Times

In Caracas on Saturday, Venezuelans showed support for President Hugo Chávez, who is in Cuba after an operation.

CARACAS, Venezuela — They run around the clock on state television, highly polished videos of President Hugo Chávez hugging children, kissing grandmothers, playing baseball and reciting poetry. As supporters around the world hold up hand-lettered signs that say, “I Am Chávez,” the president’s voice is heard in one of them shouting, “I demand absolute loyalty because I am not me, I am not an individual, I am a people!”

In reality, officials say, Mr. Chávez lies in a Cuban hospital bed, struggling through complications from cancer surgery while his country heads toward a constitutional showdown over his absence.

Mr. Chávez’s fragile health has thrown Venezuela into political uncertainty. After being re-elected in October, he is supposed to be sworn in for the start of his new term on Thursday, but the charismatic leader who has dominated every aspect of government here for 14 years may be too ill to return in time, much less continue in office for the next six years. Top government officials insist that the swearing-in is just a formality. The opposition, meanwhile, says the Constitution requires that Mr. Chávez be present or, in his absence, that a process begin that could lead to new elections.

The government’s television barrage seems intent on reassuring loyalists — and anyone who might raise questions — that Mr. Chávez is still very much the head of the nation. By keeping his image front and center, analysts say, the government can bolster its position as the caretaker of his legacy, mobilize its supporters for the battle over interpreting the Constitution and build momentum for itself in elections should Mr. Chávez die or prove too sick to govern.

“They have combined the mechanisms of left-wing struggle with the best marketing team there is,” said J. J. Rendón, a political consultant who opposes the government.

He compared the saga over Mr. Chávez’s illness to a telenovela, one of the popular Latin American soap operas, with its unexpected plot twists that keep viewers on edge. “They are always prepared for different scenarios,” he said of the government.

During past trips to Cuba for cancer treatment over the last year and a half, Mr. Chávez worked to maintain his customary visibility back home, heading televised cabinet meetings, making phone calls to government-run television programs and posting on Twitter.

But this time is different. He has not been seen or heard from since his surgery on Dec. 11.

To fill the void, the government montages combine elements of campaign ads and music videos, sometimes with the feel of a religious revival broadcast.

They are Mr. Chávez’s greatest hits, showing him on the campaign trail or in scenes from happier times during his many years in office, a nostalgic and emotionally charged way for his supporters to connect with their absent leader. Set to rock, rap or folk music, they mine parallels between Mr. Chávez and his hero, the Venezuelan independence leader Simón Bolívar, and resonate with the religious devotion with which some of his followers regard him.

In one, Mr. Chávez is seen reciting a favorite poem exalting Bolívar. Another shows glowing pictures of Mr. Chávez while choirlike voices sing, “Chávez is the triumphant commander, Chávez is pure and noble love.”

“There is a process of converting Chávez into a myth with religious roots,” said Andrés Cañizalez, a communication professor at the Andrés Bello Catholic University.

The television spots, he said, are part of “a political strategy to keep alive this idea that Chávez is not just a political leader but he’s the father of the country, he’s a patriarch, he’s a figure who protects us, who takes care of everything for us, something more than a president.”

Many of Mr. Chávez’s followers already speak of him in religious terms, as a godlike presence, and the campaign seems intended to feed those perceptions.

María Eugenia Díaz contributed reporting.

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Bill Richardson and Eric Schmidt of Google Visit North Korea

SEOUL, South Korea — Bill Richardson, the former governor of New Mexico, led a private delegation including Eric Schmidt, Google’s executive chairman, to North Korea on Monday, a controversial trip to a country that is among the most hostile to the Internet.

Mr. Richardson, who has visited North Korea several times, called his four-day trip a private humanitarian mission and said he would try to meet with Kenneth Bae, a South Korea-born American citizen who was arrested on charges of “hostile acts” against North Korea after entering the country as a tourist in early November.

“I heard from his son who lives in Washington State, who asked me to bring him back,” Mr. Richardson said in Beijing before boarding a plane bound for Pyongyang. “I doubt we can do it on this trip.”

In a one-sentence dispatch, the North’s state-run Korean Central News Agency confirmed the American group’s arrival in Pyongyang, calling it “a Google delegation.”

Mr. Richardson said his delegation planned to meet with North Korean political, economic and military leaders and visit universities.

Mr. Schmidt and Google have kept quiet about why Mr. Schmidt joined the trip, which the State Department called unhelpful. Mr. Richardson said Monday that Mr. Schmidt was “interested in some of the economic issues there, the social media aspect,” but did not elaborate. Mr. Schmidt is a staunch proponent of Internet connectivity and openness..

Except for a tiny portion of its elite, North Korea’s population is blocked from the Internet. Under its new leader, Kim Jong-un, the country has emphasized science and technology but has also vowed to intensify its war against the infiltration of outside information in the isolated country, which it sees as a potential threat to its totalitarian grip on power.

Although it is engaged in a standoff with the United States over its nuclear weapons and missile programs and habitually criticizes American foreign policy as “imperial,” North Korea welcomes high-profile American visits to Pyongyang, billing them as signs of respect for its leadership. It runs a special museum for gifts that foreign dignitaries have brought for its leaders.

Washington has never established diplomatic ties with North Korea, and the two countries remain technically at war after the 1950-53 Korean War ended in a truce.

