[House Hearing, 110 Congress]
[From the U.S. Government Publishing Office]


 
            THE MELANIE BLOCKER-STOKES POSTPARTUM DEPRESSION 
                      RESEARCH AND HEALTH CARE ACT 

=======================================================================

                                HEARING

                               BEFORE THE

                         SUBCOMMITTEE ON HEALTH

                                 OF THE

                    COMMITTEE ON ENERGY AND COMMERCE
                        HOUSE OF REPRESENTATIVES

                       ONE HUNDRED TENTH CONGRESS

                             FIRST SESSION

                                   ON

                                H.R. 20

                               __________

                              MAY 1, 2007

                               __________

                           Serial No. 110-38


      Printed for the use of the Committee on Energy and Commerce

                        energycommerce.house.gov

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                    COMMITTEE ON ENERGY AND COMMERCE

                       JOHN D. DINGELL, Michigan, Chairman
HENRY A. WAXMAN, California          JOE BARTON, Texas
EDWARD J. MARKEY, Massachusetts        Ranking Member
RICK BOUCHER, Virginia               RALPH M. HALL, Texas
EDOLPHUS TOWNS, New York             J. DENNIS HASTERT, Illinois
FRANK PALLONE, Jr., New Jersey       FRED UPTON, Michigan
BART GORDON, Tennessee               CLIFF STEARNS, Florida
BOBBY L. RUSH, Illinois              NATHAN DEAL, Georgia
ANNA G. ESHOO, California            ED WHITFIELD, Kentucky
BART STUPAK, Michigan                BARBARA CUBIN, Wyoming
ELIOT L. ENGEL, New York             JOHN SHIMKUS, Illinois
ALBERT R. WYNN, Maryland             HEATHER WILSON, New Mexico
GENE GREEN, Texas                    JOHN B. SHADEGG, Arizona
DIANA DeGETTE, Colorado              CHARLES W. ``CHIP'' PICKERING, 
   Vice Chairman                       Mississippi
LOIS CAPPS, California               VITO FOSSELLA, New York
MIKE DOYLE, Pennsylvania             STEVE BUYER, Indiana
JANE HARMAN, California              GEORGE RADANOVICH, California
TOM ALLEN, Maine                     JOSEPH R. PITTS, Pennsylvania
JAN SCHAKOWSKY, Illinois             MARY BONO, California
HILDA L. SOLIS, California           GREG WALDEN, Oregon
CHARLES A. GONZALEZ, Texas           LEE TERRY, Nebraska
JAY INSLEE, Washington               MIKE FERGUSON, New Jersey
TAMMY BALDWIN, Wisconsin             MIKE ROGERS, Michigan
MIKE ROSS, Arkansas                  SUE WILKINS MYRICK, North Carolina
DARLENE HOOLEY, Oregon               JOHN SULLIVAN, Oklahoma
ANTHONY D. WEINER, New York          TIM MURPHY, Pennsylvania
JIM MATHESON, Utah                   MICHAEL C. BURGESS, Texas
G.K. BUTTERFIELD, North Carolina     MARSHA BLACKBURN, Tennessee
CHARLIE MELANCON, Louisiana
JOHN BARROW, Georgia
BARON P. HILL, Indiana                                   
                                    _____

                           Professional Staff

                   Dennis B. Fitzgibbons, Chief of Staff
                   Gregg A. Rothschild, Chief Counsel
                     Sharon E. Davis, Chief Clerk
                   Bud Albright, Minority Staff Director

                         Subcommittee on Health

                FRANK PALLONE, Jr., New Jersey, Chairman
HENRY A. WAXMAN, California          NATHAN DEAL, Georgia,
EDOLPHUS TOWNS, New York                 Ranking Member
BART GORDON, Tennessee               RALPH M. HALL, Texas
ANNA G. ESHOO, California            BARBARA CUBIN, Wyoming
GENE GREEN, Texas                    HEATHER WILSON, New Mexico
    Vice Chairman                    JOHN B. SHADEGG, Arizona
DIANA DeGETTE, Colorado              STEVE BUYER, Indiana
LOIS CAPPS, California               JOSEPH R. PITTS, Pennsylvania
TOM ALLEN, Maine                     MIKE FERGUSON, New Jersey
TAMMY BALDWIN, Wisconsin             MIKE ROGERS, Michigan
ELIOT L. ENGEL, New York             SUE WILKINS MYRICK, North Carolina
JAN SCHAKOWSKY, Illinois             JOHN SULLIVAN, Oklahoma
HILDA L. SOLIS, California           TIM MURPHY, Pennsylvania
MIKE ROSS, Arkansas                  MICHAEL C. BURGESS, Texas
DARLENE HOOLEY, Oregon               MARSHA BLACKBURN, Tennessee
ANTHONY D. WEINER, New York          JOE BARTON, Texas (ex officio)
JIM MATHESON, Utah
JOHN D. DINGELL, Michigan (ex 
    officio)



































                             C O N T E N T S

                              ----------                              
                                                                   Page
 Hon. Frank Pallone, Jr., a Representative in Congress from the 
  State of New Jersey, opening statement.........................     1
Hon. Nathan Deal, a Representative in Congress from the State of 
  Georgia, opening statement.....................................     2
Hon. Diana DeGette, a Representative in Congress from the State 
  of Colorado, opening statement.................................     3
Hon. Joseph R. Pitts, a Representative in Congress from the 
  Commonwealth of Pennsylvania, opening statement................     5
Hon. Jan Schakowsky, a Representative in Congress from the State 
  of Illinois, opening statement.................................     6
Hon. Michael C. Burgess, a Representative in Congress from the 
  State of Texas, opening statement..............................     7
Hon. Lois Capps, a Representative in Congress from the State of 
  California, opening statement..................................     8
Hon. Tim Murphy, a Representative in Congress from the 
  Commonwealth of Pennsylvania, opening statement................     9
Hon. Gene Green, a Representative in Congress from the State of 
  Texas, opening statement.......................................    10
Hon. Marsha Blackburn, a Representative in Congress from the 
  State of Tennessee, opening statement..........................    11
Hon. Bobby L. Rush, a Representative in Congress from the State 
  of Illinois, opening statement.................................    12
Hon. Anna G. Eshoo, a Representative in Congress from the State 
  of California, prepared statement..............................    13
Hon. Edolphus Towns, a Representative in Congress from the State 
  of New York, prepared statement................................    14
H.R. 20, To provide for research on, and services for individuals 
  with, postpartum depression and psychosis......................    17

                               Witnesses

Catherine Roca, M.D., chief, Women's Programs, National Institute 
  of Mental Health, Bethesda, MD.................................    27
    Prepared statement...........................................    30
Carol Blocker, mother of Melanie Blocker-Stokes, Chicago, IL.....    31
    Prepared statement...........................................    33
Mary Jo Codey, member, President's Advisory Council of Postpartum 
  Support International, West Orange, NJ.........................    35
    Prepared statement...........................................    37
Michaelene Fredenburg, president, Life Perspectives, San Diego, 
  CA.............................................................    38
    Prepared statement...........................................    39
Priscilla K. Coleman, associate professor of human development 
  and family studies, Bowling Green State University, Bowling 
  Green, OH......................................................    41
    Prepared statement...........................................    44
Nada Stotland, M.D., professor of psychiatry and obstetrics/
  gynecology, Rush Medical College, Chicago, IL..................    58
    Prepared statement...........................................    60
    Answer to submitted question.................................   102

                           Submitted Material

``Depression During and After Pregnancy, a Resource for Women, 
  Their Families, and Friends'', Health Resources and Services 
  Administration, U.S. Department of Health and Human Services...    78


H.R. 20, THE MELANIE BLOCKER-STOKES POSTPARTUM DEPRESSION RESEARCH AND 
                            HEALTH CARE ACT

                              ----------                              


                          TUESDAY, MAY 1, 2007

                  House of Representatives,
                            Subcommittee on Health,
                          Committee on Energy and Commerce,
                                                    Washington, DC.
    The subcommittee met, pursuant to call, at 12:00 p.m., in 
room 2123 of the Rayburn House Office Building, Hon. Frank 
Pallone, Jr. (chairman) presiding.
    Members present: Representatives Green, DeGette, Capps, 
Schakowsky, Hooley, Rush, Deal, Pitts, Murphy, Burgess, 
Blackburn.
    Also present: Representative Rush.
    Staff present: John Ford, Jessica McNiece, Jesse Levine, 
Melissa Sidman, Lauren Bloomberg, Bobby Clark, Chad Grant, 
Katherine Martin, and Ryan Long.

OPENING STATEMENT OF HON. FRANK PALLONE, JR., A REPRESENTATIVE 
            IN CONGRESS FROM THE STATE OF NEW JERSEY

    Mr. Pallone. Good afternoon. The hearing will come to 
order, and today the subcommittee is meeting to hear about H.R. 
20, the Melanie Blocker-Stokes Postpartum Depression And Care 
Act. This bill is sponsored by my good friend Congressman Bobby 
Rush, who is joining us today, and I want to welcome him to the 
subcommittee and thank him for all the work he has done to 
develop this thoughtful and very important piece of 
legislation.
    Postpartum depression is a devastating mood disorder, 
ranging from the baby blues to full-blown postpartum psychosis. 
Postpartum conditions strike many women during and after 
pregnancy. It is estimated that 400,000 women suffer from 
postpartum mood changes with baby blues afflicting up to 80 
percent of new mothers.
    Beyond the baby blues, postpartum mood and anxiety 
disorders impair around 10 to 20 percent of new mothers, and 
postpartum psychosis strikes 1 in 1,000 new mothers. The causes 
of postpartum depression are complex and unknown at this time. 
However, if diagnosed properly and treated with social support, 
therapy, and medication, relief is highly attainable.
    All too often, however, postpartum depression goes 
undiagnosed because providers are not trained to detect the 
symptoms or the condition goes untreated due to social stigma 
or embarrassment. Needless to say, we must be more aggressive 
in our efforts to increase awareness and improve education 
about women, as well as the health care providers so we can 
ensure that women suffering from postpartum depression receive 
the care and treatment they need to stay healthy.
    And I am particularly grateful to New Jersey's--my notes 
say former first lady, Mary Jo Codey, but actually you are the 
current first lady since Governor Codey is now Acting Governor 
once again because our Governor Corzine had an accident. 
Although I am pleased to say that he came out of the hospital 
yesterday, but he still is not acting as the Governor. And so 
Senator Codey, who is our senate president in New Jersey is now 
Acting Governor once again. But Mary Jo Codey, who is here with 
us, has been a leader in raising awareness about mental health 
issues, particularly about postpartum depression. She and her 
husband have been tremendous advocates for those who suffer 
from mental illness in my home State of New Jersey.
    Thanks to their efforts, New Jersey has a new postpartum 
depression and screening and education law, which took effect 
last October. Now, every pregnant woman in New Jersey is 
educated about maternal mood disorders before giving birth. The 
mother of every baby born in New Jersey will be screened for 
postpartum depression, and all licensed health care 
professionals who provide pre- and post-natal care would be 
educated about maternal depression. And I just want to thank 
her again. Mrs. Codey's personal dedication to bringing light 
to these conditions which are all to often overlooked and 
misinterpreted has had a great impact on our State.
    I also wanted to mention that she is not only the current 
and former first lady, but also a member of the President's 
advisory counsel of Postpartum Support International. Now, she 
is going to be the first to tell you that our job is far from 
done. So much more research needs to go into what causes 
postpartum depression and how best to treat it, and that is why 
this legislation is critically important and why I support it. 
I wholeheartedly agree that appropriate research and attention 
needs to be devoted to this issue.
    I pledge to work with Mr. Rush to move this bill to the 
floor as quickly as possible. As we will hear from our 
witnesses today, we can't afford to delay. Too many lives are 
on the line. I want to thank all of our witnesses for appearing 
before us today. I would like to extend a warm welcome to Ms. 
Blocker, the mother of the woman for whom this legislation is 
named in her honor. Thank you for being here today. I know you 
have a 2:00 flight to catch so we may not actually get to ask 
her any questions. She may have to leave before we get to the 
questions, but I want to thank you for sharing your and your 
daughter's story with us and for all the work that you do, Ms. 
Blocker, as an advocate on this issue. And I would now 
recognize the gentleman from New Jersey for 5 minutes.

  OPENING STATEMENT OF HON. NATHAN DEAL, A REPRESENTATIVE IN 
               CONGRESS FROM THE STATE OF GEORGIA

    Mr. Deal. Thank you, Mr. Chairman.
    This is the second piece of legislation dealing with 
women's health issues that this subcommittee is having a 
hearing on today. And we thank all of you for being here. For 
any of us who are parents, the old issue is baby blues is 
something that people used to joke about. But now we know that 
some 50 to 80 percent of all women suffer it in some form or 
other.
    It is when the psychosis of the more serious kind sets in 
that we are primarily concerned with and focus our attention on 
today. And certainly it is not a joking matter. It is a very 
serious matter. It has consequences not only for the woman but 
the child and the family as a whole.
    Fortunately, we have learned that we can treat it. We need 
to learn more about how we can come to understand it, to 
predict it, and to deal with it as early as possible. And this 
legislation, I think, is going to be helpful in that regard in 
directing the NIH to do more detailed research and studies 
about the causes and what can be done to deal with the 
depression. It also creates a grant program to include 
treatment and screening for the illness.
    I thank the witnesses for their being here today, and I 
hope as we go through this hearing and the subsequent 
legislation itself that we can begin to advance the cause of 
understanding and dealing with a very serious issue that 
confronts every woman with the birth of a child, or as we will 
learn, I am sure, a woman who suffers an abortion or perhaps 
even just an involuntary termination of the pregnancy through 
no fault of anybody's part. All of the consequences of those 
acts are certainly dramatic, and we need to understand them 
better.
    Thank you all for being here. Yield back.
    Mr. Pallone. I thank our ranking member and now recognize 
Ms. DeGette.

 OPENING STATEMENT OF HON. DIANA DEGETTE, A REPRESENTATIVE IN 
              CONGRESS FROM THE STATE OF COLORADO

    Ms. DeGette. Mr. Chairman, thank you for convening this 
hearing today, and it is so wonderful to see this great panel. 
It is a critical issue to millions of women and their families 
throughout the country, and I am glad to see this committee 
really taking first steps towards passing this much needed and 
much overdue legislation. I also want to thank Congressman Rush 
for his continued efforts to pass this legislation into law.
    Whenever women's groups come to see and say well, should I 
get the guys to help with this? I remind them we still have 
only less than 15 percent of women in Congress. So even though 
we are really good, we can't do it all ourselves, and we rely 
on our partners to make issues like women's health a high 
priority.
    And, Mr. Rush, I hope that now with the new leadership of 
this committee we are going to be able to finally bring your 
goal of enacting this bill into law to reality.
    Mr. Chairman, postpartum depression is a serious condition 
that affects millions of women, and while many women battle the 
baby blues shortly after the work of their children, this is 
really a misnomer for what many other face, which is far more 
debilitating postpartum depression. According to the Department 
of Health and Human Services, postpartum depression can include 
symptoms such as sadness, lack of energy, trouble 
concentrating, anxiety, and feelings of guilt and 
worthlessness.
    Left untreated, the condition can last a number of months, 
with some lasting over a year. This debilitating illness can 
prevent the mother from bonding with her new baby and starting 
her family in a positive direction, and it can do even worse to 
the woman and her family. The effects of postpartum depression 
can be quite devastating.
    I look forward to hearing the testimony from our panel here 
today about ways that we can explore treatment and research for 
this condition and about how Mr. Rush's bill can expedite the 
process.
    I must say while I am very pleased this hearing has been 
called, I wanted to voice my disappointment with the apparent 
attention of some to discuss an unrelated issue, as the ranking 
member just mentioned, so-called post-abortion depression. In 
contrast with the issue of postpartum depression, which has 
clearly been accepted by the psychiatric and psychological 
communities as a true mental health condition, this so-called 
post-abortion syndrome is recognized by none of the established 
professional medical associations. Neither the American 
Psychological Association nor the American Psychiatric 
Association's DSM-IV, the definitive manual of mental illnesses 
and psychological phenomena recognize post-abortion syndrome or 
any related category as an identifiable mental health 
condition.
    And the debate is characterized by things that my good 
friend and respected colleague, Mr. Deal, just talked about 
where he said even pregnancies that are terminated at ``no 
fault of the woman.'' This is offensive to women throughout 
this country, and it has no place in a legitimate debate like 
the discussion we are going to have today on postpartum 
depression.
    As co-chair of the Congressional Pro-Choice caucus, I would 
be happy to debate the merits of maintaining a woman's right to 
choose at another time, but that is not the issue today. The 
issue today is postpartum depression, and I hope the witnesses 
before us will limit their discussion to the pressing issue at 
hand, H.R. 20, the Melanie Blocker-Stokes Postpartum Depression 
Research and Care Act. Women throughout this country have spent 
too much time waiting for this bill to be considered by us and 
passed by us to be distracted by political theater. It is time 
that we take up H.R. 20 now, and I yield back the balance.
    Mr. Deal. Would you yield to me since you mentioned my 
name? I am a cosponsor of the bill before us, I would point out 
to the gentlelady.
    Ms. DeGette. I would not.
    Mr. Pallone. Let me mention that I gave you 5 minutes by 
mistake. We are only given--I think you used 4 of it, so it is 
only 3 minutes.
    Ms. DeGette. Mr. Chairman, if you will give it to me, I 
will use some of it at least. I apologize.
    Mr. Pallone. It is not your fault. It is mine. OK, next is 
Mr. Pitts, I believe.

