[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
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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
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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.]
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