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THE MELANIE BLOCKER-STOKES

POSTPARTUM DEPRESSION

RESEARCH AND HEALTH CARE ACT

HEARING

BEFORE THE

SUBCOMMITTEE ON HEALTH

OF THE

COMMITTEE ON ENERGY AND

COMMERCE

HOUSE OF REPRESENTATIVES

ONE HUNDRED TENTH CONGRESS

FIRST SESSION

ON

H.R. 20

MAY 1, 2007

Serial No. 110–38

(

Printed for the use of the Committee on Energy and Commerce

energycommerce.house.gov

COMMITTEE ON ENERGY AND COMMERCE

JOHN D. DINGELL, Michigan, Chairman

HENRY A. WAXMAN, California

EDWARD J. MARKEY, Massachusetts

RICK BOUCHER, Virginia

EDOLPHUS TOWNS, New York

FRANK PALLONE, JR., New Jersey

BART GORDON, Tennessee

BOBBY L. RUSH, Illinois

ANNA G. ESHOO, California

BART STUPAK, Michigan

ELIOT L. ENGEL, New York

ALBERT R. WYNN, Maryland

GENE GREEN, Texas

DIANA DEGETTE, Colorado

Vice Chairman

LOIS CAPPS, California

MIKE DOYLE, Pennsylvania

JANE HARMAN, California

TOM ALLEN, Maine

JAN SCHAKOWSKY, Illinois

HILDA L. SOLIS, California

CHARLES A. GONZALEZ, Texas

JAY INSLEE, Washington

TAMMY BALDWIN, Wisconsin

MIKE ROSS, Arkansas

DARLENE HOOLEY, Oregon

ANTHONY D. WEINER, New York

JIM MATHESON, Utah

G.K. BUTTERFIELD, North Carolina

CHARLIE MELANCON, Louisiana

JOHN BARROW, Georgia

BARON P. HILL, Indiana

JOE BARTON, Texas

Ranking Member

RALPH M. HALL, Texas

J. DENNIS HASTERT, Illinois

FRED UPTON, Michigan

CLIFF STEARNS, Florida

NATHAN DEAL, Georgia

ED WHITFIELD, Kentucky

BARBARA CUBIN, Wyoming

JOHN SHIMKUS, Illinois

HEATHER WILSON, New Mexico

JOHN B. SHADEGG, Arizona

CHARLES W. ‘‘CHIP’’ PICKERING,

Mississippi

VITO FOSSELLA, New York

STEVE BUYER, Indiana

GEORGE RADANOVICH, California

JOSEPH R. PITTS, Pennsylvania

MARY BONO, California

GREG WALDEN, Oregon

LEE TERRY, Nebraska

MIKE FERGUSON, New Jersey

MIKE ROGERS, Michigan

SUE WILKINS MYRICK, North Carolina

JOHN SULLIVAN, Oklahoma

TIM MURPHY, Pennsylvania

MICHAEL C. BURGESS, Texas

MARSHA BLACKBURN, Tennessee

PROFESSIONAL STAFF

DENNIS B. FITZGIBBONS, Chief of Staff

GREGG A. ROTHSCHILD, Chief Counsel

SHARON E. DAVIS, Chief Clerk

BUD ALBRIGHT, Minority Staff Director

(II)

(III)

SUBCOMMITTEE ON HEALTH

FRANK PALLONE, JR., New Jersey, Chairman

HENRY A. WAXMAN, California

EDOLPHUS TOWNS, New York

BART GORDON, Tennessee

ANNA G. ESHOO, California

GENE GREEN, Texas

Vice Chairman

DIANA DEGETTE, Colorado

LOIS CAPPS, California

TOM ALLEN, Maine

TAMMY BALDWIN, Wisconsin

ELIOT L. ENGEL, New York

JAN SCHAKOWSKY, Illinois

HILDA L. SOLIS, California

MIKE ROSS, Arkansas

DARLENE HOOLEY, Oregon

ANTHONY D. WEINER, New York

JIM MATHESON, Utah

JOHN D. DINGELL, Michigan (ex officio)

