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

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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.

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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.

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What Hungry Dogs May Teach Us About Ourselves

New Insights Into Dog Hunger Hormones May Lead to Strategies for Humans

The other day I was walking my dog when I ran into Dr. Jeffrey Friedman. In 1994, his Rockefeller University team discovered leptin, the hormone that controls appetite. People with low leptin are voraciously hungry—and obese.

Friedman offered a treat to Ellie, my 11-pound Havanese dog, but she turned up her snout. I mentioned that Charlie, my late Golden Retriever was so food-obsessed we had to hold him back from scrambling under parked cars to nab chucked leftovers. Could it be hormones? I thought my question was rather facetious because I was talking to a dog-owning hunger-hormone expert.

Turns out, he said, some dogs are prone to the same hormone defect as humans. He referred me to a University of Cambridge study. I got home, fed my dog (she only likes one kind of dog food), found the dog-hormone scientific article and emailed the leading investigator, Dr. Eleanor Raffan.  A few days later, we SKYPEd.

Raffan told me the leptin defect was more common among Labradors and flat-coated retrievers compared to other breeds—no surprise to Lab owners. Here’s what may come as surprise: Among the Labradors, the mutation was much higher among guide dogs compared to the rest of them — 50 percent versus 25 percent. Raffan has a hunch that food-obsessed puppies might be easier to train, giving them a leg-up into the guide-dog program.

Oddly enough her studies did not find the mutation in golden retrievers. I have to believe that Charlie, my late golden, must have some other yet-discovered hormone defect; that his biological drive for food is somewhere on that spectrum between the picky-eating Havanese and the food-focused Labradors. To be sure, Raffan’s research provides insights into why some dogs may be hungrier than others, but in larger sense it’s providing more clues to the physiology of hunger—and may lead to new ways to staunch the obesity epidemic in dogs and humans. (Apparently dogs are getting fatter, too) Already there are a few experimental drugs that seem to be helping the rare people with leptin problems.

However, if you do not have the defect, the leptin shots and any touted leptin diets won’t do anything. That’s because for most of us, eating too much is not just about one mutation, but probably lots of hormones that control hunger, satiety, stress—not to mention all kinds of emotions that go into appetite. Sometimes we eat when we’re not hungry. Still, Studies like this one (that highlight the power of our hormones ) will likely lead to new ways to help those with the rare hormone defect, and certainly shed light on the basic biology of appetite. As Dr. Friedman told me,  “I don’t think on the whole that humans have come to grips entirely with how powerful our basic drives are, how difficult it is to use conscious means to control them.”

And yet.. and yet. When my kids were as young as my son was is in this photo, we spent a lot of time baking cupcakes and brownies. The stirring had a soothing effect on the kids. I gained weight. Friends (perhaps unaware of our daily cooking habit) kindly said it was just my hormones. (of pregnancy? of motherhood?) Nope, it was Duncan Hines Ready-to-Spread Icing. To be sure, understanding hormones will glean insight into our human urges, but sometimes the solution is not rewiring our brains, but rewriting the grocery list.

 

For further readings, this New York Times piece delves into the dog hunger hormone.

Check out this commentary by Harvard scientists that puts  leptin findings in perspective.

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Get Me Out: A History of Childbirth from the Garden of Eden is on sale!

Get Me Out: A History of Childbirth from the Garden of Eden to the Sperm Bank is on sale. For one week only, the e-book is only $1.99!! That’s cheaper than a  cappuccino. It lasts longer and doesnt spill.

Ever wonder how sperm banks choose their “donors”—Get Me Out has the inside scoop. Every wonder about what women were told in ancient times about getting pregnant? Okay maybe you didn’t, but Get Me Out tells about that too. 