But Mr. Richardson’s trip comes at a particularly delicate time for Washington. In the past weeks, it has been trying to muster international support to penalize North Korea for its launching last month of a long-range rocket, which the United States condemned as a violation of United Nations Security Council resolutions banning the country from testing intercontinental ballistic missile technology.

North Korea has often required visits by high-profile Americans like former Presidents Jimmy Carter and Bill Clinton before releasing American citizens held there on criminal charges. Mr. Richardson, who is also a former ambassador to the United Nations, traveled to Pyongyang in 1996 to negotiate the release of Evan Hunziker, who was held for three months on charges of spying after swimming across the river border between China and North Korea.

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Tehran Is Choked by Annual Buildup of Air Pollution

TEHRAN — Already battered by international threats against their nation’s nuclear program, sanctions and a broken economy, Iranians living here in the capital are now trying to cope with what has become an annual pollution peril: a yellowish haze that engulfs Tehran this time of year.

For nearly a week, officials here and in other large cities have been calling on residents to remain indoors or avoid downtown areas, saying that with air pollution at such high levels, venturing outside could be tantamount to “suicide,” state radio reported Saturday.

On Sunday, government offices, schools, universities and banks reopened after the government had ordered them to shut down for five days to help ease the chronic pollution. Tehran’s normally bustling streets were largely deserted.

Residents who dare to go outside cover their mouths and noses with scarves or surgical masks, but their eyes tear up and their throats sting from the mist of pollutants, which a report by the municipality of Tehran says is made up of a mixture of particles containing lead, sulfur dioxins and benzene.

“It feels as if even God has turned against us,” Azadeh, a 32-year-old artist, said on a recent day as she looked out a window in her apartment that often offers a clear view of Tehran, a sprawling city that is home to millions. But on this day, Azadeh, who did not want her full name used, saw only the blurred outlines of high-rise buildings and the Milad communications tower in the distance. The setting sun was reduced to a yellowish coin by the thick blanket of smog.

The haze of pollution occurs every year when cold air and windless days trap fumes belched out by millions of cars and hundreds of old factories between the peaks of the majestic Alborz mountain range, which embraces Tehran like a crescent moon.

Iran is prominently represented in the World Health Organization’s 2011 report on air quality and health, with three of its provincial towns among the organization’s list of the world’s 10 most-polluted cities. According to the report, Tehran has roughly four times as many polluting particles per cubic meter as Los Angeles. Many cities known for their poor air quality, like Mexico City, Shanghai and Bangkok, are cleaner than Tehran.

But since 2010, when American sanctions on Iranian imports of refined gasoline began to bite, the situation has grown worse, according to the report by the municipality of Tehran.

Faced with possible fuel shortages, Iran surprised outsiders by quickly making up for the loss of imports by producing its own brew of gasoline. While the emergency fuel kept vehicles running, local experts warned that it was creating much more pollution.

A recently released report by Tehran’s department of air quality control contained blank spaces where there should have been information about levels of benzene and lead — components of gasoline — in the capital’s air. But the report did state that while Tehran experienced more than 300 “healthy days” in 2009, in 2011 there were fewer than 150.

Iran’s Health Ministry has reported a rise in respiratory and heart diseases, as well as an increase in a variety of cancers that it says are related to pollution.

The state newspaper Resalat on Saturday called the pollution a continuing crisis, and it urged the authorities to act. “Why is it that when the winds pick up, this problem is again quickly forgotten?” an editorial asked. Another newspaper, Donya-e-Eqtesad, which is critical of the government, pressed for an improvement in gasoline standards.

The pollution caused by the use of the emergency fuel concoction has been a taboo subject here, as officials try to portray each measure to counter the economic sanctions as a success that should not to be criticized by the local news media.

On state television, several officials have denied that the yellow haze has anything to do with the locally produced gasoline.

In an interview on Saturday, Ali Mohammad Sha’eri, the deputy director of Iran’s Environmental Protection Organization, strongly denied that the pollution was linked to gasoline. However, he said that only 20 percent of the emergency fuel was up to modern standards. “Hopefully in three months that level will be 50 percent,” he said.

Meanwhile, the government has imposed strict traffic regulations in Tehran, Isfahan and other major population centers. An odd-even traffic-control plan based on the last digit of vehicle license plates keeps about half of the approximately three and a half million cars in Tehran off the streets on a daily basis.

Other plans to combat the pollution have been less realistic, analysts say. President Mahmoud Ahmadinejad has long advocated a plan to move civil servants from Tehran to reduce overpopulation in the capital. In 2010, the governor of Tehran Province ordered crop-dusters to dump water on the smog in an effort to dissipate it. There have also been plans for placing air purifiers in the city, but experts say they will not work in open spaces.

For those living in Tehran and unable to leave town for a vacation home on the Caspian Sea, waiting for the winds to pick up seems to be the only option.

“My head hurts, and I’m constantly dead tired,” said Niloufar Mohammadi, a university student. “I try not to go out, but I can smell the pollution in my room as I am trying to study.”

Azadeh, the artist, said the pollution forced her to stay indoors, adding to her sense of isolation. Step by step her world was being curtailed, she said. The Western sanctions imposed on Iran make her feel like a pariah, she explained. The government’s mismanagement of the economy and the resulting inflation have left her with little purchasing power, she said; she has stopped shopping for everything but essential items. And last week, security officers removed her illegal satellite dish from her roof.

“The pollution is the last straw for me,” she said. “We should wait helpless for winds to pick up and clean the air before we can safely leave our houses. It shows we have lost all power to control our lives.”

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