OPENING STATEMENT OF HON. JOSEPH R. PITTS, A REPRESENTATIVE IN 
         CONGRESS FROM THE COMMONWEALTH OF PENNSYLVANIA

    Mr. Pitts. Thank you, Mr. Chairman, and thank you for 
convening this hearing on such an important issue, and I would 
like to thank each of the witnesses for sharing their expertise 
with our committee today. Like all of us, I believe that 
postpartum depression is a very real and serious disease, and I 
commend the efforts of my colleague, Congressman Rush, to 
expand research and treatment of postpartum depression.
    However, while attention is being focused on postpartum 
depression, it is sadly evident that post-abortion depression 
goes widely unrecognized and untreated. Because of the 
emotional issues that often surround a woman's decision to have 
an abortion, many women are reluctant to even talk about their 
experiences. And some women don't come to terms with the 
emotional impact of their abortion until years later, and this 
was evidenced in today's newspaper in the Washington Times that 
cited hundreds, even thousands, of anecdotes and affidavits 
referred to in the recent Supreme Court decision. I will submit 
that for the record.
    I believe that increased research on post-abortion 
depression will lead to a greater awareness of this issue and 
the development of compassionate outreach and counseling 
programs to help post-abortive women. We continue to learn more 
about the psychological impact of giving birth and of 
miscarrying, and yet there is also much to be discovered about 
post-abortion depression. Women who choose to have an abortion 
should also be given the care and concern that is given to 
women who give birth or miscarry. Post-abortive women deserve 
the care and treatment that their unique circumstances demand.
    While we know all too little about the extent and substance 
of post-abortion emotional response, everyone agrees that the 
decision to have an abortion is fraught with emotion. It only 
makes sense then to continue to explore the psychological 
impact of abortion on women that has recently begun to garner 
attention due to the courageous voices of women like Michaelene 
and the women of Silent No More campaign.
    And the research is indeed giving statistical significance 
to what they have been saying. A study by a pro-choice 
researcher in New Zealand found that 78\1/2\ of 15- to 18-year-
old girls who have abortion display symptoms of major 
depression, compared to only 31 percent of their peers who do 
not have abortions. This same study found that 27 percent of 
21- to 25-year-old women who have had abortions have suicidal 
idealization compared to only 8 percent of peers who do not 
have abortions. Yet there is a need for comprehensive research 
in the United States to better understand the effects of 
abortion on women in the United States.
    It is widely acknowledged that many medical procedures can 
affect not only the patient's physical state but the patient's 
mental state as well. And we need to be able to document the 
potential emotional impact of abortion. Women deserve to know 
the long-term effects of abortion on their mental and emotional 
well being. Women who have had abortions deserve to have mental 
health professionals who acknowledge the emotional impact of 
abortion and have the tools to treat it.
    Most of the advances in mental health in recent years have 
been preceded by increased awareness of specific mental health 
causes and triggers. Accurate research can foster awareness 
because it makes a problem concrete. Information about the 
emotional impact of abortion may also help us to determine 
early warning signs of depression for women who choose abortion 
so that these women can receive help as quickly as possible, 
not have to struggle alone for a long period of time.
    I strongly support continued research of postpartum 
depression and miscarriage-related depression; however, I 
believe that we also need to devote Federal resources to 
research and treatment of post-abortion depression. Women who 
suffer from this type of depression deserve to have this tragic 
result brought out of the shadows and recognized in our 
culture.
    No matter what pregnancy outcome a woman experiences, there 
should be help made available. This speaks to the emotional 
issues that she may be encountering. Mr. Chairman, I look 
forward to hearing from our distinguished witnesses, learning 
their views, recommendations on these important issues. And 
while I would like to thank all of our witnesses, I would 
specifically like to thank Priscilla Coleman for discussing 
important research on an issue that is often ignored, and 
Michaelene Fredenburg for having the courage to share such a 
personal difficult story that many women are unable to share. 
And I yield back the balance of my time.
    Mr. Pallone. Thank you. The gentlewoman from Illinois, Ms. 
Schakowsky.

 OPENING STATEMENT OF HON. JAN SCHAKOWSKY, A REPRESENTATIVE IN 
              CONGRESS FROM THE STATE OF ILLINOIS

    Ms. Schakowsky. Thank you, Mr. Chairman. I want to thank 
you for holding this hearing, and I also want to express my 
gratitude to Representative Rush for his persistence and 
perseverance on the issue of postpartum depression research and 
care. I have co-sponsored the Melanie Blocker-Stokes Postpartum 
Depression Research and Care for the past four Congresses. This 
year the bill has over 100 co-sponsors, and it is time to pass 
this important legislation.
    I am distressed that rather than address this important 
particular issue, some members of this committee seemed 
determined to change the subject to an unrelated issue that 
they know is certain to be controversial as well as unsupported 
by science. Postpartum depression is an all too common problem, 
affecting an estimated 10 to 15 percent of women in the 
postpartum period. Yet the problem is underrecognized and 
undertreated. This period of hormonal upheaval and life-
altering lifestyle change and stress can place a woman at 
increased risk for mood disorders.
    Unfortunately we know that many women suffer in silence. 
Research confirms that the majority of mothers experiencing 
postpartum depression do not seek help from anyone, and only 
one in five seek help from a health professional. In addition 
to the suffering that this causes new mothers at a time when 
they are expected to be happiest--and I remember that pressure 
and that feeling--and most fulfilled, this disorder can have 
immediate and long-term consequences on the mother/child bond 
and the subsequent emotional and cognitive development of the 
child.
    In other words, this is a woman's health issue and a 
children's health issue. Early identification and treatment can 
spare months of suffering and minimize the impact on both 
mother and child. The good news that we have an array of 
effective treatment options for mood disorders, including 
psychotherapies and a range of pharmaceutical options which can 
be used to assist women with postpartum depression.
    On the other hand, we need to know more about factors 
contributing to the development of postpartum depression and 
postpartum psychosis as well as predictors and correlates of 
these disorders. Most importantly, we need to find effective 
means of promptly identifying women who are suffering from 
these conditions and engaging them in treatment. It is time 
that this health issue got the attention it deserves. This 
hearing is a first step in the right direction. I yield back.
    Mr. Pallone. Thank you. Dr. Burgess.

OPENING STATEMENT OF HON. MICHAEL C. BURGESS, A REPRESENTATIVE 
              IN CONGRESS FROM THE STATE OF TEXAS

    Mr. Burgess. Thank you, Mr. Chairman. I don't know that I 
completely understood this morning we were delivering opening 
statements, and I apologize if I covered some of this in the 
previous panel. But let me just go back to one of the things 
that we were talking about from the last panel, and Dr. 
Bennett, I think, in her testimony for the American Heart 
Association talked about the alarming lack of awareness for 
heart disease. And certainly that applies to postpartum 
psychosis/postpartum depression.
    Last Congress when we had a hearing on this and I learned 
of Mr. Rush's bill, I eagerly sought and was accepted as a 
cosponsor on this bill, and I have been this year as well. I 
think there are a number of good things that will come to bear 
if we can deliver this bill, no pun intended. Let me just talk 
about a couple things though, as far as the robustness of the 
information part.
    We talked in title I, there is basic research, the 
mipodemalilogic studies. We talked about diagnostic techniques, 
some new therapies, all of which are important. But the line on 
information and decimating information to the public and to 
physicians is--I would like to see that a more robust section 
of this bill. And I hope to be able to work with the primary 
sponsor of this bill to make certain that we define some of the 
deliverables. We define some of the appropriate metrics that 
might be applied so that we can at least see that we are 
helping this situation.
    I would just say from a 25-year practice in obstetrics, I 
did see firsthand how disruptive and how frightening it could 
be to have a patient with postpartum psychosis. And I know it 
was frightening for me, and I know it was frightening for the 
family and for the patient herself. I was very fortunate. I 
never lost a patient to this disease. I did lose a patient to 
her psychosis during pregnancy at 20 weeks, and as you can 
imagine, I also lost the baby at that point as well. So I do 
think we need to include in our discussion the entire spectrum 
of whether they be postpartum or midpartum issues because the 
hormonal interplay can encompass such a vast number of issues.
    And clearly as we get further down the road with our study 
of genomics and genomic personalized medicine, this is going to 
be an area where further research is certainly warranted. But I 
thank the chairman of my other subcommittee for bringing this 
bill to our attention and certainly look forward to working 
with him to make it the best bill possible when we pass it out 
of committee.
    Mr. Pallone. Thank you, Dr. Burgess. Mrs. Capps.

   OPENING STATEMENT OF HON. LOIS CAPPS, A REPRESENTATIVE IN 
             CONGRESS FROM THE STATE OF CALIFORNIA

    Mrs. Capps. Thank you, Chairman Pallone. I am thankful for 
this hearing as I was for the one that preceded it, both having 
to do with issues that particularly affect women and those who 
care about them. I want to thank our witnesses today, those who 
are here to talk about postpartum depression, and also to thank 
the author of the bill, our colleague Mr. Rush from Illinois, 
and the namesake of the bill. A tragic story, as there are so 
many tragic stories.
    This is an important women's health issue because 
particularly tomorrow, we will be observing Mental Health 
Parity Day. That topic certainly is related to the topic of our 
hearing. Postpartum depression, that is the serious 
psychological mental health issue that follows upon giving 
birth, for so many women is very real, has been documented, and 
on some level, affects most new mothers and their families. And 
we need more awareness for all women about what postpartum 
depression is.
    As a nurse for many years, I have seen firsthand how much 
women and their families, their partners, have struggled with 
this difficult condition. Particularly in a program that I 
directed for teen parents, I saw the devastating effects of 
postpartum depression on an already stressed situation for 
young adolescent mothers.
    To me, it is just tragic still, with as much as we know 
about this mental health condition, that there is such a great 
stigma associated with postpartum depression. So many women 
still feel so ashamed of the feelings that they are 
experiencing. This mainly comes because so many people don't 
understand the condition.
    I am proud to be a cosponsor of H.R. 20 in order to expand 
research at the NIH into understanding postpartum depression 
further to provide grants for support services into the 
community. Access to treatment and support services is really 
most important, in my opinion, not only for women experiencing 
it, but for the entire family. This is information that should 
be widely disseminated across the country to mitigate some of 
the stigmas that are attached and to allow women and their 
families, who will sometimes be the first to observe symptoms, 
the opportunity for early intervention.
    A mother who is debilitated by postpartum depression has 
trouble being a good mother, has trouble with their feelings of 
self-worth and this is something that is so treatable and so 
preventable. I can't stress enough how important it is to focus 
on care for the mother and other family members as they go 
through a rough time postpartum.
    I look forward to hearing from our witnesses today, 
particularly those who will tell you their stories of 
postpartum depression so we can learn more about what is being 
done currently about this situation, how we can help provide 
access to services for women and their families. Every women 
who cannot access treatment for postpartum depression 
translates into the suffering of a whole family.
    I think it is also demeaning, Mr. Chairman, that we have 
extraneous--this is such a serious topic in itself, and we can 
have other discussions of other issues. But postpartum 
depression deserves our full attention in this hearing. I yield 
back.
    Mr. Pallone. Thank you. Mr. Murphy is recognized.

   OPENING STATEMENT OF HON. TIM MURPHY, A REPRESENTATIVE IN 
         CONGRESS FROM THE COMMONWEALTH OF PENNSYLVANIA

    Mr. Murphy. Thank you, Mr. Chairman, and thank you for 
holding this hearing. I worked as a psychologist for over 25 
years, and in that context, I saw countless children who really 
struggled in their relationship with their mothers. Many of 
those mothers were suffering symptoms of postpartum depression 
that unfortunately were oftentimes undiagnosed, untreated, 
except through denial, and we know that denial is not an 
adequate treatment for mental illness. We saw these mothers who 
were struggling, who were depressed, emotionally distant, 
rejecting, angry, sometimes abusive, ashamed, and loving all at 
the same time. Huge conflicts took place in their lives.
    What is so important, as we try and grasp this, is that we 
understand that over half the cases of postpartum are 
untreated, many undiagnosed. It goes along also with what 
happens in other areas of mental illness where the mental 
health care is not integrated with the medical care. Or people 
are not paying attention to these issues, or they think it is 
all in their head and just a good night's sleep will take care 
of it or other sorts of--because treatment sometimes has not 
advanced us beyond the era of the Salem witch trials where we 
blame the patient for their problems.
    We have to make sure that we are not ignoring all the 
problems that mothers experience. I hope we also include in 
these discussions such things as not only mothers who deliver a 
healthy baby, but those who have a child who is born with 
handicaps, those who have a premature infant, those who have 
experienced an abortion, those who also have a miscarriage. In 
any case, a mother feels a loss and problems that we have to 
deal with, and not get it caught up in other issues of how we 
may feel about those labels but understand it is a value, it is 
a life, it is a person with real emotions and real issues 
there.
    In this context, I hope that we as a nation can come to 
better terms with how we view mental illness overall. We have 
to understand that it is an illness. We have to understand that 
it can be diagnosed, that it can be treated, that real lives 
are at stake, not only those who suffer the illness, but those 
who are family members. And we need, with compassion and care 
and concern, to put this into real policy that makes a 
difference for the millions of families across America who 
depend upon us for drawing the light to this. Make sure that 
funding goes for research. Making sure that practitioners are 
out there with proper training to diagnose and treat this.
    Along these lines, I hope that all of these are some of the 
outcome of H.R. 20, mental health parity issues, and other 
issues which this Congress will be dealing with. I look forward 
to hearing the testimony of today's witnesses, and I thank the 
chairman.
    Mr. Pallone. Thank you. I recognize our vice-chair, Mr. 
Green.

   OPENING STATEMENT OF HON. GENE GREEN, A REPRESENTATIVE IN 
                CONGRESS FROM THE STATE OF TEXAS

    Mr. Green. Thank you, Mr. Chairman, for holding the hearing 
to examine depression and mental health after pregnancy. 
Postpartum depression affects the majority of American families 
in one way or another, whether it is the form of baby blues or 
clinical depression or psychosis.
    In my hometown of Houston, we learned all too well the 
dangers that can result from undiagnosed or mistreated 
postpartum depression. In 2001, Andrea Yates drowned her five 
children and was sentenced to life in prison. A native 
Houstonian, a valedictorian from Milby High School that is in 
our district, Andrea had everything going for her, a bright 
future as a registered nurse at the top cancer center in our 
country.
    Yet Andrea's adult years were filled with warning signs 
about her tendency toward depression and psychosis. Because of 
her history of suicide attempts, hospitalizations, and drug 
therapies for her depressive episodes, the doctor warned her 
that additional children could spark more psychotic behavior. 
Nevertheless, she became pregnant a fifth time and stopped her 
drug therapy.
    We all know the unfortunate end to this story, which 
shocked not only our community but the Nation at large. Sadly, 
families all across America are dealing with the effects of 
postpartum depression psychosis and are not getting the help 
they need. In general, women aren't getting the information 
they need to detect the warning signs of postpartum depression. 
Families and support networks are left feeling helpless about 
what they can do to help their loved ones, and access to mental 
health care is severely lacking.
    As members of our subcommittee, however, we can take 
action. I have cosponsored the Kennedy-Ramstad bill to provide 
equal insurance coverage for mental health benefits, and I know 
we need the support there. Let us pass this bill and put our 
money where our mouth is when it comes to supporting access to 
mental health care.
    In the meantime, however, we must realize the importance of 
awareness. I know a young woman who suffered from postpartum 
depression, yet resisted treatment because she thought of 
herself simply as a bad mother, failing to bond with her new 
son. These thoughts resulted not only from depression but also 
from the stigma that unfortunately still exists within our 
society when it comes to mental illness. Through education and 
awareness, we can make significant strides toward helping 
postpartum mothers identify their depression, seek the 
treatment they need, and get them on their way toward 
developing that all-too-important bond with their new children.
    And again I would like to thank my witnesses for being here 
today, and particularly Ms. Blocker's willingness to share her 
family story with the subcommittee. I can only imagine the pain 
associated with telling your daughter's story and we are 
pleased to know that you are doing a world of good in educating 
us and the public about this important issue.
    And I would also like to thank our colleague Bobby Rush for 
his persistence and dedication on this issue. And I yield back, 
Mr. Chairman.
    Mr. Pallone. Thank you. I recognize the gentlewoman from 
Tennessee, Mrs. Blackburn.

OPENING STATEMENT OF HON. MARSHA BLACKBURN, A REPRESENTATIVE IN 
              CONGRESS FROM THE STATE OF TENNESSEE

    Mrs. Blackburn. Thank you, Mr. Chairman. And I really want 
to thank all of our witnesses for taking the time to be here 
today. As a mom, I have many, many times wondered why it seemed 
to be so difficult for people to define the baby blues or 
postpartum depression and why it was so hard and so difficult 
for so many of the medical community to realize what it was 
when it happened because having a baby should be such a joyous 
time.
    But then you come through, and you have had 9 months of 
carrying extra weight. Your back aches. Your body changes. You 
have had nausea and all these different things that you have 
had to deal with through pregnancy. And then the baby arrives, 
and you get this overwhelming feeling because your life has 
changed. Your family responsibilities have changed. Maybe you 
are not going right back to work, or you are going back to a 
different description of your job.
    All of this leads a woman into that pattern of doubting 
their own self-worth, doubting their self-esteem, and into that 
downward spiral where you feel like days never end. And it is 
difficult to get your hands around that as you try to care for 
a new baby and a new home life and wonder how in the world you 
are going to get yourself back to a normal routine.
    It does put a very difficult situation in front of so many 
women who are not only first-time moms but many times second or 
third-time pregnancies with those new babies. And I appreciate 
the sponsor's work on the bill. I appreciate the committee 
taking a look at the bill. I do recognize and appreciate the 
intent of the legislation to expand and intensify the research 
activities around postpartum depression and postpartum 
psychosis.
    I do hope however that the bill is not too prescriptive for 
the NIH and that it will allow the NIH the opportunity to 
decide the best ways to go about studying postpartum 
depression. And with that, Mr. Chairman, I yield back the 
balance of my time and look forward to the witnesses.
    Mr. Pallone. Thank you. I recognize Mr. Rush, the sponsor 
of our legislation.

