Randi Hutter Epstein M.D. M.P.H.

By Leave a Comment

Preventing PostPartum Depression Should Be Considered a Public Health Issue

I gave birth to my first son, Jack, 25 years ago in London. The birth went smoothly but I was a little freaked out when I was told that once I got home, a visiting nurse/midwife was going to stop by every day for at least 10 days.

I pictured Mary Poppins minus the show tunes. What I got was more Woodstock circa 1960. My motherhood-checker (I can’t remember her official title) wore Birkenstocks and a flowing multicolored skirt. Instead of reprimanding me, as I feared, she was encouraging and answered all kinds of new-mom questions. She also weighed my son in the same kind of antiquated scale used by my local fishmonger.

Six weeks postpartum, my earthy-crunchy helper returned. This time she wasn’t asking about Jack. She asked about me. We sat crossed-legged on the carpet and she ran through a checklist of postpartum depression signs sprinkled into a seemingly casual conversation. Had I needed help, I would have been funneled to the right place.

Two years later, as I once wrote in the New York Times, I delivered twins in a New York City hospital and left before 48 hours. The doctors signed discharge forms and I guess I waved goodbye and that was that. I went home to my toddler, husband and extended family. But I missed my English caregiver who blanketed me with support. She made me feel part of a supportive community.

I was thinking about my birth experiences again when I read the news about a new drug for postpartum depression, called brexanolone. Like most people who read the reports, I was stunned by the price tag ($34,000) and curious about the delivery system: a 60-hour infusion in a certified medical center during which time women have to pump and dump breast milk to ensure brexanolone doesn’t contaminate the baby’s food supply. Who was going to access this newfangled treatment?

Even if the price drops and it’s made into a pill (apparently one is in the works), medication, alone, isn’t a solution. We need networks to spot women in need and resources to get them help.

Last fall, I met a group of dynamic, compassionate experts at a conference in Pittsburgh called: Partnering for Change: Expanding Women’s Mental Health Treatment and Reducing Health Disparities. I was there to talk about the history of women’s health. They taught me about the future.

Dr. Sarah Homitsky is the medical director of the Women’s Behavioral Health at Allegheny Health Network there. Since August, 2016 her center has been providing psychological support to new mothers diagnosed with clinical depression.

Here’s how it works: When pregnant women are seen at the obstetrician’s office, they are provided with an electronic tablet. A few times during pregnancy and once after childbirth, they fill out a questionnaire and the responses go directly to their doctor who, in turns, alerts a therapist if the score indicates clinical depression.

“We get in touch with every woman within 48 hours and schedule an intake within two weeks,” Homitsky told me. That’s a pretty remarkable turnaround.

Women are then provided with weekly hour-long sessions in cognitive behavior therapy or interpersonal therapy. They can get medication, too. The program is funded in part by the Alexis Joy Foundation, founded by Steven D’Achille in memory of his wife who died by suicide six weeks after her daughter’s birth on October 10, 2013.

So far, some 2,500 women have been offered weekly counseling. There’s also an intensive program that provides three-hour sessions three times a week. Women are encouraged to bring their babies (where they do baby massage and learn about mother-baby bonding) and also their pre-school children (childcare is provided). In addition to psychotherapy women learn stress management techniques. Best of all, they realize they are not alone. Women get help not just from experts but from each other.

Let’s face it, motherhood is an awesome yet overwhelming time. Many of us are lucky to have family and/or friends around. Sure I missed my British-Birkenstock-wearing visitor. But I had other networks. After I gave birth to the twins, I heard about a local mother-of-twins support group and attended a few meetings and wrote about it, but never bothered going back. I think because at the time, I had two big dogs, a toddler and two babies in a double-stroller so I was like a magnet for advice-givers. I may not have loved all the unsolicited information but I never felt alone.

I’m not trying to over-simplify post partum depression. A group of friends isn’t going to prevent susceptible women from clinical depression.