Aug. 17-24 from BookBub — $1.99

https://www.bookbub.com/books/get-me-out-by-randi-hutter-epstein@BookBub

 

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The Accidental Activist: from Sperm to Politicians

When Dr. Stephanie Dahl returned to her native North Dakota after a fellowship in reproductive medicine further east, she imagined she would join the region’s only fertility clinic helping people make babies. Simple as that. In 2006, it was the only fertility clinic between Minneapolis and Seattle. She expected a flood of patients. What she never expected was a career transformation of sorts. This mild-mannered doctor turned into a political activist, thanks to all the renewed talk of Personhood. Personhood is an ancient term with a muddled definition. The word goes back to biblical times when philosophers tried to guess the moment a seed turns into a soul-filled being. The country thought the courts settled the debate with Roe v. Wade. That decision focused on viability, or the ability to survive independently outside the womb. But the word has crept back into political hallways. Lawmakers in several states have tried to pass bills that would give personhood a legal definition. And this is how some folks want it defined: Personhood starts the moment sperm meets egg. That means this single cell would the full rights of a U.S. citizen. So far, no bills have made it to law but the drawn-out process to block them seems to waste a lot of time and money that could be put to better use. To be sure, we know much more about  the innermost details of a growing embryo. But do these insights provide any information to help everyone agree on a revised personhood timeline? While most doctors perceive this as a threat to abortion rights—which  it is—the potential legislation also impacts the treatment of complicated pregnancies and limits infertility procedures. And that’s why fertility experts are worried. And that’s why Dr. Dahl has become an activist. And that’s why professional fertility associations have formed their own anti-personhood committees to defeat  potential legislation. If a person is a sperm-and-egg, you really can’t put them in freezers. That is what happens when doctors make extra embryos and freeze them for potential future use. And you certainly can’t discard them when they are no longer needed. At issue is not only the definition of personhood (At conception? At viability? At birth?) but who should be making the decision: scientists, courts or clergy. And if it is clergy, which religion? Beliefs on this issue vary as widely as the people who hold them. This past week, North Dakota senate passed two personhood bills, putting Dr. Dahl on guard once again.

Here’s a snippet of my recent conversation with Dr. Dahl:

RHE: Can you explain these bills?

SD: The first bill that passed the North Dakota senate would amend the N.D. constitution to read: “The inalienable right to life of every human being at any stage of development must be recognized and protected.” The vague language could lead to devastating unintended consequences for pregnant women and woman who’d like to become pregnant. The second bill limits some types of in vitro fertilization, criminalizes doctors, outlaws abortion with no exemptions for victims of rape or incest, and makes it difficult to treat ectopic pregnancies.

RHE: In your blog you mention cancer, what does that have to do with fertility?

SD: Chemotherapy and radiation therapy, which are used to treat cancer, can adversely affect the ovaries and destroy a woman’s ability to become pregnant in the future. The best option to preserve future fertility for women with cancer is to perform in vitro fertilization and freeze the resulting embryos. Some centers freeze eggs, however, that technology is not as successful as IVF and is not yet available at our center. Another bill introduced in the senate would have prohibited embryo freezing (for all families including infertility patients and cancer patients), limited the number of eggs we could attempt to fertilize (either one or two), and banned some forms of birth control. Luckily, that bill did not pass. Our cancer patients have enough to worry about with their diagnosis and treatment. They shouldn’t have to forfeit their chances of becoming a mother in the future as well.

RHE: Do you ever think it would be easier to move to a state with more progressive attitudes about fertility so you can just do what you do best?

SD: I have thought about leaving the state, but I want the people in North Dakota to have this care available locally. I think what we do is important. I love my job. When patients bring their newborns for me to snuggle, it’s the best part of my day. So I try to push the politics to the background. I’m here to give patients quality care. We now have thousands of babies across North Dakota that would not have been possible without interventions like IVF. But I hear comments from senators that you wouldn’t believe. Just the other day, one told me that if God decided a woman’s womb should not bear children, doctors should not intervene. And I said, “Does that mean if God decides you should have a heart attack, doctors shouldn’t intervene either?”

 

For further reading as well as thorough history of the personhood debates, check out 102-year-old Howard Jones’s latest book, Personhood Revisited: Reproductive Technology, Bioethics, Religion and the Law. Dr. Jones, sharp as ever, along with his late wife, Georgeanna Seegar Jones, created America’s first test tube baby and has been in thick of the fertility debates since  day one.

 

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