 OPENING STATEMENT OF HON. BOBBY L. RUSH, A REPRESENTATIVE IN 
              CONGRESS FROM THE STATE OF ILLINOIS

    Mr. Rush. Well, thank you, Mr. Chairman, and I want to 
thank you and Ranking Member Deal and all of my colleagues for 
this hearing and for highlighting the important issue of 
postpartum depression. Mr. Chairman, although I am not a member 
of this subcommittee, I really want you to know how 
appreciative I am for you allowing me and my witnesses to come 
forward before this subcommittee.
    Mr. Chairman, I authored the Melanie Blocker-Stokes 
Postpartum Research and Care Act back in 2001, after being 
engaged, along with other members of my community, in prayer 
and interest and being engaged in seeking to find out the 
whereabouts of Melanie Blocker-Stokes. She had disappeared, I 
think, mid-week, and we knew the Blocker family. We knew the 
work that Mrs. Carol Blocker, the mother, had done in 
education, and she had been a teacher.
    And we were all concerned, and then I believe it was on a 
Saturday afternoon, the news banner interrupted the normal 
broadcasting on the television and said that Melanie Blocker-
Stokes had been found, that she had jumped out of a hotel 
window in the near north side of the city of Chicago and that 
she had killed herself. And we were all stunned as a community, 
and then upon further study and hearing the news, I heard for 
the first time about postpartum depression and postpartum 
psychosis. The tragic story of Melanie's suicide as a result of 
postpartum psychosis and the overwhelming support of the mental 
health community including Dr. Nada Stotland demonstrated for 
me that the Congress needed to add on this issue of postpartum 
psychosis and postpartum depression. It demonstrated a need for 
more research and service for mothers.
    And so in 2001, I introduced the Melanie Blocker-Stokes 
Postpartum Care and Research Act. And, Mr. Chairman, 6 years 
later, this non-controversial bill to aid mothers and 
motherhood remains detained in this community. Mrs. Blocker 
said it best in her testimony. ``Hundreds of thousands of women 
who have suffered from postpartum depression and psychosis are 
still waiting for Congress to act.''
    Mr. Chairman, I am hopeful that today's hearing and the 
support of all the subcommittee Democrats and Ranking Member 
Deal and others including just overwhelming support from over 
100 bipartisan cosponsors. I really want to highlight Dr. 
Burgess for his early support of this bill.
    This bipartisan support is a signal that change is on the 
horizon. As many of you know, the needs of researchers to 
combat postpartum depression are more and more significant each 
and every year. Research indicates some form of postpartum 
depression affects approximately 1 in 1,000 new mothers 
resulting in upwards of 400,000 new cases each and every year. 
Of the new postpartum cases this year, less than 15 percent of 
mothers will receive treatment; although, scientists argue with 
treatment, over 90 percent of these mothers could overcome 
their depression
    Chairman Pallone, my legislation is bipartisan, and 
Congress must step up and meet this growing problem head on. It 
is scientifically established----
    Mr. Pallone. I have got to tell you you are over a minute.
    Mr. Rush. Recognized and endorsed. Mr. Chairman, I just 
want to go on and proceed. Thank you so very much for this 
hearing, and I yield back the balance of all of my time that is 
left.
    Mr. Pallone. Thank you. That concludes the opening 
statements by members of the subcommittee.
    Any other statements by Members may be included at this 
point in the record as well as the text of H.R. 20.
    [The prepared statements of Ms. Eshoo and Mr. Towns as well 
as H.R. 20 follows:]

Prepared Statement of Hon. Anna G. Eshoo, a Representative in Congress 
                      from the State of California

    Mr. Chairman, thank you for holding this important hearing 
on H.R. 20 the Melanie Blocker-Stokes Postpartum Depression 
Research and Care Act. I commend you for your attention to this 
critical issue, and thank Rep. Rush for sponsoring this 
legislation.
    Postpartum depression is a serious mental health condition 
which in various forms affects up to 80 percent of new mothers 
after childbirth. While there is no known cause of post-partum 
depression, experts believe the hormonal and physical changes 
that occur after childbirth, as well as the added 
responsibility of caring for a new life are factors that may 
lead to postpartum depression in some women.
    While the ``baby blues'' are common in new mothers, a full-
blown depressive episode is not a normal occurrence and 
requires active intervention. A woman suffering from postpartum 
depression needs treatment from her physician or therapist and 
emotional support from family and friends in order to recover 
her physical and mental well-being. Unfortunately, many women 
who suffer from postpartum depression don't receive the 
treatment they need because of the costs associated with mental 
health care.
    There is also a social stigma attached to the ``baby 
blues'' that prevents many women from seeking the appropriate 
treatment. Some women don't tell anyone about their symptoms 
because they feel embarrassed, ashamed, or guilty about feeling 
depressed when they're supposed to be happy. They worry that 
they will be viewed as an unfit parent. If left untreated, this 
illness can lead to other health problems such as substance 
abuse and clinical depression. Postpartum psychosis, the most 
severe type of postpartum depression, can lead to suicide if 
untreated.
    I'm proud to cosponsor H.R. 20, which intensifies and 
expands research efforts through the National Institutes of 
Health (NIH) in order to better understand the causes of 
postpartum depression. A main goal of research under this bill 
is to find better treatments and a cure for this mental 
illness. The bill also authorizes grant funding and increases 
clinical research in order to develop more cost-effective 
treatment programs for new mothers and their families.
    This important legislation will go a long way to help women 
and families battle this all too common mental illness. I look 
forward to hearing from the witnesses today and urge my 
colleagues to support the bill.
                              ----------                              

[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]

    Mr. Pallone. We will turn to our witnesses. I want to 
welcome all of you. We originally had two panels, but we are 
just going to have one, so everybody is together. And you are 
all there, so you realize it.
    Let me introduce the members of the panel. First is Dr. 
Catherine Roca, who is the Chief of Women's Programs at the 
National Institutes of Mental Health. I would ask Mr. Rush if 
he would introduce Ms. Blocker, who is our next panelist. I 
will yield for the gentleman briefly.
    Mr. Rush. Well, Mr. Chairman, it is going to be hard to be 
brief, but I will attempt to be brief. I want to welcome one of 
the most extraordinary and superb women that this nation has 
ever called a citizen. Mrs. Carol Blocker was born and raised 
in Chicago, and for the past 30 years, she has been a public 
school teacher for the Chicago public schools. And I am proud 
to say that two of my grandsons were her students. Mrs. Blocker 
is the mother of two and a grandmother of two. And in 2001, the 
death of her daughter, Melanie Blocker-Stokes, was a defining 
moment. And she has been fighting for mothers ever since.
    Mr. Chairman, Mrs. Blocker established the Melanie Blocker-
Stokes Foundation, which educates and unites mothers, 
grandmothers, and families across this country to combat 
postpartum depression. I am proud to be her Congressman. I am 
proud to be the sponsor of this particular piece of 
legislation, and I am proud to call her my friend.
    And, Mr. Chairman, I want to join with you in welcoming 
Mrs. Blocker to this subcommittee.
    Mr. Pallone. Thank you, and we welcome Ms. Blocker. I have 
already made several statements about our next witness, who is 
Ms. Mary Jo Codey, who--it keeps saying former first lady, but 
actually is the current first lady because Senator Codey is 
currently the Acting Governor. And she really has single-
handedly brought to the attention of our State the whole issue 
of postpartum depression and mental health issues in general. 
She has just done so much so thank you for being here again.
    And then next is Michaelene Fredenburg who is president of 
Life Perspectives from San Diego. And then we have Dr. 
Priscilla Coleman who is associate professor of human 
development and family studies at Bowling Green State 
University in Ohio. And then last is Dr. Nada Stotland, who is 
professor of psychiatry and obstetrics/gynecology at the Rush 
Medical College in Chicago.
    Thank you all for being here, and I should mention we have 
5-minute opening statements. They become part of the hearing 
record, but each of you may, in the discretion of the 
committee, submit additional brief and pertinent statements in 
writing for inclusion in the record. And I am going to start 
with Dr. Roca.

  STATEMENT OF CATHERINE ROCA, M.D., CHIEF, WOMEN'S PROGRAMS, 
       NATIONAL INSTITUTE OF MENTAL HEALTH, BETHESDA, MD

    Dr. Roca. Thank you, Mr. Chairman. Thank you for inviting 
me to speak today, and thank you, Ranking Member Deal and 
members of the subcommittee.
    On behalf of the National Institute of Mental Health, part 
of the National Institutes of Health, an agency in the 
Department of Health and Human Services, I am pleased to 
present a brief overview of the current research for 
understanding and treating postpartum depression. And while I 
will be speaking primarily about research at National Institute 
of Mental Health, I want to acknowledge that research in this 
area is also being conducted elsewhere at the National 
Institute of Health, including the National Institute of Drug 
Abuse, the National Institute of Child Health and Human 
Development, the National Institute for Nursing Research, among 
others.
    Postpartum depression is a serious brain disorder that 
poses health risks to both mother and infant. Postpartum 
depression is part of a spectrum of mood disorders that affect 
women after the birth of a child ranging from mild, such as we 
have heard about postpartum or maternal blues, to severe 
including postpartum depression and postpartum psychosis.
    The maternal blues refers to a transient depressed mood 
that can last for a few days to a week. It is extremely common, 
affecting approximately 50 percent of new mothers. Postpartum 
depression describes a sustained period of 2 weeks or more of 
depressed mood that interferes with one's ability to perform 
day-to-day tasks and can be incapacitating. It is associated 
with a personal or family history of depression, depression 
during pregnancy, stress and lack of social support. Untreated 
postpartum depression has been associated with poor infant 
outcomes and poses a health risk to the mother, including the 
risk of suicide.
    Postpartum psychosis, which is rare, is associated with a 
personal or family history of bipolar or schizoaffective 
disorder. It typically occurs usually, usually within the 2 
weeks after childbirth and is associated with agitation, 
hallucination, and besides occasionally leading to violent 
behavior.
    According to a recent report, of the Health and Human 
Services Agency for health care research and quality, 
approximately 14 percent of women experience a new episode of 
depression during the first 3 months postpartum. Understanding 
the causes of these mood disorders is important for developing 
new treatments, as well as creating preventive interventions. 
The National Institute of Mental Health is currently funding a 
number of studies that examine the role of stress, hormones, 
genetics, psychosocial and cultural factors that may contribute 
to the development of postpartum depression.
    Because postpartum depression occurs in the context of a 
major change in reproductive hormone levels, there have been 
questions surrounding the role of estrogen and progesterone in 
postpartum depression. The National Institute of Mental 
Health's Intramural Research Program supports several studies 
in this area.
    For example, one intramural research study follows women 
during the postpartum period to assess whether the onset of 
depression is associated with a change in reproductive hormone 
levels. A companion study will determine whether estradiol 
administration can relieve symptoms of postpartum depression.
    And finally, researchers are exploring the role of 
reproductive hormone withdrawal as a potential cause of 
depressive symptoms in healthy women. In addition to this 
intramural research, the National Institute of Mental Health 
supports a variety of extramural studies on postpartum 
depression. Investigators are encouraged to submit research 
grant applications through program announcements on women's 
mental health in pregnancy and in the postpartum period.
    Depression that occurs during pregnancy poses some unique 
challenges for both the patient and health care provider. The 
National Institute of Mental Health has supported a number of 
studies, indicating that both interpersonal and cognitive 
behavioral therapies are effective in treating many women with 
depression during pregnancy and in the postpartum period.
    However, not all women respond to or can take advantage of 
these therapies. Other research is examining the risk of 
stopping antidepressant use during pregnancy. Women with 
recurrent major depression who discontinue their medication 
during pregnancy have a fivefold greater risk of relapsing than 
those who continue on their medication.
    Other studies raise concerns about the use of selective 
serotonin reuptake inhibitors during pregnancy. For example, 
selective serotonin reuptake inhibitors increase the risk of 
primary pulmonary hypertension, a rare but serious condition in 
newborns. However, untreated depression also poses risks to the 
newborn, including low birth rate and behavioral abnormalities. 
By cofunding a large center grant with the National Institute 
of Health Office of Research in Women's Health on medication 
use in pregnancy, NIMH is taking steps to obtain data on this 
important issue so that women and their doctors can be better 
informed as to the risks and benefits of antidepressant 
treatment during pregnancy.
    To successfully influence treatment practice, data must 
also be decimated, and for this reason, NIMH has teamed with 
several other Federal agencies to provide information on 
postpartum for the public and health care providers. The 
National Institute of Mental Health has assisted in updating 
information for consumers on postpartum depression for the 
Health and Human Services Office on Women's Health Web site.
    Additionally, the National Institute of Mental Health has 
worked with the Health and Human Services Health Resources and 
Services Administration staff to develop a consumer booklet on 
depression during and after pregnancy that was released on 
April 17, 2007. This brochure offers tips, identifying the 
condition in mothers, and six steps to help treat it 
successfully. Called ``Depression During and After Pregnancy: A 
Resource for Women, their Families, and Friends,'' the booklet 
is designed to increase awareness among women and clinicians.
    Overall, the National Institute of Mental Health supports 
an active research base to advance the understanding, 
treatment, and ultimately prevention of postpartum depression. 
This research continues to be a critical source of information 
for women, families, and health care providers seeking to 
better understand how to detect, manage, and treat this 
devastating illness.
    Thank you for the opportunity to provide this information 
to you, and I would be happy to answer any questions that you 
have.
    [The prepared statement of Dr. Roca follows:]

                   Testimony of Catherine Roca, M.D.

    Good afternoon, Mr. Chairman and members of the 
subcommittee. On behalf of the National Institute of Mental 
Health (NIMH), part of the National Institutes of Health, an 
agency of the Department of Health and Human Services (HHS), I 
am pleased to present a brief overview of the current research 
for understanding and treating postpartum depression. 
Postpartum depression is a serious brain disorder that poses 
health risks to both mother and infant. Postpartum depression 
is part of a spectrum of mood disorders that affect women after 
the birth of child, ranging from mild (maternal blues) to 
severe (postpartum depression and postpartum psychosis).
    The ``maternal blues'' refers to a transient depressed mood 
that can last a few days to a week. It is extremely common, 
affecting approximately 50 percent of new mothers. \1\
---------------------------------------------------------------------------
    1 Henshaw, C. Mood disturbance in the early puerperium: a review. 
Archives of Women's Mental Health. 2003 Aug; Suppl 2:S33-42.
---------------------------------------------------------------------------
     Postpartum depression (PPD) describes a sustained period 
(2 weeks or more) of depressed mood that interferes with one's 
ability to perform day-to-day tasks and can be incapacitating. 
It is associated with a personal or family history of 
depression, depression during pregnancy, stress, and lack of 
social support. Untreated postpartum depression has been 
associated with poor infant outcomes and poses a health risk to 
the mother, including the risk of suicide. Postpartum 
psychosis, which is rare, is associated with a personal or 
family history of bipolar or schizoaffective disorder. It 
typically occurs early, usually in the first two weeks after 
childbirth and is associated with agitation, hallucinations, 
and bizarre ideas, occasionally leading to violent behavior.
    According to a recent report of HHS' Agency for Healthcare 
Research and Quality, approximately 14 percent of women 
experience a new episode of depression during the first three 
months postpartum. \2\
---------------------------------------------------------------------------
    2 Gaynes, BN, Gavin N, eta l. Perinatal Depression: Prevelence , 
Screening Accuracy, and Screening Outcomes.
---------------------------------------------------------------------------
     Understanding the causes of these mood disorders is 
important for developing new treatments, as well as creating 
preventive interventions. NIMH is currently funding a number of 
studies that examine the role of stress, hormones, genetics, 
psychosocial, and cultural factors that may contribute to the 
development of PPD.
    Because PPD occurs in the context of a major change in 
reproductive hormone levels, there have been questions 
surrounding the role of estrogen and progesterone in PPD. The 
NIMH's Intramural Research Program (IRP) supports several 
studies in this area. For example, one IRP study follows women 
during the postpartum period to assess whether the onset of 
depression is associated with a change in reproductive hormone 
levels. A companion study will determine whether estradiol 
administration can relieve symptoms of postpartum depression. 
Finally, researchers are exploring the role of reproductive 
hormone withdrawal as a potential cause of depressive symptoms 
in healthy women.
    In addition to this intramural research, NIMH supports a 
variety of extramural studies on postpartum depression. 
Investigators are encouraged to submit research grant 
applications through program announcements on women's mental 
health in pregnancy and the postpartum period.
    Depression that occurs during pregnancy poses some unique 
challenges for both the patient and the health care provider. 
NIMH has supported a number of studies indicating that both 
interpersonal and cognitive-behavioral therapies are effective 
in treating many women with depression during pregnancy and in 
the postpartum period. However, not all women respond to, or 
can take advantage of, these therapies. Other research is 
examining the risk of stopping antidepressant use during 
pregnancy. Women with recurrent major depression who 
discontinued their medication during pregnancy had a five-fold 
greater risk of relapsing than those who continued on their 
medication. \3\
---------------------------------------------------------------------------
    3 Cohen LS, Altshuler LL, Harlow BL, Nonacs R, Newport DJ, Viguera 
AC, Suri R, Burt VK, Hendrick V, Reminick AM, Loughead A, Vitonis AF, 
Stowe ZN. Relapse of major depression during pregnancy in women who 
maintain or discontinue antidepressant treatment. JAMA. 2006 Feb 1; 
295(5):499-507
---------------------------------------------------------------------------
     Other studies raise concerns about the use of selective 
serotonin reuptake inhibitors (SSRIs) during pregnancy. For 
example, SSRIs increase the rate of primary pulmonary 
hypertension, a rare but serious condition, in newborns. 
However, untreated depression also poses risks to the newborn, 
including low birth weight and behavioral abnormalities. By co-
funding a large center grant with the NIH Office of Research on 
Women's Health on medication use in pregnancy, NIMH is taking 
steps to obtain data on this important issue so women and their 
doctors can be better informed as to the risks/benefits of 
antidepressant treatment during pregnancy.
    To successfully influence treatment practice, data must be 
disseminated. For this reason, NIMH has teamed with several 
other Federal agencies to provide information on PPD for the 
public and health care providers. NIMH has assisted in updating 
the information for consumers on postpartum depression for the 
HHS Office on Women's Health Web site, www.womenshealth.gov. 
Additionally, NIMH worked with HHS' Health Resources and 
Services Administration staff to develop a consumer booklet on 
depression during and after pregnancy that was released on 
April 17, 2007. The brochure offers tips on identifying the 
condition in mothers and six steps to help treat it 
successfully. Called ``Depression During and After Pregnancy: A 
Resource for Women, Their Families, and Friends,'' the booklet 
is designed to increase awareness among women and clinicians. 
The companion Web site may be found at http://mchb.hrsa.gov/
pregnancyandbeyond/depression/
    Overall, NIMH supports an active research base to advance 
the understanding, treatment, and ultimately prevention of 
postpartum depression. This research continues to be a critical 
source of information for women, families, and healthcare 
providers seeking better ways of detecting, managing, and 
treating this devastating illness.
    Thank you for the opportunity to provide this information 
to you. I would be happy to answer any question you may have.
                              ----------                              

    Mr. Pallone. Thank you, Dr. Roca. Ms. Blocker.