Studies have documented that women who have had bouts of depression before pregnancy are more likely to suffer post partum depression. Other studies show a lack of support increases the risk of post partum depression. We seem to have accrued plenty of data, now we need real outreach.

The Pittsburgh center is one of twenty such clinics in the United States. But getting access to this kind of care shouldn’t be hit or miss. It should part of routine healthcare for all pregnant women and new mothers.

As Homisky said, maybe the media focus on the new drug will shine a spotlight on this crucial public health issue. “We need to do a better job supporting our mothers. We as perinatal providers need to advocate not just for medication, but for improved home visits and affordable child care.

As she said, we have to continue to ask ourselves: How do we strengthen the social support that postpartum women need and deserve?

At least, her center is one step in the right direction.

By Leave a Comment

A New Play Shines Light on Women Long Forgotten

In the years leading up to the Civil War, about a dozen or so female slaves were part of a series of gruesome experiments that culminated in a huge advance in gynecology.

They were operated on over and over in a ramshackle shed in Dr. J. Marion Sims’ Alabama backyard. Sims was determined to figure out a way to heal vaginal tears caused by long labors.

He succeeded and became world famous. In addition to his surgical cure—a technique that would spare women worldwide some of the ravaging consequences of giving birth—Sims also invented the speculum and founded a woman’s hospital in New York. For more than a century he was hailed as one of the great humanitarian physicians.

For years, the story of J. Marion Sims focused on his achievements. But lately, his story has been revived without glossing over his journey to prominence, culminating not only in heated discussions.

Yet, however the story is told, the spotlight has always been on Dr. Sims. Harriet A. Washington wrote about him in Medical Apartheid. Her book along with subsequent articles prompted protests that resulted in the removal of a Sims statue that had been on Fifth Avenue in New York City. Deborah Kuhn McGregor wrote about him in From Midwives to Medicine. I also wrote about Sims and his legacy in Get Me Out: A History of Childbirth from the Garden of Eden to the Sperm Bank.

But who are these women? There are no diaries, nothing about what they had to say. We know the names of three of them. Lucy. Betsey. Anarcha. So when we write, they become two-dimensional, lumped together in one group: “The slave women.” To be sure, Washington dug deep to bring a voice to Anarcha Wescott, but so many of the women have remained anonymous because we just don’t have the information.

Now, Charly Evon Simpson, a playwright, has given voice to the voiceless. Her new play, Behind the Sheet, is inspired by the real events allowing her to shift the spotlight from Simms to the slaves.

We meet these young pregnant slaves who endured operations—some of them had up to 30 surgeries. But for the first time we are forced to imagine them in three dimensions, as yearning, bonding, compassionate, jealous, hurting women. Simpson gives these women agency.

Ben Brantley in the New York Times said the production “takes on cumulative power in its steady, clear eyed depiction of a time when it was a given that pain would be borne uncomplainingly by human beings regarded as chattel.”

While some of the dialogue is lifted right from J. Marion Sim’s autobiography, Simpson adds a plot twist.

In her play, the doctor is George Barry. We also meet Philomena, his assistant/pregnant mistress/slave. In real life, there was no Philomena. Or rather, there’s no record of Sims having a mistress or impregnating a slave. I found the injected storyline added heft to the play—we see his own mistress suffering and we see happens to her after her child with him causes her to suffer from tears. We see what happens to her after Sims finds his cure and heads north.

Harriet Washington, the Medical Apartheid author, ethicist and historian, applauded the play as a must-see—but, as she wrote in Nature,  the Philomena addition “muddies the already murky ethical waters of volition, coercion, sentiment and motivations.”

The night I went, there were audible gasps from the audience. The woman behind me sobbed. I assumed people went for the reason I did. We knew the story and were curious to know how this fictionalized version would come alive on stage. But perhaps this was news to some of them. And that’s a good thing. This is an important chapter in medical history that needs to be debated in wide circles outside of academia.

Simpson, in an interview with Science Friday, said that her goal was not to bring what has been written to the stage but to infuse life to the women, long forgotten. “I’m a black woman and have ancestors who were enslaved,” Simpson said. “I wanted to give them back the humanity that society at the time stripped way.”