 STATEMENT OF CAROL BLOCKER, MOTHER OF MELANIE BLOCKER-STOKES, 
                          CHICAGO, IL

    Ms. Blocker. Good afternoon, Chairman Pallone, Ranking 
Member Deal, Congressman Rush, and members of the subcommittee. 
My name is Carol Blocker, and I am the mother of Melanie 
Blocker-Stokes, the proud grandmother of Summer Skyy, and an 
advocate for all women, mothers, and grandmothers, throughout 
this country who has suffered from postpartum depression.
    Melanie Blocker-Stokes, the inspiration for Congressman 
Rush's postpartum depression bill, took her life on June 11, 
2001, less than 5 months after giving birth to her first 
daughter, my grandchild, Summer Skyy. Today, 6 years after the 
introduction of this bill, Melanie and hundreds and thousands 
of women have suffered from postpartum depression and 
psychosis. I am still waiting for Congress to act.
    We want justice, Mr. Chairman, and that is why I ask for 
the House Energy and Commerce Subcommittee on Health to 
immediately pass H.R. 20, the Melanie Blocker-Stokes Postpartum 
Depression Research and Care Act.
    Congressman Rush has truly championed this cause, and I 
commend him for honoring my daughter's life and legacy through 
this legislation. I also want to thank every Democrat of this 
subcommittee for cosponsoring H.R. 20 and thank the Republican 
Ranking Member, Congressman Deal. H.R. 20 has over 100 
cosponsors, demonstrating it is not a political issue. It is a 
public health issue.
    Many of you may recall my daughter's story from my 
September 2004 testimony. However, it bears repeating.
    My daughter Melanie was born and raised in the city of 
Chicago. As both a child and an adult, she was beautiful, 
accomplished, and the light of my life. She was educated at St. 
George Private School in Hyde Park. She went to the Immaculata 
High School in Chicago and Spelman College in Atlanta, Georgia.
    After she completed Spelman College, Melanie returned home 
to Chicago and went to work for Astra Zeneca Pharmaceutical 
Company where she rose to become a sale manager. And she 
married Dr. Sam Stokes. Sam and Melanie were so happy in their 
marriage and their lives together. And they were even happier 
when they learned in 2000 that a child was on the way. Their 
whole family, Sam's family and ours, were ecstatic.
    When my granddaughter, who Melanie named Summer Skyy, was 
born on February 23, 2001, my daughter's pregnancy was normal. 
But 6 weeks after Melanie gave birth, at the routine postpartum 
checkup, she said that she felt hopeless and she retreated to 
her room. And we couldn't get her to go back to the doctor or 
back to her job or back into the world.
    One day, I found Melanie in her bedroom, and she was 
hollowed-eyed and gaunt, and she was rocking in her glider. And 
her lips and tongue were peeling from malnutrition because 
Melanie couldn't eat or sleep. When I went to her bathroom to 
get her a cold towel, I found a butcher's knife, and I asked 
Melanie--I said what are you going to do with this? And she 
looked at me, and she said she didn't know, but she thought she 
was going to have to die.
    At that moment, I knew that something was very, very wrong 
with Melanie, and I called her doctor. And her doctor said she 
was suffering from postpartum depression. Over the next 7 
weeks, Melanie was hospitalized three times, and each time, the 
doctors prescribed different combinations of anti-depression 
and anti-anxiety and anti-psychotic medications. But Melanie's 
depression had deepened to the point where she couldn't or 
wouldn't take the pills.
    She talked about suicide and looked for ways to harm 
herself. Once she even asked her brother to buy her a gun. 
Another time, she took the screen out of my high-rise apartment 
window while visiting me. And another time, we found that she 
had snuck away from her house and had tried to drown herself in 
Lake Michigan.
    And each time, we went to the doctor, and each time, there 
were more prescriptions and more assumptions, but we never 
heard the word postpartum psychosis. When Melanie came home 
after her third stay at the hospital, she seemed to have been a 
little bit better, but I was still worried. And my fears were 
founded. On the night before Melanie disappeared, I told her 
husband Sam, I said don't you let her out of your sight. But 
Sam had to leave for a meeting the next morning, and when he 
left, Melanie fled.
    The day was June 10, 2001, less than 6 months after Summer 
Skyy was born. We searched Chicago looking for her all weekend. 
We posted fliers. Sam went on local television news pleading 
for Melanie to come home. Your baby needs you, and I need you. 
But Melanie didn't answer. While we searched, Melanie went to a 
hotel in Chicago and checked into a room on the 12th floor. She 
then wrote six suicide notes, and the notes included one to 
God, one to Sam, and also six of them were lined up on the 
nightstand in her room. We found them after she was dead.
    On June 11, 2001, as the sun rose over Lake Michigan, my 
beautiful daughter stepped out of a 12th floor window to her 
death, and I think my heart died that day. After hearing my 
daughter's story, Congressman Rush asked what could have been 
done to prevent my daughter's tragic end and what additional 
resources were needed to help physicians and families recognize 
and understand and treat this terrible syndrome, postpartum 
psychosis, which affects about 1 in every 1,000 new mothers.
    I discussed the symptoms with Congressman Rush, and I 
talked to him about how Melanie began losing touch with reality 
and suffered from disoriented thinking and delusions and battle 
hyperactivity and mania. I told him about how her psychosis 
became like a monster that entered my daughter's brain, and it 
couldn't be controlled.
    Even in the milder forms of postpartum depression, this 
disease manifests itself with lack of interest in newborn 
child, fear of harming the child, fatigue, sadness, 
hopelessness, guilt, inadequacy and worthlessness.
    Some research indicates that between 50 to 75 percent of 
all new mothers suffered with this baby blues, yet little is 
known about how we as families can prevent the tragedy that 
fell on my family. Chairman Pallone and Ranking Member Deal, 
this legislation bipartisan. It is scientifically established 
and recognized by the mental health community. The bill will 
expand and intensify itself in the National Institute of Health 
and National Institute of Mental Health on the causes, 
diagnoses, and treatment of postpartum depression and 
postpartum psychosis.
    This bill would provide much-needed money to groups who are 
educating our communities and working directly with women who 
suffer from a postpartum depression and postpartum psychosis.
    In closing, Mr. Chairman, this legislation is long overdue. 
If this legislation had been in place in 2001, we might have 
recognized my daughter's troubles and prevented her death, and 
maybe my granddaughter would have her mommy today.
    Mr. Chairman and members of the committee, I hope and pray 
that you will finally act on this legislation and spare 
countless other women and their families from this horrible 
consequence of this disease. I implore you to do the right 
thing, answer my prayer, and honor my daughter's life and save 
the lives of hundreds of thousands of other women and children 
and families throughout this country. I hope you have the 
political will to pass H.R. 20, the Melanie Blocker-Stokes 
Postpartum Depression Research and Care Act. Thank you.
    [The prepared statement of Ms. Blocker follows:]

                       Statement of Carol Blocker

     Good Afternoon Chairman Pallone, Ranking Member Deal, 
Congressman Rush and members of the subcommittee.
     My name is Carol Blocker, and I am the mother of Melanie 
Blocker Stokes, the proud grandmother of Sommer Skyy, and an 
advocate for all women-mothers-and grandmothers throughout this 
country who have suffered from postpartum depression.
     Melanie Blocker Stokes, the inspiration for Congressman 
Rush's postpartum depression bill, took her life on June 11, 
2001, less than 5 months after giving birth to her first 
daughter, my grandchild, Sommer Skyy.
     Today, 6 years after the introduction of this bill, 
Melanie and hundreds of thousands of women, who have suffered 
from postpartum depression and psychosis are still waiting for 
Congress to ACT.
     We want justice Mr. Chairman, and that is why I ask for 
the House Energy and Commerce Subcommittee on Health to 
immediately pass H.R. 20, the Melanie Blocker Stokes Postpartum 
Depression Research and Care Act.
     Congressman Rush has truly championed this cause and I 
commend him for honoring my daughter's life and legacy through 
this legislation.
     I also want to thank every democratic member of this 
subcommittee for co-sponsoring H.R. 20--and thank the 
Republican ranking member, Congressman Deal. H.R. 20 has over 
100 cosponsors, demonstrating it is not a political issue--it's 
a public health crisis.
     Many of you may recall my daughter's story from my 
September 2004 testimony; however, it bears repeating.
     My daughter, Melanie, was born and raised in the city of 
Chicago. As both a child and an adult, she was beautiful, 
accomplished, and the light of my life.
     We educated her at St. George private school in Hyde Park; 
she went to the Immaculata High School in Chicago, and Spelman 
College in Atlanta, Georgia. After she completed Spelman 
College, Melanie returned home to Chicago and went to work for 
Astra Zeneca Pharmaceutical Company, where she rose to become a 
sales manager, and she married Dr. Sam Stokes.
     Sam and Melanie were so happy in their marriage and their 
lives together. They were even happier when they learned, in 
2000, that a child was on the way. The whole family, Sam's 
family and ours, were ecstatic when my granddaughter--who 
Melanie named Sommer Skyy--was born on February 23, 2001.
     My daughter's pregnancy was normal.
     But, 6 weeks after Melanie gave birth, at the routine 
postpartum checkup, she said that she felt ``hopeless'' and she 
retreated to her room. We couldn't get her to go back to the 
doctor, or back to her job, or back into the world.
     One day I found Melanie in her bedroom and she was hollow-
eyed and gaunt, and she was rocking in her glider. Her lips and 
her tongue were peeling from malnutrition, because Melanie was 
not eating or sleeping.
     When I went to her bathroom to get her a cold towel, I 
found a butcher's knife, and I asked Melanie, I said, ``What 
are you doing with this?'' She looked at me and said she didn't 
know, but she thought she was going to have to die.
     At that moment, I knew that something was very, very wrong 
with Melanie and I called her doctor. Her doctor said she was 
suffering from postpartum depression.
     Over the next 7 weeks Melanie was hospitalized three 
times, and each time the doctors prescribed different 
combinations of anti-depression, anti-anxiety and anti-
psychotic medications, but Melanie's depression had deepened to 
the point that she wouldn't or couldn't take the pills.
     She talked about suicide and looked for ways to harm 
herself. Once she even asked her brother to buy her a gun.
     Another time she took the screens out of my high-rise 
apartment windows while visiting me.
     And another time we found that she had snuck away from her 
home and tried to drown herself in Lake Michigan. Each time we 
went back to the doctor, and each time there were more 
prescriptions and more assumptions, but we never heard the 
words postpartum psychosis.
     When Melanie came home after her third stay in the 
hospital she seemed to be a bit better, but I was still 
worried, and my fears were founded.
     On the night before Melanie's disappearance, I told her 
husband Sam, ``Don't you let her out of your sight.'' But Sam 
had to leave for a meeting the next morning, and when he left 
the apartment Melanie fled. The day was June 10, 2001, less 
than 6 months after Sommer Skyy was born.
     We searched Chicago looking for her all weekend. We posted 
flyers and Sam went on the local television news, pleading, 
``Melanie, please come home. I need you. Your baby needs you.'' 
But Melanie didn't answer.
     While we searched, Melanie went to a hotel in Chicago and 
checked into a room on the twelfth floor. She then wrote six 
suicide notes. The notes included one to God and one to Sam, 
and all six of them were lined up on the night stand in her 
room. We found them after she died.
     On June 11, 2001, as the sun rose over Lake Michigan, my 
beautiful daughter stepped out of a twelfth floor window to her 
death.
     And I think my heart died that day.
    After hearing my daughter's story, Congressman Rush, asked 
me what could have been done to prevent my daughter's tragic 
end, and what additional resources were needed to help 
physicians and families recognize, understand and treat this 
terrible syndrome--postpartum psychosis--which affects about 
one in 1,000 new mothers.
     I discussed the symptoms with Congressman Rush. I talked 
to him about how Melanie began losing touch with reality, 
suffered from distorted thinking and delusions, battled 
hyperactivity and mania.
     I told him about how her psychosis became like a monster 
that entered my daughter's brain, and it could not be 
controlled.
     Even in the milder forms of postpartum depression, this 
disease manifests itself with lack of interest in a newborn 
child, fear of harming the child, fatigue, sadness, 
hopelessness, guilt, inadequacy and worthlessness.
     Some research indicates that between 50 to 75 percent of 
all new mothers suffer with these ``baby blues,'' yet little is 
known about how we, as families, can prevent the tragedy that 
fell on my family.
     Chairman Pallone, Ranking Member Deal, this legislation is 
bipartisan. It is `scientifically established'', and recognized 
by the mental health community.
     The bill will expand and intensify research in the 
National Institutes of Health and National Institutes of Mental 
Health on the causes, diagnoses and treatments of postpartum 
depression and postpartum psychosis.
     This bill will provide much needed money to groups who are 
educating our communities and working directly with women who 
suffer from a postpartum depression and postpartum psychosis.
     In closing Mr. Chairman, this legislation is long overdue. 
If this legislation had been in place in 2001, we might have 
recognized my daughter's troubles and prevented her death.
     Maybe my granddaughter would have her mommy today.
     Mr. Chairman and members of the committee, I hope and pray 
that you will finally act on this legislation and spare 
countless other women and their families from the horrible 
consequences of this disease.
     I implore you to do the right thing--answer my prayers and 
honor my daughter's life. Save the lives of hundreds of 
thousands of other women, children, and families throughout 
this country by finding the political will to pass H.R. 20, the 
Melanie Blocker Stokes Postpartum Depression Research and Care 
Act.
                              ----------                              

    Mr. Pallone. Thank you so much, Ms. Blocker. Thank you for 
both sharing the story of your daughter, but also for having 
the fortitude to come forward and make us do something about it 
so it doesn't happen to others. We certainly appreciate it. I 
know that you have to leave and catch a plane. She has 
indicated to us that she will take any written questions that 
we forward to her, but she has to leave at this time. Thank you 
again.
    Ms. Blocker. Thank you.
    Mr. Pallone. And now we will have Ms. Codey. Thank you for 
being here.

   STATEMENT OF MARY JO CODEY, MEMBER, PRESIDENT'S ADVISORY 
  COUNCIL OF POSTPARTUM SUPPORT INTERNATIONAL, WEST ORANGE, NJ

    Ms. Codey. Mr. Chairman, Ranking Member Deal, and members 
of the subcommittee, thank you for calling this important 
hearing and inviting me to testify on behalf of those who 
suffer from postpartum mood disorders. I am a member of the 
President's Advisory Council of Postpartum Support 
International and a kindergarten teacher in the West Orange 
Public School System.
    I was first introduced to postpartum depression, or PPD, 
through my own experience after I delivered my oldest son, 
Kevin, 22 years old. Nothing prepared me for what has been the 
worst experience of my life. Not even having breast cancer 
could compare.
    One of the worst aspects of PPD is that it strikes at a 
time when you expect to be overjoyed. When you aren't, you feel 
shame, guilt, inadequacy, and isolation. No matter how much 
support you receive from those around you, you lose touch with 
them and with yourself. You fail to bond with your baby. You 
can't function, and you have no idea what is happening or where 
to turn for help.
    Although I had all the signs of PPD, no one seemed to know 
what was wrong. After I began to have terrifying intrusive 
thoughts about hurting my son, I checked myself into a mental 
institution for a month but found no help there. Eventually I 
found a psychiatrist who did know about PPD. For months, we 
tried different antidepressants, but the intrusive thoughts 
increased until I couldn't stand it and resolved to commit 
suicide. As a last ditch effort, the psychiatrist prescribed a 
MAO inhibitor. Within weeks, the intrusive thoughts began to 
recede and finally disappeared.
    In total, it took me almost a year to get better, but I 
endured depression again with my second and final pregnancy, 
during which I underwent 11 rounds of shock therapy. When it 
was all done, I came to be angry that so little was known about 
this disorder. I thought it was unfair for women and their 
family not to be educated about it.
    PPD isn't a woman's illness. It is a family illness, and I 
didn't want anyone to have to go through what my family and I 
had experienced. So I began sharing my story with medical and 
mental health professionals, women's groups, and the media. And 
I began working with PPD support and mental health groups. My 
husband also is a long-time advocate for the mentally ill, and 
circumstances gave us a window of opportunity.
    During his 14-month of tenure as Governor, New Jersey 
created a comprehensive campaign called ``Recognizing 
Postpartum Depression: Speak Up When You're Down.'' And I am 
proud to be the spokesperson for this campaign. New Jersey's 
postpartum depression screening and education law, which was 
signed by Governor Corzine a year ago and took effect in 
October, is an outgrowth of the efforts that began during my 
husband's administration.
    Now, every pregnant woman in our State has to be educated 
about maternal mood disorders before giving birth and screened 
for PPD after. All licensed health care professionals who 
provide pre and post-natal care have to be educated about 
maternal depression. Health organizations around our State have 
received funding to develop programs that respond to the law, 
and they continue to expand their services even as we meet here 
today. I am proud that our law, which is the first of its kind, 
has become the model for other States that seek to develop 
programs. But that is happening slowly. Meanwhile, too many 
cases are going undiagnosed and untreated.
    Maternal depression is one of the most common complications 
of childbirth. It strikes without regard to age, race, 
education, or economic background. It robs women of the ability 
to bend with their new babies and isolates them from their 
loved ones. It robs children of mothers who can provide the 
love and care they need. Congress has a moral obligation to 
women and their families across the whole country to provide 
more research to determine the full extent of this public 
health crisis. More education, screening, treatment and support 
is needed to avoid needless suffering. It will take a Federal 
mandate to do that effectively.
    I have supported Congressman Rush's bill since it was first 
introduced, and I am proud that New Jersey's law inspired 
Senator Menendez to introduce the Mother's Act.
    I urge you with all my heart to expand the work we are 
doing in New Jersey by giving us a national law. Thank you and 
sorry.
    [The prepared statement of Ms. Codey follows:]

                       Testimony of Mary Jo Codey

     Mr. Chairman and members of the subcommittee, thank you 
for calling this important hearing and inviting me to testify 
on behalf of those who suffer from postpartum mood disorders. 
My name is Mary Jo Codey. I am the wife of Richard Codey, 
former governor, current acting governor, and senate president 
of New Jersey. I am also a member of the President's Advisory 
Council of Postpartum Support International, and a teacher in 
the West Orange Public School System.
     I was first introduced to postpartum depression--or PPD--
through my own experience after I delivered my oldest child, 
Kevin, 22 years ago. Nothing prepared me for what has been the 
worst experience of my life. Not even having breast cancer 
could compare.
     One of the worst aspects of PPD is that it strikes at a 
time when you expect to be overjoyed. When you aren't, you feel 
shame, guilt, inadequacy, and isolation. No matter how much 
support you receive from those around you, you lose touch with 
them and with yourself. You fail to bond with your baby. You 
can't function. And you have no idea what's happening, or where 
to turn for help.
     Although I had all the signs of PPD, no one seemed to know 
what was wrong. After I began to have terrifying, intrusive 
thoughts about hurting my son, I checked myself into a mental 
institution for a month but found no help there.
     Eventually, I found a psychiatrist who did know about PPD. 
For months, we tried different antidepressants, but the 
intrusive thoughts increased until I couldn't stand it and 
resolved to commit suicide. As a last-ditch effort, the 
psychiatrist prescribed an MAO inhibitor. Within weeks, the 
intrusive thoughts began to recede and finally disappeared.
     In total, it took me almost a year to get better. But I 
endured depression again with my second and final pregnancy, 
during which I underwent 11 rounds of shock therapy.
     When it was all done, I came to be angry that so little 
was known about this disorder, which strikes an estimated 
11,000 to 16,000 women a year in my state alone. I thought it 
was unfair for women and their families not to be educated 
about it. PPD isn't a woman's illness; it's a family illness. 
And I didn't want anyone to--have to go through what my family 
and I had experienced. So I began sharing my story with medical 
and mental health professionals, women's groups, and the media. 
And I began working with PPD support and mental-health groups.
     My husband also is a long-time advocate for the mentally 
ill, and circumstances gave us a window of opportunity. During 
his 14-month tenure as governor, New Jersey created a 
comprehensive campaign called ``Recognizing Postpartum 
Depression: Speak Up When You're Down.'' I am proud to be the 
spokesperson for this campaign, which features

      a 24-hour helpline;
      a bilingual Web site with valuable information 
for women, their families, and medical professionals;
      literature;
      and public-service announcements.

     New Jersey's Postpartum Depression Screening and Education 
law--which was signed by Governor Corzine a year ago and took 
effect in October--is an outgrowth of the efforts that began 
during my husband's administration. Now, every pregnant woman 
in our state has to be educated about maternal mood disorders 
before giving birth and screened for PPD after. And all 
licensed health care professionals who provide pre- and post-
natal care have to be educated about maternal depression. 
Health organizations around our state have received funding to 
develop programs that respond to the law, and they continue to 
expand their services even as we meet here today.
     I'm proud that our law, which is the first of its kind, 
has become the model for other states that seek to develop 
programs. But that is happening slowly. Meanwhile, too many 
cases are going undiagnosed and untreated.
     Maternal depression is one of the commonest complications 
of childbirth. It strikes without regard to age, race, 
education, or economic background. It robs women of the ability 
to bond with their new babies and isolates them from their 
loved ones. It robs children of mothers who can provide the 
love and care they need.
     Congress has a moral obligation to women and their 
families across the whole country to provide more research to 
determine the full extent of this public health crisis and more 
education, screening, treatment, and support to avoid needless 
suffering. It will take a Federal mandate to do that 
effectively.
     I urge you to expand the work we are doing in New Jersey 
to the national level by passing H.R. 20. Thank you.
                              ----------                              

    Mr. Pallone. No, thank you so much. Thank you for all that 
you do because you really prove that getting out there and 
working on this issue makes a difference based on what we did 
in New Jersey and now in supporting the Federal bill. So thank 
you again. Mrs. Fredenburg.

      STATEMENT OF MICHAELENE FREDENBURG, PRESIDENT, LIFE 
                  PERSPECTIVES, SAN DIEGO, CA

    Ms. Fredenburg. Mr. Chairman, good afternoon. My name is 
Michaelene Fredenburg. I am the president of Life Perspectives. 
I live in San Diego, California.
    I am very grateful that you are considering H.R. 20 as it 
is critical to study and to treat postpartum depression, and I 
am also grateful for the opportunity to tell my story today.
    As a teenager, I assumed that abortion was necessary for 
women to complete their educational and career goals. So it is 
not surprising that when I became pregnant at 18 that I 
considered abortion. I also thought about adoption; however, 
when I talked to my live-in boyfriend, he was furious that I 
was pregnant and demanded that I have an abortion or he would 
kick me out.
    I turned to my employer for advice. She was another woman. 
And after listening to my story, she really urged me as well 
that it was really a logical solution to the situation that I 
was in. And she offered to set up the appointment for me.
    My experience at the abortion clinic was painful and 
humiliating. It was nothing like what I had thought of when I 
had defended a woman's right to choose. I was completely 
unprepared for the emotional fallout after the abortion. I 
thought that the abortion would erase my pregnancy. I thought I 
could move on with my life, but I wasn't able to.
    Although I didn't feel this way before the procedure, it 
was now clear to me that the abortion ended the life of my 
child, and I soon found myself in a cycle of self-destructive 
behavior that included an eating disorder. I experienced 
periods of intense anger, followed by periods of profound 
sadness. For weeks and sometimes months at a time, I was too 
fatigued to do more than eat or take a shower during the day. I 
lost interest in food, and my weight fell dangerously low.
    There were also periods where I was able to pull myself 
together and lead a normal life, at least outwardly. I did see 
a number of doctors for the fatigue and the weight loss. They 
tested me for everything from cancer to lupus to AIDS. I didn't 
tell them about the feelings I was having as a result of the 
abortion because I didn't see a connection. And this continued 
for the next few years until suicidal thoughts began to scare 
me, and that is when I finally reached out to a therapist for 
help.
    And with the help of that therapist and other supportive 
friends, my time of self-condemnation and self-punishment came 
to an end, and I was finally able to enter into a healthy 
grieving process. In addition to grieving the loss of my child, 
I slowly became aware of the impact that my choice had on other 
family members.
    My parents believed that somehow they had failed me, and 
they still grieve over the loss of their grandchild. When I 
first told my sister, she cried and said she just didn't want 
to know. She didn't want to know about the niece or nephew that 
is missing. My oldest son found out when he was quite young, 
and he still struggles with the loss of the sibling and the 
reality that I am the cause of that loss. My youngest son 
hasn't been told yet, and it breaks my heart that some day he 
will have to deal with this loss.
    In addition to coping with the fallout that my abortion has 
caused to my family, there are still times that are painful for 
me. After all, healing doesn't mean forgetting. Mother's Day is 
particularly difficult.
    Over the years, I have heard many heartrending stories 
about abortion. Although each story is unique, a common thread 
moves through all of them, and that is that abortion changes 
you. Yet there is no form in place to help abortion 
participants and those closest to them to explore this tragic 
truth. Planned Parenthood says one out of four women of 
childbearing years has had at least one abortion in this 
country.
    Although abortion has touched many of us, we rarely share 
our personal experiences. Shame or guilt may play a role in 
secreting our abortions. The rancorous public debate certainly 
doesn't encourage dialog. We also lack the language to discuss 
the conflicted emotions that trouble us. Whatever the reason, 
silence perpetrates the myth that we stand alone in our 
abortion experiences or at least that we stand alone in our 
emotional debris.
    Very recently, a pro-choice group that tries to stay 
neutral on this issue released a line of e-cards to women who 
have experienced abortion. Within the first 7 days, hits on 
their Web site went from 200 to 15,000 a day, and over a 1,000 
of those e-cards were mailed out.
    There are tens of millions of women who are hurting, and we 
are beginning to understand that. But if they don't have a safe 
place to deal with their emotions, she may need to repress or 
numb them in order to cope. And that is when she can find 
herself dealing with prolonged feelings of sadness, nightmares, 
loss of self-esteem, perhaps eating disorders or substance 
abuse or even attempted and completed suicides.
    Although some women are able to move on from their 
abortion, many are left with physical or emotional scars that 
impact them for years and sometimes decades. In all the noise 
that surrounds abortion, women are often forgotten. I believe 
it is time to stop that noise and start listening to women who 
have experienced pregnancy losses.
    I have been grateful that you have taken time today to 
listen, and I do urge you to take steps to understand the 
impact abortion and other pregnancy losses have on women. Thank 
you very much.
    [The prepared statement of Ms. Fredenburg follows:]

                   Statement of Michaelene Fredenburg

    Mr. Chairman, good afternoon; my name is Michaelene 
Fredenburg, I am the president of Life Perspectives, and I live 
in San Diego, California. I am grateful that you are 
considering H.R. 20, as it is a critical to study and treat 
post-partum depression. I am also grateful for the opportunity 
to testify before this Committee today.
    As a teenager, I assumed legalized abortion was necessary 
for women to attain their educational and career goals. So it's 
not surprising that when I became pregnant at 18, I thought 
about having an abortion. I also considered adoption.
    My 28-year-old live-in boyfriend was furious when he 
discovered I was pregnant. He immediately demanded that I have 
an abortion or he would kick me out. I turned to my employer 
for advice. After I told her about my situation, she 
recommended abortion. She said it was the only logical option 
and offered to arrange one for me.
    My experience at the abortion clinic was painful and 
humiliating--nothing like I'd imagined when I defended a 
woman's ``right to choose.'' Although the young women awaiting 
their abortions were anxious and tearful, the clinic staff was 
cold and aloof. I met briefly with a ``counselor'' who 
characterized my 8-week pregnancy as a ``couple of cells'' and 
the ``products of conception.'' As I lay alone in the procedure 
room, I could hear footsteps move down the hall and turn into a 
room. This was repeated several times, each time the footsteps 
were louder and closer. My anxiety steadily built and then 
peaked when the abortion provider and her assistant entered the 
room. I began to have second thoughts, and I asked the 
assistant if I could have a few minutes. The doctor yelled, 
``Shut her up!'' and started the suction machine.
    It was not an empowering experience. I felt violated and 
betrayed.
    I was completely unprepared for the emotional fallout after 
the abortion. I thought the abortion would erase the pregnancy. 
I thought I could move on with my life. I was wrong. Although I 
didn't feel this way before the procedure, it was now clear to 
me that the abortion ended the life of my child.
    The mere presence of my boyfriend caused deep hurt and 
pain. I found it difficult to work. I soon found myself in a 
cycle of self-destructive behavior that included an eating 
disorder.
    Desperate for a fresh start, I broke up with my boyfriend, 
quit my job, and moved from Minnesota to Hawaii. Although 
Hawaii was breathtakingly beautiful and bursting with life, I 
felt dead inside. It didn't take long for me to realize I 
couldn't escape from myself.
    I experienced periods of intense anger followed by periods 
of profound sadness. For weeks and sometimes months at a time, 
I was too fatigued to do more than eat a meal and shower during 
the day. I lost interest in food, and my weight fell 
dangerously low. There were also periods when I seemed able to 
pull myself together and lead a normal life--at least 
outwardly.
    I saw a number of doctors for the fatigue and weight loss. 
They tested me for everything from lupus to cancer to AIDS. I 
didn't tell them about the feelings I was having as a result of 
the abortion. I didn't see a connection between the abortion 
and my current physical symptoms. This continued for the next 
few years until suicidal thoughts began to scare me. That's 
when I finally went to see a therapist.
    With the help of counselors and supportive friends, my time 
of self-condemnation and self-punishment came to an end. I was 
finally able to enter into a healthy grieving process.
    In addition to grieving the loss of my child, I slowly 
became aware of how my choice to abort had impacted my family. 
A choice they only learned about when I decided to go public 
with my experience.
    Although I repeatedly assured my parents that I never 
doubted their willingness to provide support and assistance if 
I'd decided to carry the baby to term, they still believed that 
somehow they'd failed me and they were at least partly 
responsible for the death of their grandchild. When I first 
told my sister, she cried and said she wished she didn't know 
about the niece or nephew who was missing.
    My oldest son found out when he was quite young, and he 
still struggles with the loss of a sibling and the reality that 
his mother was the cause of the loss. My youngest son hasn't 
been told yet. It breaks my heart that one day he'll also have 
to deal with a loss that I inflicted.
    In addition to coping with the fallout that my abortion has 
caused in my family, there are still times that are painful for 
me. After all, healing doesn't mean forgetting. Mother's Day is 
particularly difficult. The year my child would have graduated 
from high school was also filled with pain.
    If my child had gone to college, she would have graduated 
this year. This child would now be a young woman with gifts and 
abilities, hopes and dreams--her whole life ahead of her. There 
will always be a hole in my heart--a hole in the fabric of our 
family and our community.
    Over the years I've heard many heartrending stories about 
abortion. Although each story is unique, a common thread moves 
through them all--abortion changes you. Yet, there is no forum 
in place to help abortion participants and those closest to 
them explore this tragic truth.
    Planned Parenthood claims that 1 out of 4 women of 
childbearing years in the United States have had at least one 
abortion. Although abortion has touched many of us, we rarely 
share our personal experiences. Shame or guilt may play a role 
in secreting our abortions. The rancorous public debate 
certainly doesn't encourage dialogue about this personal and 
extremely sensitive topic. We also lack the language to discuss 
the conflicted emotions that trouble us. Whatever the reason, 
silence perpetuates the myth that we stand alone in our 
abortion experiences or at least that we're alone in the 
emotional debris.
    It is normal to grieve after a pregnancy loss whether the 
loss is caused by a miscarriage, stillbirth, adoption, 
infertility or an abortion. Most of us know someone who has 
suffered the loss of a child through miscarriage. The loss in 
an abortion is similar except for two important factors: the 
woman opted for the abortion, many times succumbing to pressure 
from others, and the abortion is often kept a secret. An 
important part of grieving is talking. Since an abortion is 
typically a secret, it is more difficult to talk about it.
    Even when she does want to talk about the abortion 
experience, her efforts are often met with resistance. Her 
partner typically doesn't want to talk about it. Well-meaning 
family and friends may try to ``help'' her by encouraging her 
to move on with her life and forget about the abortion. She may 
fear that pro-life individuals will condemn her and pro-choice 
individuals deny her feelings. With no safe place to deal with 
her emotions, she may need to repress or numb them in order to 
cope.
    This repressed grief can lead to prolonged feelings of 
sadness, nightmares, loss of self-esteem, eating disorders, 
substance abuse, destructive relationships, an inability to 
bond with future children or even attempted and completed 
suicides. If the abortion loss is followed by additional 
pregnancies losses such as a miscarriage or infertility, the 
multiple losses will only increase the inner chaos and pain.
    Although some women are able to move on from their 
abortion, many are left with physical or emotional scars that 
negatively affect their lives for years and sometimes decades.
    In all the noise surrounding abortion, women are often 
forgotten. It is time to stop the noise and start listening to 
women who have experienced pregnancy losses. I am grateful that 
you have taken the time to listen and I urge you to continue to 
take steps to understand the impact abortion and other 
pregnancy losses have on women.
                              ----------                              

    Mr. Pallone. Thank you. Dr. Coleman.

STATEMENT OF PRISCILLA K. COLEMAN, PH.D., ASSOCIATE PROFESSOR, 
   HUMAN DEVELOPMENT AND FAMILY STUDIES, BOWLING GREEN STATE 
                 UNIVERSITY, BOWLING GREEN, OH

    Ms. Coleman. Good afternoon, Mr. Chairman, members of the 
Health Committee. My name is Priscilla Coleman, and I am an 
associate professor of human development and family studies at 
Bowling Green State University in Ohio. I have published 
extensively in both national and international peer-reviewed 
journals on the psychological effects of abortion. Thank you 
for the opportunity to address you today.
    H.R. 20 pertains to postpartum depression which has 
fortunately gained attention in recent years with a few highly 
publicized cases. The psychological suffering experienced by 
many women and their families following childbirth has been 
seriously understudied, and this issue is before you today in 
hopes of expanding research and intervention efforts.
    In contrast, the psychological suffering endured by many 
women post-abortion has received minimal focused attention by 
lawmakers and governmental agencies. And the emotional distress 
experienced by countless women is often denied or obscured at 
various levels of society, despite well-documented scientific 
evidence.
    Abortion is experienced at least once by approximately 35 
percent of women by age 45. There is consensus among most 
social and medical science scholars that a minimum of 10 to 30 
percent of women who abort suffer from serious, prolonged, 
negative psychological consequences. With nearly 1.3 million 
U.S. abortions each year, the conservative 10 percent figure 
yields approximately 130,000 new cases of mental health 
problems each year.
    The results of the three largest studies in the world have 
shown that abortion is associated with an increased risk of 
mental health problems when compared the childbirth. A 
proliferation of smaller empirical studies published within the 
last 10 years in peer-reviewed psychology and medical journals 
has likewise documented the adverse psychological consequences 
of abortion. When compared the childbirth, the option of 
abortion carries an increased risk of depression, anxiety, 
sleep disturbance, and other forms of mental illness, in 
addition to suicide, substance use and abuse, relationship 
problems, parenting difficulties and even suicide.
    I would like to highlight one particularly strong study 
conducted by New Zealander David Ferguson and colleagues. 
Results of Ferguson's longitudinal study indicated that 42 
percent of the women who had aborted reported major depression 
by age 25. Thirty-nine percent of post-abortive women suffered 
from anxiety disorders. In addition, 27 percent reported 
suicidal ideation. Seven percent indicated alcohol dependence, 
and 12 percent were abusing drugs.
    In the published article, Ferguson, an outspoken pro-choice 
individual, sternly challenged the American Psychological 
Association's recent conclusion that ``well-designed studies of 
psychological responses following abortion have consistently 
shown the risk of psychological harm is low'' noting that this 
strong conclusion was based on a small number of studies, which 
suffer from significant methodological problems as well as a 
general disregard for studies showing negative effects. Dr. 
Ferguson was quoted by the New Zealand Herald as saying ``if we 
were talking about an antibiotic or an asthma risk and someone 
reported adverse reactions, people would be advocating further 
research to evaluate risks'' and ``I see no good reason why the 
same rules don't apply to abortion.''
    My colleagues and I have diligently, designed, executed and 
published studies that have addressed the flaws of earlier 
research. Please see appendix A submitted with my testimony. 
Among the collective strengths of the studies are the 
following: use of appropriate control group, unintended 
pregnancy carried to term, or other forms of perinatal loss, 
control for preexisting psychological problems, controls for 
personal and situational factors associated with the choice to 
abort, use of long-term data collection strategies, use of 
medical claims data with diagnostic codes assigned by trained 
professionals, which eliminate the problem of concealment found 
to be as high as 60 percent in the older abortion studies and 
large samples, most in the thousands. The need for a large, 
nationally representative, longitudinal study of women faced 
with an unintended pregnancy has been voiced repeatedly by 
researchers, including the former Surgeon General C. Everett 
Koop in the Reagan administration.
    Sociopolitical agendas permeating the design, publishing, 
funding and dissemination of research have undoubtedly thwarted 
research progress. However, in the interest of the millions of 
women who undergo one of the most common surgical procedures 
currently available in the United States and elsewhere 
throughout the world, it is clear that more intensive study is 
warranted. Such research will continue to be a target of 
political attacks. Nevertheless, as Thorbin colleagues noted in 
2003, ``a commitment to such research would seem to be morally 
neutral common ground upon which both sides of the abortion 
choice debate would agree is critical.'' Thank you.
    [The prepared statement of Ms. Coleman follows:]
    
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
    
    Mr. Pallone. Thank you, Dr. Coleman. And our last witness 
is Dr. Nada Stotland.