Behind the Sheet had sold-out performances at the Ensemble Studio Theatre and is now extended until March 10th. Here’s more information about the show.

By Leave a Comment

How To Deliver Bad News

Melissa Thomas, a former Medical Service Corps office in the U.S. Army and a current medical student, wrote a heart-wrenching piece in the New York Times Magazine about the moment she learned of her husband’s death. He was in the army, too, and, like Melissa, served several missions on the front lines in Iraq and Afghanistan. He didn’t die in warfare. He died while snowshoeing in Colorado on New Year’s Eve Day four years ago. An avalanche killed him.

I know Melissa. She’s a compassionate, deep-thinking doctor-in-training. But there’s more to her story than coping with tragic news. There’s a message for future doctors.

As doctors, we like to think that it’s all about saving lives. But we also know that being a caregiver sometimes requires being the one that breaks the news that a loved one is dead.

Melissa has told me that as part of medical training, she’s known that she has to consider carefully which words she’ll use. She had a friend, for instance, who was told by a doctor that her husband’s heart stopped beating after complicated surgery.  We all live in denial when harsh news hits us. So Melissa’s friend didn’t understand what was going on until the doctor finally said, “Your husband is dead.” Then he shot out of the room leaving the woman alone.

Yes, words matter. But Melissa barely remembers the words when she was told that her husband died. What she remembers is the comfort; the way the officers stood by her side. The way they spoke in calm tones, rather than sounding like a computer.

This is a lesson—albeit one learned in such a harsh way—that she is trying to take with her as she becomes a full-fledged physician.

I have a colleague who is a professor at Yale drama school and teaches voice classes. The vast majority of her students are aspiring actors. A few years ago, she was invited to speak to a group of physicians. Someone realized that we, doctors, never learn about how we speak, just what we say.

One of my former professors told me that he had this issue with one of his trainees who spoke in a chipper voice no matter the content. But he thought it was inappropriate to comment on her tone.

Why inappropriate? If we teach medical communication in medical schools these days, shouldn’t voice count too?

Yes words matter but, it’s like that mom-ism “It’s not what you said, it’s your tone.” Doctors could take note of that too.

By Leave a Comment

Tuning in to Stressing Out

Having spent most of my career on college campuses (I’ve basically never left since I got my undergraduate degree in 1984), I’ve had the opportunity to meet amazing students. Their list of achievements never ceases  to astonish me. But at the same time, their remarkable successes concern me. I worry that in their race to collect awards to bloat their already swollen resumes, they lose sight of the point of it all. What will happen when everything they do isn’t graded? What will happen when they reach their goals but there’s not another award in sight? How will they find fulfillment?

As the Writer in Residence at Yale School of Medicine, I read a lot of essays. One of my second-year medical students penned a piece that articulates the pressures that she and her peers feel. But she also offers advice—words of wisdom that she is trying to follow and hoping others will too. I’m happy to post her essay as a guest piece on my blog:

HAMSTER WHEELS: BREAKING THE CYCLE

BY CHAARUSHI AHUJA

When we were younger, my sister wanted a hamster, but my parents were quick to deny her request. They had heard too many frustrated stories from other parents who were annoyed by the critter’s incessant spinning in place. They found the hamsters’ habit of tirelessly chasing the ladder in front of its eyes to be pointless, and so they figured, not interesting, for a pet.

Ten years out, it baffles me that the quality my parents rejected in a hamster is what we are now embracing as a society. When I look around, I see young people, like my peers and me, running on our own wheels, pursuing fleeting goals with no real end or pauses in sight.

The National College Health Assessment reported recently that 60% of current college students felt “extreme anxiety” within the last two months of the survey.  Younger generations, the Gen Z-ers and millennials, consistently report the highest levels of stress compared to any other generation so far.

The number should shock me. But it doesn’t.