  STATEMENT OF NADA STOTLAND, M.D., PROFESSOR, PSYCHIATRY AND 
    OBSTETRICS/GYNECOLOGY, RUSH MEDICAL COLLEGE, CHICAGO, IL

    Dr. Stotland. Thank you. Chairman Pallone and members of 
the House subcommittee, thank you for the opportunity to speak 
with you today. I commend the subcommittee for holding this 
hearing on postpregnancy mental health in women, and I also 
commend my Congressman, Representative Bobby Rush, for 
reintroducing the Melanie Blocker-Stokes Postpartum Depression 
Research and Care Act and for his personal efforts to move this 
bill through Congress. I greatly appreciate his leadership on 
this vital issue.
    My name is Nada Stotland, M.D., M.P.H. I serve as vice 
president of the American Psychiatric Association, the medical 
specialty society representing more than 38,000 psychiatric 
physicians nationwide and have been a practicing psychiatrist 
for more than 25 years. I have devoted my career to the 
psychiatric aspects of women's reproductive health care, and I 
have treated many women suffering profoundly painful and 
disruptive psychiatric disorders following what should be a 
joyous experience, childbirth.
    To appropriately treat patients, psychiatrists depend on 
accurate diagnostic tools to help us identify the mental 
illnesses suffered by our patients and to determine the care 
our patients need. The diagnostic and statistical manual of 
mental disorders, or DSM, has become a central part of this 
process. DSM provides the most comprehensive diagnostic 
framework for defining and describing mental disorders and is 
included in over 650 State and Federal statutes and 
regulations. DSM-IV is based on decades of research, including 
systematic empirical studies conducted through 12 field trials 
involving more than 88 sites in the United States and 
internationally and the evaluation of more than 7,000 patients. 
A 27-member task force worked for 5 years to develop the 
manual, and I was a member of the work group addressing 
premenstrual dysphoric disorder.
    Let us clarify our terms for a moment. When used to 
describe a mood, the word depression refers to feelings of 
sadness, despair, and discouragement, which are feelings normal 
for any person to experience from time to time.
    But depression is also a clinical and scientific term, 
referring to a mental disorder. DSM-IV classifies depression by 
severity, recurrence, association with mania, and the time of 
its occurrence specifically including postpartum or after the 
birth of a baby.
    Mental symptoms following childbirth can occur in the form 
of baby blues or as mental disorders such as postnatal 
depression or psychosis. Postpartum depression, which is 
clinical depression occurring after childbirth, is an agonizing 
and disabling disorder that affects the whole family. It 
significantly impacts the mother's general and mental health 
and increases the risk of negative parenting behaviors that 
measurably impact the child's social, emotional, and behavioral 
development.
    Postpartum psychoses are psychotic disorders arising after 
childbirth. These are acute, severe illnesses triggered by the 
biologic and psychological stresses of pregnancy and delivery 
that occur after 1 or 2 of every 1,000 births.
    Symptoms include severe agitation, mood lability, 
confusion, thought disorganization, hallucinations, and 
sleeplessness. The results of misdiagnosis or lack of access to 
effective treatment can be horrific, with some mothers 
committing infanticide followed in up to 62 percent of the 
cases by suicide. Sadly, several such cases have occurred among 
Representative Rush's constituents.
    But since the subject came up, let me comment briefly on 
the so-called post-abortion depression and psychosis issue. I 
am familiar with many of the studies advocates for federally 
funded research use to support their efforts. Many are 
conducted under the auspices of or by individuals employed by 
organizations whose purpose is fundamentally political and 
anti-abortion in nature.
    We should be cautious about politicizing Federal research. 
I want to be clear here. Advocates of earmarked Federal 
research for post-abortion and depression and psychosis are 
using a diagnosis that does not exist. The DSM-IV does not 
recognize any such disorders. H.R. 20, however, deals with very 
real mental illness that brings needless anguish to tens of 
thousands of new mothers every year.
    Postpartum depression and psychosis are real, and the need 
for additional research and access to mental health services is 
widely acknowledged. I hope the subcommittee will not allow 
itself to be diverted from the agenda of the Melanie Blocker-
Stokes Postpartum Depression Research and Care Act that is so 
deserving of your support.
    We need to take postpartum mental health care seriously. 
All new mothers should be evaluated for depression. Educating 
physicians, health professionals, patients, and families about 
the warning signs of serious postpartum conditions is a key 
aspect of this goal.
    I want to call your attention--it was mentioned earlier--to 
a recent publication from Health Resources and Services 
Administration entitled ``Depression During and After 
Pregnancy: A Resource for Women, their Families and Friends.'' 
This resource addresses postpartum mental health in a 
straightforward way to help women recognize that they may need 
help. I have provided a copy of the document for the 
subcommittee, and I hope it can be included in the record of 
today's hearing.
    This Government document is an excellent resource that 
should be widely disseminated. I urge you to move H.R. 20 to 
enactment. It would provide essential funding to develop 
programs and systems of care to treat postpartum depression and 
postpartum psychosis. If I may, I would like to suggest that 
the bill also include funding for programs that will train 
physicians and other health professionals to recognize serious 
postpartum mental health issues so patients may be referred to 
mental health professionals for appropriate care. And we would 
be happy to work with you to develop this provision.
    Finally, the subcommittee and Congress as a whole must 
recognize that quality care is useless if women can't access 
treatment because their health insurance discriminates against 
mental illnesses. It is time to end the artificial divide 
between mind and body in insurance coverage and to provide 
treatment for mental illness in the same manner as other 
medical and surgical care. I commend the bipartisan majority of 
this subcommittee for cosponsoring the Paul Wellstone Mental 
Health and Addiction Equity Act of 2007, H.R. 1424, and I urge 
all the members of the subcommittee and of the House of 
Representatives to promote mental health parity.
    In conclusion, postpartum depression and the rare 
postpartum psychosis cause avoidable hurt, misery, and in the 
extreme, serious injury and death. This act offers hope and 
practical solutions for women who need help, and I hope the 
subcommittee will move forward with the agenda in this bill.
    Thank you again for the opportunity to speak with you 
today. I would be happy to answer any questions the 
subcommittee may have. Thank you.
    [The prepared statement of Dr. Stotland follows:]

              Testimony of Nada L. Stotland, M.D., M.P.H.

    Good afternoon, Chairman Pallone, Vice Chairman Green, 
Ranking Member Deal, and members of the Health Subcommittee. I 
am honored to appear before you today.
    My name is Nada L. Stotland, M.D. I hold Doctor of Medicine 
and Master of Public Health degrees and have been a practicing 
psychiatrist for more than 25 years. Currently, I have a 
private clinical practice and have devoted most of my career as 
a physician to the psychiatric aspects of women's reproductive 
health care.
    I speak today on behalf of the American Psychiatric 
Association (APA), where I presently serve as an elected member 
of the Board of Trustees. APA is the medical specialty society 
representing more than 38, 000 psychiatric physicians 
nationwide. Our members are on the front lines of treating 
mental illness across the country. They serve as clinicians, 
academicians, researchers, and administrators.
    By way of personal background, my interest in women's 
reproductive health issues began with the personal psychology 
of pregnancy, labor, and childbirth. I gave birth to four 
wonderful daughters, now adults, and I was determined that 
their births be as safe as possible. I studied methods of 
prepared childbirth, used them, and became the Vice President 
of the national Lamaze prepared childbirth organization. My 
daughter Naomi is now an obstetrician/gynecologist and the 
mother of two children of her own.
    I commend the Subcommittee for holding this important 
hearing on post-pregnancy mental health in women. Before I 
begin my testimony, I want to take a brief moment to 
acknowledge the determined persistence of my own Congressman 
and a member of the Committee--Representative Bobby Rush--in 
reintroducing H.R. 20 and in continuing his personal efforts to 
move his bill through the House. I greatly appreciate his 
leadership on this vital issue, particularly with respect to 
the impact of untreated depression in minority populations, 
including minority women. This is an important and sorely 
neglected issue.

                     Mental Health Issues and Women

    Before focusing on post-pregnancy depression, it would be 
useful to discuss some general issues related to women's mental 
health. Burt and Hendrick, writing in their ``Concise Guide to 
Women's Mental Health,'' put it succinctly, noting that ``Women 
use more health care services than any other group in the 
United States. They make more visits to doctors' offices than 
do men, fill more prescriptions, have more surgeries . . . and 
spend two out of every three health care dollars.''
    Specific gender differences in the prevalence of mental 
illnesses in the United States are well recognized. This is 
true of prevalence rates for some disorders, but also in the 
way in which some disorders present at the diagnostic 
interview, and also in comorbidities. For example, not only are 
depression and dysthymia (a chronic form of depression) more 
common in women than men, but both are more likely to be 
accompanied by anxiety disorders in women than men. And the 
features of psychiatric illnesses present in women are likely 
to be different than when present in men.
    The landmark Surgeon General's Report on Mental Health, 
issued by then-Surgeon General David Satcher, M.D., in 1999, 
provides much valuable information. Anxiety disorders (panic 
disorder, phobias, obsessive compulsive disorder, panic 
disorder, PTSD, etc.) are the most prevalent disorders in 
adults and are found twice as often in women as in men. Panic 
disorder is about twice as common among women as men, with the 
most common age of onset between late adolescence and mid-adult 
life. In the general (non-military) population, the 1-year 
prevalence rate of posttraumatic stress disorder is about 3.6 
percent, with women accounting for nearly twice the prevalence 
as men. The highest rates of PTSD are found among women who are 
the victims of crime, especially rape.
    Mood disorders take a huge toll in the form of human 
suffering, lost productivity and suicide. They rank among the 
top ten disabling conditions worldwide. The most familiar mood 
disorders include major depression, dysthymia and cyclothymia 
(alternating depression and manic states that do not rise to 
the level of bipolar disorder). Again, with the exception of 
bipolar disorder, mood disorders are twice as common in women 
as in men, and in the case of seasonal affective disorder 
(depression occurring in the late fall and winter), seven times 
more common in women than men. Victims of domestic violence (an 
estimated 8 to 17 percent of women in the United States each 
year) are at increased risk for mental health problems. The 
mental health problems of domestic violence include depression, 
anxiety disorders including as noted PTSD, eating disorders, 
substance abuse and suicide.
    Few would doubt the huge impact of depression alone on 
society and on the economy. Major depression is a seriously 
debilitating illness. Depressed persons see their physicians 
more often than others, and misdiagnosed depression can lead to 
extensive, expensive diagnostic tests (with obvious 
implications for health care costs). The most serious 
consequence of untreated depression is suicide. Major 
depressive disorders account for up to one-third of all deaths 
by suicide. While men in the U.S. commit suicide four times as 
often as women, women attempt suicide four times as often as 
men.

   The Importance of the Diagnostic and Statistical Manual of Mental 
                            Disorders (DSM)

    Psychiatrists and other mental health professionals depend 
on accurate diagnostic tools to help them identify precisely 
the mental illnesses their patients suffer, an essential step 
in deciding what treatment or combination of treatments the 
patient needs. The Diagnostic and Statistical Manual of Mental 
Disorders (or DSM) has become a central part of this process. 
DSM is, simply, the internationally-recognized standard for the 
diagnosis of mental disorders. As such, it provides the most 
comprehensive diagnostic framework for defining and describing 
mental disorders. DSM-IV is embodied in over 650 state and 
Federal statutes and regulations.
    The DSM-IV is based on decades of research and was 
developed through an open process involving more than 1,000 
national and international researchers and clinicians drawn 
from a wide range of mental and general health fields. The 
special 27-member DSM-IV Task Force worked for five years to 
develop the manual in a process that involved 13 work groups, 
each of which focused on a section of the manual. I myself was 
a member of the work group addressing late luteal phase 
dysphoric disorder, or premenstrual dysphoric disorder, as it 
came to be known. The work groups and each of their advisory 
groups of 50 to 100 individuals developed the manual in a 
three-step process.
    The first step in the three-stage empirical review was the 
development of 150 reviews of the scientific literature, which 
provided the empirical database upon which DSM-IV decisions 
could be made. In the second step, task force work groups 
reanalyzed 50 separate sets of data which provided additional 
scientific information to that available in the published 
literature. Finally, the task force conducted 12 field trials 
with funding from the National Institute of Mental Health, 
National Institute on Drug Abuse, and the National Institution 
of Alcoholism and Alcohol Abuse, involving more than 88 sites 
in the United States and internationally and evaluations of 
more than 7,000 patients. As you can see, the DSM-IV is based 
on systematic, empirical studies.
    The DSM-IV's codes are in agreement with the International 
Classification of Diseases, Ninth Edition, Clinical 
Modification (ICD-9-CM). ICD-9-CM is based on the ICD-9, a 
publication of the World Health Organization, used worldwide to 
aid in consistent medical diagnoses.
    The DSM-IV's codes often are required by insurance 
companies when psychiatrists, other physicians and other mental 
health professionals file claims. The Centers for Medicare and 
Medicaid Services (CMS) require mental health care 
professionals to use the DSM codes for the purposes of Medicare 
reimbursement.

                    DSM and Depression and Psychosis

    One of the more unfortunate aspects of our culture is that 
we tend to use diagnostic terms in everyday language. We say, 
for example, that a student who gets a ``C'' on a mid-term is 
``depressed,'' or that someone who is acting in an agitated way 
is ``psychotic.'' Doing so underscores a misunderstanding of 
the terms and thus embodies the stigmatic way in which we too-
often approach mental illnesses. For purposes of today's 
hearing it may be useful to briefly discuss depression and 
psychosis in the context of the DSM.
    Depression: When used to describe a mood, the word 
``depression'' refers to feelings of sadness, despair, and 
discouragement. As such, depression may be a normal state of 
feelings which any person could experience from time to time. 
``Depression'' is also a clinical and scientific term, and in 
these contexts may refer to a ``symptom'' seen in a variety of 
mental or physical disorders, or it may refer to a ``mental 
disorder'' itself. DSM-IV classifies depression by severity, 
recurrence, association with mania, and time of occurrence, 
including after the birth of a baby.
    Psychosis: Psychosis is part of a severe mental disorder 
and is characterized by a person's gross impairment in 
perceiving reality. A psychotic person may be delusional or may 
experience hallucinations, disorganized speech, or disorganized 
or catatonic behavior. Psychosis may show up, for example, in 
patients who are suffering from schizophrenia, delusional 
disorders, and some mood disorders including manic-depression 
or bipolar disorder.

                    Postpartum Psychiatric Disorders

    Mental disorders following childbirth was first mentioned 
over 400 years before the birth of Christ, by Hippocrates, who 
described the case of a woman in Cyzicus who ``gave birth with 
difficult labor,'' became sleepless and wandered at night, 
eventually suffering great distress before becoming rational 
again.
    Today we know from research that disturbances can occur in 
the postpartum period in the form of ``baby blues,'' or more 
seriously as postnatal depression or psychosis. Onset of baby 
blues occurs within days of delivery and can impact a 
significant number (some suggest 28 to 80 percent) of mothers 
across cultures. Features include emotional lability; it is 
unrelated to past history, and the symptoms are self-limited. 
Women with baby blues benefit from reassurance that the 
symptoms are common and will quickly disappear, but should be 
advised to seek help if symptoms are severe or persist for more 
than two weeks.
    Postpartum depression is an affective disorder lasting more 
than two weeks, typically with an onset beginning two to four 
weeks postpartum, the severity of which meets criteria for DSM-
IV designation. Special attention to postpartum depression is 
warranted because--in addition to the impact on maternal 
general and mental health--it increases the risk of negative 
parenting behaviors and puts children at risk for adverse 
outcomes in social, emotional, and behavioral development. Many 
cases are missed because new mothers are discharged so quickly 
from the hospital, and thereafter most care is provided by 
physicians focused on the care and wellness of the infant, and 
many families are uninformed about the nature and occurrence of 
the disorder. The literature shows risk factors including 
financial hardship, physical and emotional abuse, and a 
previous history of depression, particularly depression 
occurring antepartum.
    Postpartum psychoses are psychotic disorders arising after 
childbirth. These are acute, severe illnesses occurring after 
one or two of every 1,000 births. Symptoms include mood 
lability, severe agitation, confusion, thought disorganization, 
hallucinations and sleeplessness. Most researchers believe that 
postpartum psychosis is a manifestation of bipolar disorder. 
These episodes of psychotic illness are triggered by the 
biologic and psychological stresses of pregnancy and delivery. 
The results of misdiagnosed psychosis occurring postpartum or 
lack of access to effective treatment can be, frankly, 
horrific, with some mothers committing infanticide followed (in 
up to 62 percent of the cases) by suicide. Sadly, several such 
cases have occurred among Representative Rush's constituents.
    One important factor in responding appropriately to 
postpartum disorders is to call attention to their existence. 
New mothers need to understand the difference between ``the 
blues'' and feelings of overwhelming and persistent sadness. 
Physicians can help by preparing their patients with some 
reassuring but straight talk about the fact that childbirth and 
new parenthood can indeed be stressful and reactions to 
motherhood can't always be predicted. Peripartum emotional 
support is important; families should be included in education 
efforts, assessment of possible risks, and in the provision of 
supports. In particular, efforts by policymakers to call 
attention to the problem are most welcome and helpful.

                       What can be Done to Help?

    Postpartum depression (and the rarer postpartum psychosis) 
cause needless hurt, misery, and at the extremity, serious 
injury and even death. First, we need to recognize that these 
illnesses are absolutely real. As I suggested at the start of 
my testimony, we have a tendency to incorporate psychiatric 
terminology into everyday use, using words like ``depressed'' 
or ``psychotic'' in non-clinical ways that misstate and distort 
their meaning. The same is true of the overuse of the term 
``baby blues'' to colloquially mean anything and everything 
from transient mild sadness to severe and persistent postpartum 
depression. Both examples reflect stigma about mental illness 
and desensitize us to the potentially serious consequences of 
untreated postpartum depression or psychosis.
    Second, we need to take postpartum mental health seriously. 
If there is any evidence of postpartum difficulties, new 
mothers should be screened for depression. To achieve this 
objective, we need to help educate patients, families, and 
health professionals about the warning signs that a new 
mother's ``baby blues'' may, in fact, be a much more serious 
condition.
    I want to call your attention to a recent press release 
from the Health Resources and Services Administration (HRSA), 
announcing a publication entitled ``Depression During and After 
Pregnancy: A Resource for Women, Their Families, and Friends.'' 
This 20 page booklet can be downloaded in PDF format at 
www.mchb.hrsa.gov/pregnancyandbeyond/depression.
    It is a well-written resource that addresses postpartum 
mental health in a straightforward, non-alarmist way that even 
includes a simple self-assessment screening instrument to help 
women recognize that they may need help. I have a copy with me 
and would be glad to leave it with you for inclusion in the 
record of today's hearing. It really ought to be widely 
publicized to physicians, nurses, clinics, hospitals, and 
community health and mental health centers. I'd like to commend 
HRSA for producing the pamphlet.
    Third, the Subcommittee should move forward with H.R. 20, 
which Representative Rush has pursued so passionately. The bill 
lays out a straightforward agenda for research, resource 
coordination, and improved services to improve the diagnosis 
and treatment of postpartum depression, and--most importantly--
to fund programs to establish and operate programs and systems 
of care for treating post-partum depression and postpartum 
psychosis. These include:

        Outpatient and home-based health services
        Case management
        Screening
        Comprehensive treatment services
        Inpatient care management
        Assisted homemaker services
        Respite or daycare
        Family supports

    These practical and mostly low-cost proposals would go a 
long way toward bringing care where it is needed, particularly 
to lower-income and/or minority populations who may not have 
the necessary access to services or the means to secure what is 
needed.
    If I might, I'd like to make one suggestion, and that is to 
include provisions to fund programs to ensure that physicians 
and other health professionals are fully trained to recognize 
the possible presence of serious postpartum mental health 
issues, and thus be able to refer for appropriate follow-up and 
treatment by psychiatrists or other mental health professionals 
qualified to provide such care. APA would be glad to work with 
the Subcommittee if it would be helpful.
    Finally, the Subcommittee and the full Congress must 
recognize that the best diagnostic criteria are useless if 
women can't get treatment because their health insurance 
discriminates against treatment of mental illness. It is long-
past time to eradicate stigma-driven insurance discrimination 
and provide for treatment of mental illnesses in the same way 
that we do other medical/surgical care. Patients should not 
have to pay more for mental health care, and they should not 
get less of what they need. Committees in the House including 
your own are poised to take up mental health parity 
legislation, and as you know the Senate Committee on Health, 
Education, Labor and Pensions has already approved the Kennedy-
Domenici bill, S. 558. I urge the House to quickly follow suit, 
and to follow the Kennedy-Ramstad bill with legislation to end 
similar discrimination against psychiatric care in the Medicare 
program.
    Mr. Chairman, as a woman, as a physician, and particularly 
as a psychiatrist, I have great sympathy and compassion for all 
of my patients, women and men, adults and adolescents, who 
struggle with mental illnesses. The Melanie Blocker-Stokes 
Postpartum Depression Research and Care Act offers hope and 
practical solutions for women who need help, and I hope the 
Subcommittee with move forward with the agenda in the bill.
    Again, if this Congress wants to take one single action 
that would make a world of difference for all women--for all 
persons--seeking treatment for mental disorders, I respectfully 
suggest that the right action would be to enact a Federal law 
requiring non-discriminatory coverage of treatment of mental 
illnesses as part of all insurance. It is time to end the 
artificial mind/ body split in insurance coverage. Well over 
half the House of Representatives and more than two-thirds of 
the Senate have cosponsored legislation in this or previous 
Congresses to achieve this result. On behalf of my patients, I 
respectfully urge you to address the unmet mental health needs 
of the nation's women, and men, children and adolescents, by 
enacting non-discriminatory coverage of treatment of mental 
illnesses.Thank you again for the opportunity to speak with you 
today. I would be happy to answer any questions you or other 
members of the Subcommittee may have.
                              ----------                              