It’s because what my generation often takes pride in is our relentless ability to collect accomplishments. We win some and then wake up the next day to keep winning some more. We don’t take breaks; we are constantly plugged in, constantly accessible, and constantly on the go. Our drive is applaudable. It brings about innovation, inventions and positive changes in our world. But it comes at the cost of our own sanity.

When I started medical school last year, I felt immense pride for all the hard work, sweat and tears that went into getting admitted. I beamed at the white coat ceremony, excited to enter training for a profession that I had been dreaming of for years. My enthusiasm, though, was short-lived.

One week into school and I moved on from my “win” and was already thinking of goals that lay ahead. What research should I do? What was my strategy for the next time I would have to apply and get admitted? In other words, what was going to be my next set of accomplishments that would shine on my wall, lead to respect, and maybe give me the same rush of excitement that I had gotten when I got my letter of acceptance.

This story, consciously or subconsciously, applies to almost everyone I know. We are running and running, until the thrill of the chase turns to utter stress, which morphs (for three out of five) into a health hazard: extreme anxiety.  The irony, for me, is that I’m training to be a healer.

So, to prevent this pervasive culture from seeping into my life, here’s my new goal: I vow to create time for “reset weekends”. Once every month or two, I disconnect from my work completely; I hop off my hamster wheel and just sit in my cage. I go and find hobbies and passions that give me as much satisfaction as the thought of winning or accomplishing does. On my last reset weekend, I played badminton with my family, checked my phone a mere 4 times that day (a decrease of about 196% ), journaled extensively for 3 hours, and read a novel that had been on my mind for months.

These weekends strengthen my drive. I retune by reflecting on my actions and why the goals I am chasing are meaningful. I pause the journey, and make sure that I am not just spinning, but rather moving forward in a meaningful and satisfying way.

Resetting doesn’t have to be entire weekends; it can be a day, or mere hours—as long as the time reprograms the pursuit and revitalizes it to be more meaningful. One of my friends resets by taking week long vacations twice a year. Although not frequent enough and too long for my taste, it works for him. He is incredibly productive, healthy, and content.

Just imagine this: what if each one of us took moments to hop off the hamster wheel to celebrate, to feast, and to appreciate how far our hard work has taken us. Then rather than downtrodden hamsters fatigued by the constant squeak, squeak, squeak, we all stepped on again, refueled, reenergized, and re-motivated.

By Leave a Comment

19th Century Climate Change Debates Sound Woefully Familiar Today

This morning, NPR reported on the United Nation’s recent and “sobering” new report about climate change, saying that we are doomed to live in dangerous conditions unless new technologies can remove greenhouse gasses from the atmosphere. For anyone writing or thinking about climate change issues today, it would be worth your while to pick up Deborah Coen’s Climate in Motion: Science, Empire and the Problem of Scale. Of course, for me, the fun facts were the ones that had to do with medicine.

In the early 1900s, scientists created devices to record factors in the environment that were linked to health, such as measuring ultraviolet radiation, ozone levels, and the “feel” of temperature. Humidity was measured using none other than a strand of hair. Scientists back then realized what women have probably known for millennial: your hair gets frizzy in sticky weather. But here’s what most of us didn’t know:  The way humidity effects the length of a strand of hair is standardized, meaning that you can calculate the amount of humidity based on how much hair shrinks or lengthens. It’s not willy-nilly but linked to the amount of moisture in the air. Thus came the Hair Hygrometer. Here’s a piece in Scientific American about how to make your own hair Hygrometer using rubbing alcohol, cotton and other household items.

Around the same time, scientists started to worry about the impact of deforestation, urbanization, and the draining of wetlands on climate. In other words, as Coen explains, these 19th century experts worried about the human impact on climate. Doctors, she writes, believed that climate had a powerful influence on human sexual function. Coen writes why this 19th century tumult matters today in this recent piece in The Conversation. They even prescribed climatic cures to relieve their ailments. Their fears fomented into political infighting—that often had nothing to do with the science but more to do with assumptions, egos, and short-term solutions to development. Sound familiar?