    Ms. DeGette. Mr. Chairman, I would ask unanimous consent 
that the document Dr. Stotland referred to, the HRSA document, 
be placed in the record.
    [The information appears at the conclusion of the hearing.]
    Mr. Pallone. Without objection, so ordered. Sure, we will 
try to get you a copy. I don't know if we have enough for 
everyone, but we will get one to you. We are going to take 
questions now, and I will start out myself with some questions 
of Mrs. Codey.
    I noticed that in your testimony you mentioned the doctors 
were unable to diagnose you with postpartum depression even 
though all the signs and symptoms were evident you indicated. 
So what more do you think this Congress can do to make sure 
that health care providers are more educated about postpartum 
depression? I don't know actually if it was the providers who 
weren't aware. But what can we do so that women don't go 
undiagnosed?
    Ms. Codey. When I had postpartum depression, I had no idea 
what it was or that anyone could possibly be down after having 
a baby, and I think if health care providers in the hospital 
were educated about postpartum depression, they could have said 
to me there is this disease called postpartum depression, and 
we think you have it because you have unplugged your phone and 
you are withdrawn. I think if they were educated, they could 
reach out a hand to someone in need and do a lot for women 
because there was a lot of self-blame on my part.
    Mr. Pallone. So it is not a question of the doctors doing 
something differently. They just weren't aware?
    Ms. Codey. No, not at all.
    Mr. Pallone. Now, that is significant. I really think that 
is very significant. Now, in terms of Mr. Rush's bill, the one 
that we are considering for the H.R. 20, and I know you have 
the New Jersey bill that has now become the law. How does that 
dovetail? Do you think that this Federal bill would help women 
suffering from postpartum depression or even decrease the 
number of women suffering from it, or is there anything that we 
should add to the bill? And again I am referencing the New 
Jersey law, but we don't have to reference that.
    Ms. Codey. I think the way it is worded is excellent, and I 
just pray that it goes through. I think that postpartum 
depression, to diagnose it, it sounds so complicated. It is 
really maybe 10 questions that you have to ask a new mother and 
just making her aware that it exists. And maybe somewhere along 
the first year after birth, she may experience it, is really 
great. It is a lifesaver.
    Mr. Pallone. OK, thanks a lot really. Thank you so much. 
Now, there are so few people that experience something, are 
able to describe it so well, and then are able to lead to 
changes in the law that are meaningful. So I just want to thank 
you again.
    I wanted to ask Dr. Roca a couple questions. You testified 
14 percent of women experience a new episode of depression 
during the first 3 months of postpartum. What types of studies 
has National Institutes of Mental Health currently funding to 
examine the role of stress, hormones, and other factors that 
might contribute to the development of postpartum depression?
    Dr. Roca. Yes, I did mention, because of the part of the 
testimony that our intramural program is actually looking 
specifically at the interplay between reproductive hormone 
change and stress hormones.
    Mr. Pallone. So tell us a little bit about those studies.
    Dr. Roca. Well, there are studies that are looking at, for 
example, there seem to be a subgroup of women who are 
susceptible to mood state changes with reproductive hormone 
change, drops in estrogen, progesterone, which of course happen 
at the time following delivery. These reproductive hormones, we 
know, modulate the stress hormone axis, and so there are some 
studies ongoing. They are examining the relationship between 
these two systems, and the reason that is important is that we 
know in depression of other types, that the stress response in 
many individuals is disregulated, I guess you could say. It is 
not acting in the same sort of way that it usually does, so 
that usually people, when they are stressed, they for example 
get an increase in cortisol.
    People who are depressed appear to have sort of that system 
in overdrive if you will, that there is this sustained stress 
response that you don't have under normal circumstances. And so 
that is one of the things that our intramural researchers are 
looking at. Now, that is the biological aspect of stress.
    We also have some additional extramural studies that are 
looking at, for example, animal models, again looking at 
biological stress. Some of the environmental factors that could 
be stressors, such as domestic violence situations for example, 
economic stressors, because we know that rates of postpartum 
depression can be higher in groups of women who are in the 
lower economic scales.
    Mr. Pallone. OK, thank you very much. I appreciate it. Mr. 
Deal.
    Mr. Deal. Thank you, Mr. Chairman. First of all is I would 
like to point out is that I have not only been a sponsor of 
this current bill but have been a sponsor of it in previous 
Congresses. And I have no intention of politicizing this issue, 
and I somewhat am offended that my colleague would think that I 
am doing that. I am not. I have no intentions of doing so, but 
I do think we should have empathy for and understand any 
consequences of the termination of a pregnancy, regardless of 
the reasons for it. And miscarriage is listed as one of the 
findings in this bill itself as one of the areas that ought to 
be looked at perhaps.
    In fact, during my wife's four pregnancies, I was the most 
empathetic father-to-be you could ever imagine. I got morning 
sickness. She didn't. After the children were born, I even got 
roseola, which my pediatrician said was not supposed to be 
anybody other than infants that got it, but I got it. I was 
empathetic. Thankfully, neither of us suffered from postpartum 
depression. I did suffer from sticker shock when I got the bill 
from my second child, who--my wife had become pregnant when I 
was in the Army, and I had my first child at the Government's 
expense. It cost me $7 and had no insurance when I got out of 
the Army and had the second child. I had sticker shock, but I 
didn't have postpartum depression.
    But it is a serious issue, and it is one that deserves 
serious consideration. And one of the things, Dr. Roca, that I 
guess we all need to understand, as we dealt with some 
structural changes at NIH during the last Congress, one of the 
things we were trying to achieve was to get the institutes to 
categorize findings to share information. You mentioned a 
number of different studies that were going on, and I presume 
those were in different institutes. Has that sharing of 
information occurred? Is there more that needs to be done in 
that area?
    Dr. Roca. I think the communication between the institutes 
has actually been pretty good in this area. We do have a 
coordinating body through the National Institute of Health's 
Office for research in women's health. And we also, through a 
Federal working group called the Safe Motherhood Work Group, 
coordinate efforts with a number of other Federal partners such 
as the Center for Disease Control, as I mentioned, the Agency 
for Health Quality, and also as I mentioned, the booklet that 
Dr. Stotland showed to the subcommittee was an effort that 
combined a number of Federal partners that was put out by HRSA.
    Mr. Deal. So we are not duplicating? We are sharing 
information when it is appropriate?
    Dr. Roca. Yes, I would say that.
    Mr. Deal. All right, is there any prohibition now for NIH 
undertaking further studies on postpartum depression? There is 
nothing that would prohibit NIH from doing that, is there?
    Dr. Roca. No, there isn't, and we actually have a program 
announcement, as I mentioned, that encourages investigators to 
submit research in this area, both at the, what we call the R0-
1 or the Investigator-Initiated Large Grants, as well as the R-
21, which is a mechanism that encourages new, smaller studies 
for people to get pilot data, for example.
    Mr. Deal. All right, so but this legislation would be 
encouraging at least and assist in that undertaking of this 
specific area?
    Dr. Roca. I can't comment on the legislation because that 
is at the level of policy.
    Mr. Deal. All right, I got you. Well, Mr. Chairman, I don't 
think I have any other questions except to thank the ladies for 
being here and your input into this issue and discussion and to 
thank my colleague, Mr. Rush, for his persistence in this and 
for allowing me to be a part of the process as we attempt to 
move this issue forward and hopefully see it signed into law. 
Thank you. I yield back.
    Mr. Pallone. Thank you. The gentlewoman from Colorado.
    Ms. DeGette. Thank you so much, Mr. Chairman. Sometimes we 
feel like it is deja vu all over again in this committee. My 
staff just thoughtfully pulled the testimony from Wednesday, 
September 29, 2004 at which many of us were present, including 
myself and Dr. Stotland. And at that hearing--I won't 
mercifully read everything, but Mrs. Capps and I said at that 
hearing how the testimony of Ms. Blocker was some of the most 
compelling testimony that we have ever heard in Congress. And 
even though this is the second time I have heard it, I would 
say that again.
    It is so compelling, and to think about what you said, Ms. 
Codey, about how you have this new, little infant, and you are 
checked into a psychiatric hospital for a month. And they still 
can't figure out what is the matter with you. It shows two 
things. Number 1, we really need legislation and research. And 
No. 2, we really need to do it now. This testimony was from 
2\1/2\ years ago, and here we still sit here today.
    So I want to thank all of the witnesses, and I do want to 
say to Ms. Fredenburg and Dr. Coleman, I too think that we 
should really do dispassionate and value-neutral research on 
anything that would cause a mental disorder. And I especially 
appreciate you, Ms. Fredenburg, coming in, talking about your 
own personal issues. I did have some questions for Dr. 
Stotland, and, Dr. Stotland, I wanted to ask you in her written 
testimony, Dr. Coleman said that there are three studies, the 
David and colleagues study in family planning perspectives, the 
American Journal of Orthopsychiatry, and then a study from 2002 
done by Dr. Coleman and some others in the ``Canadian Medical 
Association Journal,'' which she says show that abortion is 
associated with an increased risk of mental health problems 
when compared to childbirth. Are you familiar with those 
studies?
    Dr. Stotland. I am familiar in general with that study at 
the moment.
    Ms. DeGette. What is your opinion on that general body of 
literate?
    Dr. Stotland. Well, let me contradict what Dr. Coleman said 
about there being no consensus. There is a strong consensus in 
the psychiatric and psychological communities that there may be 
a chronological relationship but no causal relationship between 
abortion and mental health problems. Remember that people who 
have abortions are generally in difficult circumstances, and we 
do have deep empathy for that situation. And we do hope that 
anybody who has any situation before or after any procedure, if 
we have mental health parity, can get care for it. But there is 
a consensus, a strong consensus that there is not a causal 
relationship between abortion and mental disorders.
    Ms. DeGette. Now, in your last testimony, I asked you the 
question about these studies, and you had said to me that those 
studies don't control for the patient's previous mental state. 
Do you recall that answer?
    Dr. Stotland. Yes.
    Ms. DeGette. Would that answer still be true today, or have 
there been intervening studies in the last----
    Dr. Stotland. There have been attempts to control for that. 
There are many other methodological difficulties with the 
studies, most prominently that we have to compare women who 
have abortions with women who would want to have an abortion 
and are not allowed to. To compare women who have abortions 
with just women at large or women who have babies is not 
appropriate. Women who have babies, by and large, want to have 
those babies, find themselves in better circumstances to 
support that. And that is a serious methodological problem with 
much of the negative research.
    Ms. DeGette. And would you agree with the assertion that 
Dr. Coleman and others have made that the issue of post-
abortion syndrome has not been really studied?
    Dr. Stotland. No, I would not agree. It has been studied 
quite a lot, and that is why there is no official diagnosis 
because there is not a valid body of scientific information to 
warrant investigating further.
    Ms. DeGette. Now, I would assume that you would, like me, 
support any kind of value-neutral research that would lead to 
the causes of mental health disorders?
    Dr. Stotland. Overall?
    Ms. DeGette. Yes.
    Dr. Stotland. Certainly.
    Ms. DeGette. And so if there was an adverse effect in 
general of abortion on people's mental health, I would assume 
that would be something you would want to have researched and 
then want to have some protocols around?
    Dr. Stotland. Well, I have two concerns. One is that we not 
legislate psychiatric diagnoses because we have a very intense 
scientific process for doing those. So we not put a label on 
reactions, which women have many of. And I am also a bit 
concerned that when we do put a label in erroneously or invent 
a diagnosis that we frighten a lot of people who are trying to 
make difficult medical decisions.
    But to study the causes of mental illnesses is, of course, 
something we are all about.
    Ms. DeGette. And just one last question is how would you 
see that then as different from what we are trying to do in 
this hearing today, which is talk about postpartum depression?
    Dr. Stotland. Well, as you heard from my colleague at the 
NIH, you have to focus your studies. There are infinite number 
of things you could study, and you develop further studies on 
the basis of basic studies that are accepted as valid and go 
forward from there. You can't study absolutely everything.
    Ms. DeGette. Thank you. Thank you very much, Mr. Chairman.
    Mr. Pallone. Thank you, Ms. DeGette. Mr. Pitts.
    Mr. Pitts. Thank you, Mr. Chairman. Dr. Coleman, your 
research and that of others like Dave Ferguson from New Zealand 
seems to be showing that abortion is riskier to women's mental 
health than childbirth, yet older studies fail to show this. 
How do you account for this discrepancy? And then secondly, 
many people tend to think that any negative effects of abortion 
are mild and short-lived. Is your research indicating that some 
women may have significant difficulty getting beyond the 
experience?
    Ms. Coleman. Thank you for the questions. They are 
important questions. Actually since 2002, the group that I work 
with has published 14 studies in tab peer-review journals. One 
was published in the ``American Journal of Obstetrics and 
Gynecology'' the No. 1 OB/GYN journal in the world. In that 
study, we found that women who had a prior abortion had 10 
times the marijuana usage and a subsequent pregnancy. That is 
just an example of one of the findings, but what we have 
systematically tried to do is to look at the shortcomings of 
the research in this area, which were dramatic prior to about 
10 years ago.
    High attrition rates. There were studies published in 
journals that have the politically correct findings, indicating 
that women didn't have any problems with abortion. There was 
one study published in the premier social psychology journal 
that had a 60 percent dropout rate 3 weeks post-abortion. How 
can you possibly conclude anything when you lose more than half 
your sample?
    And so there was high dropout rates. Women often conceal an 
abortion. About half of the women studied don't reveal an 
abortion. Controlling for previous psychological problems is 
another issue that we actually have done in six of our studies. 
We have also look at predictors of the choice to abort, like 
violence in the home, sociodemographic factors. We have 
attempted to rule out or to remove those compounds so we have a 
pure analysis of the association between the abortion and any 
mental health problems.
    So there are all these methodological issues that we have 
tried to address. We have nationally representative samples 
that we have used. There are studies where the data was 
collected by labor department, other bodies, and we happen to 
find reproductive history in the variable list. But these 
studies are insufficient in that we are not asking enough 
questions. We are not getting at the heart of the suffering. We 
are getting a general picture, and actually Dr. Stotland said 
that the consensus is that there is not a causal relationship.
    Well, if you look at the body of literature, and, yes, we 
have done longitudinal studies now. Your second question asked 
about the possibility that women may not get over this or it 
may not resolve quickly. And actually our longitudinal studies 
are indicating that prior to the last 10 years, I think the 
farthest out was about 2 years that were sampled. So the topic 
has been insufficiently studied, but I would say that we 
definitely need more research energy funneled into this.
    But I would say that the studies that are out there now 
provide a pretty good case for causality because the 
perspective, we see that the abortion precedes the mental 
health problems. We are controlling for extraneous factors. So 
you can't determine causality with any psychological variable 
that you can't manipulate. We can't randomly assign women to 
have an abortion or a baby. That is unethical.
    So you work from what you have, and we are building a case, 
and women are suffering.
    Mr. Pitts. Thank you. Michaelene, when you sought help, was 
the therapist able to adequately diagnose you, and prior to 
your decision to see a therapist, did anyone suggest that you 
might be suffering from post-abortion depression? How do you 
think your experience would have been different had the post-
abortion depression been diagnosed earlier on?
    Ms. Fredenburg. Excuse me. I do believe that I would have 
been spared really years of suffering, and I don't think that 
even the symptoms would have gotten as far along as they were 
if we were able to catch it earlier. Part of the problem is 
that I had never heard anybody talk about this experience or 
actually any experience after an abortion. And so I didn't even 
know there was such a thing or to reach out.
    When I finally did, it was to someone who I felt was a safe 
person, and she had said to me that there may be a connection 
between the two and it was something to investigate. And that 
something, fortunately she was able to refer me to a therapist, 
that over time we were able to deal with that. So but I 
certainly, not knowing--and I find out from so many women, I 
still hear it 35 years later, that they had no idea that there 
would be any type of negative, emotional ramifications 
afterwards. And that is what keeps them suffering in silence 
for years and decades, and there is no need for that.
    Mr. Pitts. What helped you most in your recovery process?
    Ms. Fredenburg. Well, I felt like I was halfway there when 
someone was able to help me with making a connection between 
the cause. And once that had happened, there was a lot of work 
to do after that, but suddenly there was a structure around it. 
And I had hoped that I could overcome these difficulties. So 
that to me was the most important thing, and then after that, 
it was just having the proper care and support and diligently 
working through this, knowing that there was hope. And then at 
some point, the hope that I could help others, and I think that 
is pretty common when we have been through something difficult. 
If you believe that you can help somebody else, that gives you 
that extra to push through.
    Mr. Pitts. Thank you, Mr. Chairman.
    Mr. Pallone. Thank you. Mr. Rush.
    Mr. Rush. Thank you, Mr. Chairman. Dr. Roca, in your 
testimony, you stated ``NIMH supports an active research base 
to advance the understanding, treatment and ultimately 
prevention of postpartum depression. This research continues to 
be a critical source of information for women, families, and 
health care providers, seeking better ways of detecting, 
managing and treating this devastating disease.'' My question 
to you is is it safe to assume, based on your testimony, that 
NIH and the National Institute of Mental Health would benefit 
from additional dollars and attention in the area of postpartum 
depression?
    Dr. Roca. I hesitate only because I am here for the science 
and not the policy. I should mention though that research in 
this particular area of postpartum depression does benefit from 
research in other areas of mental illness. For example, a lot 
of the studies that have been done on depression, major 
depression, and bipolar disorder, do also inform the work that 
is being done in postpartum depression. So just to, while we 
are funding much in this more narrow area, to let you know, 
that the information that we are gaining in other areas of 
research will impact this area as well.
    Mr. Rush. Well, do you find that the current research and 
studies that have been funded include a diverse pool of mothers 
from urban and rural areas and multiple ethnicities and various 
social and economic backgrounds?
    Dr. Roca. This has been a problem overall, trying to make 
sure that the research is really addressing the broad scope of 
the American population. I would say in the past that most of 
the research has been done on white, middle-class subjects. 
However, we are taking steps to really try to broaden our 
research.
    There is a mandate, if you will, for NIH as a whole, to 
make sure that all groups are broadly represented in clinical 
studies and that the National Institute of Mental Health, in 
particular, we have been taking a look at this early on in 
grants, making sure they have a diverse pool of subjects.
    And also if they are having trouble with recruitment, 
trying to get them some strategies that they can use to work 
with communities. And one example of that, for example, is we 
have a program announcement on community participatory 
research, and that is really geared towards helping researchers 
partner with communities so that we can get the diverse 
background so that our research does apply to all segments of 
the population.
    Mr. Rush. In the area of educating mothers and families, 
what strategies do the NIH or NIMH implement to deal with 
mothers who lack access to the Internet?
    Dr. Roca. Well, I am not sure exactly what studies we have 
with regards to this area, but I could submit something for the 
record. In general, much of our work, in terms of disseminating 
information, is done in partnership with other Federal agencies 
so that we are not duplicating or spending the resources twice.
    Mr. Rush. Thank you. Dr. Stotland, again I want to welcome 
you to this committee. Would you discuss the existing resources 
for the treatment of women with postpartum psychiatric 
illnesses, both public and private, and their families? Do you 
find that the existing resources are adequate now, or are they 
inadequate for the dissemination of information?
    Dr. Stotland. Thank you for asking that. For both 
information and treatment, the resources are very sadly 
lacking. We have had a drastic decrease in both private and 
public psychiatric beds. Some of the people we have heard about 
before might not be able to get into a hospital now because 
there aren't beds. And part of that is because there isn't 
adequate public or private reimbursement for the hospitals to 
keep those beds open.
    And so we have a crying need for better mental health 
resources all the way around.
    Mr. Rush. And from your testimony, I have deduced the fact 
that you believe that health insurance should be extended to 
include more protection, more funding for mental health issues.
    Dr. Stotland. Yes, right now, there is terrible 
discrimination. Most people have no idea. If you went home and 
looked at your insurance policy today--not yours. Yours is a 
bit better, I think. But the average person has no idea until 
somebody in their family gets into trouble that they have fewer 
visits, fewer days, lower reimbursement. In Medicare instead of 
a 50 percent co-pay, you would have a 80 percent co-pay if you 
are going for mental health care. There is gross discrimination 
going on against people who have these ailments.
    Mr. Rush. It has been testified earlier that one of the 
conditions, determinant conditions, that exist is stress. 
Stress plays a very important role in the area of postpartum 
psychosis of postpartum diseases, illnesses rather. Can you 
give me some idea about is there any relationship between 
postpartum psychiatric illness and race and ethnicity?
    Dr. Stotland. I am glad you asked that question. You asked 
it a few moments ago as well. We don't have nearly enough 
information about that. We know that postpartum depression and 
psychosis, as we just heard from Mrs. Blocker, can happen to 
anybody of any status. However, we know that people of color 
don't have as much access to care. We know they are more likely 
to be poor. We know they are more likely to be subjected to 
violence. We know that they are more likely to have less 
support in society and all those things. Plus the fact that 
there is increased stigma in communities of color about seeking 
care in the first place.
    So there is a very strong need for us to find out those 
differences and to address those people who are afraid to seek 
care where we have care.
    Mr. Rush. Thank you very much. And I yield back, Mr. 
Chairman.
    Mr. Pallone. All right. Dr. Burgess.
    Mr. Burgess. Thank you, Mr. Chairman. I want to thank 
everyone. This has really been a well thought out and well 
conducted panel, and I have certainly learned a lot. And I 
thought I knew a lot coming in, but Dr. Roca, let me ask you 
because we heard--and unfortunately Ms. Blocker wasn't able to 
stay with us, but it really seemed to be a problem in her mind 
that the differential diagnosis between postpartum depression 
and postpartum psychosis was not made. How critical was that?
    Dr. Roca. It is a critical distinction because postpartum 
psychosis is a psychiatric emergency. Obviously postpartum 
depression needs treatment as well, but because postpartum 
psychosis is often associated with, for example, command 
hallucinations, in other words, hearing voices to harm their 
child or with intense suicidal ideation, it is an emergency. So 
it is a critical distinction to make diagnostically.
    Mr. Burgess. Through three hospitalizations and multiple 
medical therapies, surely this had to be considered in the 
differential at some point in a patient who is not responding 
to what otherwise would--she held the bag up, and I didn't get 
to see what was in it. But I have got to assume there was 
maximum medical therapy exerted for postpartum depression 
within the confines of that plastic bag. Don't you think?
    Dr. Roca. She did mention, I believe, that there were anti-
psychotics in there. I don't know----
    Mr. Burgess. Well, let me ask you this. Are there cases 
that are just with treatment that no matter how hard we try and 
how much we recognize and how much we do that they are just 
tough cases and they don't respond to treatment? I don't know. 
I am not a psychiatrist, so I am asking you.
    Dr. Roca. In any psychiatric or medical condition, there 
are cases that are more difficult to manage, yes.
    Mr. Burgess. Yes, I believe that is true as well. Again I 
referenced in my opening statement that I lost a patient at 20 
weeks who took her own life. And obviously that wasn't 
postpartum, but it was clearly, even to this day, some of it 
was pretty hard on me as her caregiver. And just imagine what 
her family went through. I have just got to tell you. I don't 
think I have ever prescribed a monomenoxabase inhibitor in my 
entire life. I didn't even know they were still around. But is 
that one of the things that is out there in the armamentarium?
    Dr. Roca. Yes, MAO inhibitors are still used.
    Mr. Burgess. Are they any better than the norepinephrine 
reuptake inhibitors?
    Dr. Roca. Well, it depends on the individual. They are 
effective treatments, just as the SOIs or tricyclics are. But 
again it depends. One of the problems that we have is that in 
psychiatry as well as other areas of medicine, trying to 
understand which medication is right for which patient is quite 
difficult.
    Mr. Burgess. And I alluded to the promise of genomic 
medicine at some point, which perhaps will unlock some of those 
secrets for us. Ms. Codey, were you prescribed the 
monomenoxabase inhibitor again during the second pregnancy or 
after the second pregnancy?
    Ms. Codey. Yes.
    Mr. Burgess. And did it have the same beneficial effect the 
second time as it did the first time?
    Ms. Codey. Yes.
    Mr. Burgess. So he knew that was the right medicine? It 
just took a long time to figure it out?
    Ms. Codey. Yes
    Mr. Burgess. Let me, Ms. Fredenburg, and I do appreciate 
you being here as well. I will just have to tell you that I 
started medical school about 2 years after Roe v. Wade passed. 
So it was always part of the background during my medical 
practice, but just as you, probably about 1989, 1991, I became 
aware that I was seeing patients who had a problem around an 
anniversary date or a Mother's Day or the graduation of their 
child, their oldest living child, from high school, which 
clearly related back to an episode that they had suffered in 
the past.
    And, Dr. Roca, you alluded, I think, post-traumatic stress 
disorder, we would argue, has a hormonal basis to some degree 
at least at the initiation because of the rapid outpouring of 
cortisol and hormones. So there is some point a hormonal basis 
for the late onset of whatever we want to label it, the adult 
situational reaction, the delayed post-traumatic stress 
disorder, or the post-pregnancy lost disorder that Ms. 
Fredenburg identified. And again I think she did a good job 
about identifying it.
    My experience, those conditions were relatively amenable to 
treatment. They obviously weren't psychotic episodes. They were 
depressive episodes but relatively amenable to treatment such 
that the average trained OB/GYN could handle those cases.
    Dr. Stotland, let me ask you a question. You have studied 
late luteal phase dysphoric disorder?
    Dr. Stotland. I have. We don't call it that anymore, but 
yes.
    Mr. Burgess. What do we call it now?
    Dr. Stotland. We call is premenstrual dysphoric disorder.
    Mr. Burgess. Well, I love the DSM too, but premenstrual 
syndrome, for those who like to read the magazines, DMS is the 
popular vernacular.
    Dr. Stotland. A more severe form.
    Mr. Burgess. And what is it about the late luteal phase, do 
you think, that makes it a time that a woman is particularly 
vulnerable to that dysphoria?
    Dr. Stotland. Well, let me say two things. One of the 
reasons we changed the name is because we really couldn't link 
it to the precise hormonal levels at different times of the 
menstrual cycle, especially the late luteal phase. And some 
very interesting and creative studies were performed on that. 
But let me also say that there seems to be a group of women who 
are particularly sensitive to times of hormonal change.
    Mr. Burgess. And I would agree with that statement very 
much. But it has always seemed to me, and I don't know that I 
am smart enough to know the answer or how the modulation 
occurs. But progesterone, and estrogen level to some degree, 
but progesterone seems to be a recurrent theme in premenstrual 
tension or premenstrual syndrome, postpartum depression.
    The placenta is an organ that can produce progesterone 
under--the ovary can't even possibly keep up with what the 
progesterone that a placenta is able to produce on an average 
day. And as soon as the placenta is delivered, those levels 
plummet like a rock. So it is always in my mind--I have 
associated that perhaps there is some sort of trigger 
mechanism.
    But I will also say I was never universally successful at 
treating postpartum depression with additional progesterone and 
the promise of progesterone supplements an even what I used to 
call late luteal phase dysphoric disorder, never seemed to be 
quite as complete as I would have liked. But still progesterone 
was sort of a common thread running through those things, and 
again I will acknowledge that estrogen levels are as well. But 
does it not seem reasonable to include the woman who lost a 
pregnancy, either through a spontaneous or an elective 
termination of pregnancy? Does it not seem reasonable to 
include that progesterone or that hormonal event in the broad 
spectrum of conditions that we are considering today?
    Dr. Stotland. Well, we have heard that hormonal studies are 
underway at the NIMH in terms of postpartum depression. 
Postpartum depression has been described since the time of 
Hippocrates. Of course, an overall look at the effects of times 
of hormonal changes. A lot of dispute about menopause. There is 
a lot of dispute about--or discussion I should say--about 
contraceptives, hormonal contraceptives.
    Mr. Burgess. So the science is far from settled.
    Dr. Stotland. Right. And so, of course, studying the 
effects of hormonal change is important, and it has been 
frustrating that it would seem obvious that something is 
missing. And yet when you put it back, at least by mouth, it 
doesn't solve the problem.
    Mr. Burgess. But by----
    Mr. Pallone. We are going to have to stop here. We are 
almost----
    Mr. Burgess. What----
    Mr. Pallone. Three minutes. No, you are almost at 3 minutes 
over.
    Mr. Burgess. But the chronological issue here is one that I 
think is particularly important. And I will submit that 
question in writing, Mr. Chairman. I thank you for your 
indulgence. You are very kind.
    Mr. Pallone. Anybody gets anything in writing will be 
pleased to follow up in writing. I recognize Mrs. Capps.
    Mrs. Capps. Thank you, and what a terrific panel this has 
been, and I appreciate all of your testimonies. I am always 
struck because I have heard Carol Blocker speak before about 
that poignant, dramatic situation, and former first lady or 
first lady--currently--Codey of New Jersey. It is very brave 
for someone actually experiencing this to be--and especially 
someone public like yourself--to be willing to campaign in the 
way you are. And that is wonderful that you are championing 
what many women want to have said on their behalf because they 
are not as able or willing to do it as you are, and it is very 
eloquent.
    I want to ask questions of Dr. Roca and Dr. Stotland, and I 
wish I had--I will be like Dr. Burgess and want way more time.
    Mr. Burgess. I will give you more time.
    Mrs. Capps. Yes, you would, but I don't think the chairman 
will. Dr. Roca, your testimony is excellent. You mention the 
effects in it of not treating depression that occurs, the 
effects on the infant. That is what I would like to see, and on 
the family constellation. If treating depression while a woman 
is pregnant is ignored or not noticed, what impact is this 
likely to have in this sort of fragile time of a newborn coming 
home?
    Dr. Roca. Well, there is a literature that suggests that 
women who are depressed in the postpartum, in that early 
bonding period, that there can be some cognitive and behavioral 
changes in the infant, depending on how able that mother is to 
interact with that child.
    Now obviously people have different levels of depression 
and different ability to interact. But that is a concern that 
untreated depression can affect that early development in the 
newborn.
    Mrs. Capps. OK and that has huge ramifications on the whole 
family setting I am sure. Dr. Stotland, you were nodding during 
that, and I remember very well your testimony in a similar 
panel here in the last Congress. We have got this new addition 
today of discussion on post-abortion depression. To me, there 
is a lot of issues about women and mental health that we have 
not come to terms with. We need to address many issues. I am 
very concerned about the effects on PTSD on women in the 
military, for example. It is coming, and there might be some 
similarities. If you would identify the kinds of studies that 
have been sort of dwelling on post-abortion depression, but 
then there is this dramatic situation of full-blown psychosis. 
And is that purely distinctive--that is associated with giving 
birth. Is that unrelated? Would that have responded to mental 
health therapy during the pregnancy?
    Dr. Stotland. Exactly. Let me see if I can tease out 
something I can answer. First of all, yes, there are adverse 
effects to not treating depression both during pregnancy and 
after. It can result in small babies, prematurity, et cetera. 
Ask me another question.
    Mrs. Capps. The one that has to do with is this the same as 
post-abortion?
    Dr. Stotland. Well, in terms of postpartum psychiatric 
illnesses meet the same criteria as illnesses occurring at 
other times, but since that is a particularly vulnerable time, 
they have been noticed, as I said, since the time of 
Hippocrates. And they are basically--not everybody who has a 
first episode of postpartum psychosis, like Melanie Blocker-
Stokes, has any warning. It can just happen after delivery.
    Mrs. Capps. So there could be this out-of-the-blue kind of 
experience?
    Dr. Stotland. Absolutely.
    Mrs. Capps. And that is clearly a psychosis?
    Dr. Stotland. Yes.
    Mrs. Capps. Not just an extreme form of depression?
    Dr. Stotland. No, although some people get depressed and 
depressed and depressed, as you heard again from Mrs. Blocker, 
and then the psychotic symptoms begin to come out. And that is 
called psychotic depression.
    Mrs. Capps. I see.
    Dr. Stotland. Many women who have postpartum depression 
without psychosis have had depression during pregnancy, and we 
need to pick that up. That is going to an important part of our 
research as well. Right now, the American Psychiatric 
Association and the American College of Obstetricians and 
Gynecologists have a joint task force working on the treatment 
of depression during pregnancy because of the concerns about 
medication and, in fact, just yesterday, we were having a 
conference call.
    Reference was made to interpersonal therapy and cognitive 
behavioral therapy, and I had to say on the call but nobody can 
get them. Those are the ones we have evidence for, and there 
are not enough people trained, never mind that your insurance 
won't pay for it, to provide that care. So we need training and 
treatment money as well as research money.
    Mrs. Capps. So this hearing today is the tip of the 
iceberg?
    Dr. Stotland. Yes, it is.
    Mrs. Capps. Thank you very much. Thank you all.
    Mr. Pallone. Thank you. Well, the panel was very important 
not only in terms of our getting at the issue of legislation 
before us, but I think just in general in terms of educating us 
all about the type of research and what needs to be done in the 
future. And I want to thank you all for having the courage to 
come here and talk about your personal situations in some 
cases, and the other cases, with those who have the 
professional expertise. That has also been very enlightening. 
So we do intend to move this bill fairly quickly, so you know. 
We know that it has been hanging around far too long, as some 
of the Members have suggested. So you are not just here today 
for the hearing. You are here to help us move this bill as 
quickly as we can.
    Thank you very much. I will just remind members that you 
can submit additional questions for the record to be answered 
so the witnesses may get additional questions. We should have 
those within the next 10 days or so. And without objection, 
this meeting of the subcommittee is adjourned.
    [Whereupon, at 2:25 p.m., the subcommittee was adjourned.]
    [Material submitted for inclusion in the record follows:]
    
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