NATHAN DEAL, Georgia,

Ranking Member

RALPH M. HALL, Texas

BARBARA CUBIN, Wyoming

HEATHER WILSON, New Mexico

JOHN B. SHADEGG, Arizona

STEVE BUYER, Indiana

JOSEPH R. PITTS, Pennsylvania

MIKE FERGUSON, New Jersey

MIKE ROGERS, Michigan

SUE WILKINS MYRICK, North Carolina

JOHN SULLIVAN, Oklahoma

TIM MURPHY, Pennsylvania

MICHAEL C. BURGESS, Texas

MARSHA BLACKBURN, Tennessee

JOE BARTON, Texas (ex officio)

(V)

C O N T E N T S

Page

Hon. Frank Pallone, Jr., a Representative in Congress from the State of

New Jersey, opening statement .......................................................................... 1

Hon. Nathan Deal, a Representative in Congress from the State of Georgia,

opening statement ................................................................................................ 2

Hon. Diana DeGette, a Representative in Congress from the State of Colorado, opening statement ...................................................................................... 3

Hon. Joseph R. Pitts, a Representative in Congress from the Commonwealth

of Pennsylvania, opening statement ................................................................... 5

Hon. Jan Schakowsky, a Representative in Congress from the State of Illinois, opening statement ....................................................................................... 6

Hon. Michael C. Burgess, a Representative in Congress from the State of

Texas, opening statement .................................................................................... 7

Hon. Lois Capps, a Representative in Congress from the State of California,

opening statement ................................................................................................ 8

Hon. Tim Murphy, a Representative in Congress from the Commonwealth

of Pennsylvania, opening statement ................................................................... 9

Hon. Gene Green, a Representative in Congress from the State of Texas,

opening statement ................................................................................................ 10

Hon. Marsha Blackburn, a Representative in Congress from the State of

Tennessee, opening statement ............................................................................ 11

Hon. Bobby L. Rush, a Representative in Congress from the State of Illinois,

opening statement ................................................................................................ 12

Hon. Anna G. Eshoo, a Representative in Congress from the State of California, prepared statement ...................................................................................... 13

Hon. Edolphus Towns, a Representative in Congress from the State of New

York, prepared statement .................................................................................... 14

H.R. 20, To provide for research on, and services for individuals with,

postpartum depression and psychosis. ............................................................... 17

WITNESSES

Catherine Roca, M.D., chief, Women’s Programs, National Institute of Mental

Health, Bethesda, MD ......................................................................................... 27

Prepared statement .......................................................................................... 30

Carol Blocker, mother of Melanie Blocker-Stokes, Chicago, IL ........................... 31

Prepared statement .......................................................................................... 33

Mary Jo Codey, member, President’s Advisory Council of Postpartum Support

International, West Orange, NJ ......................................................................... 35

Prepared statement .......................................................................................... 37

Michaelene Fredenburg, president, Life Perspectives, San Diego, CA ............... 38

Prepared statement .......................................................................................... 39

Priscilla K. Coleman, associate professor of human development and family

studies, Bowling Green State University, Bowling Green, OH ........................ 41

Prepared statement .......................................................................................... 44

Nada Stotland, M.D., professor of psychiatry and obstetrics/gynecology, Rush

Medical College, Chicago, IL ............................................................................... 58

Prepared statement .......................................................................................... 60

Answer to submitted question ......................................................................... 102

SUBMITTED MATERIAL

‘‘Depression During and After Pregnancy, a Resource for Women, Their Families, and Friends’’, Health Resources and Services Administration, U.S.

Department of Health and Human Services ...................................................... 78

(1)

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

2

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.

3

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

4

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.

5

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 781⁄2 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 longterm effects of abortion on their mental and emotional well being.

Women who have had abortions deserve to have mental health proVerDate 11-SEP-98 10:39 Feb 29, 2008 Jkt 000000 PO 00000 Frm 00010 Fmt 6633 Sfmt 6633 Q:\DOCS\110-38 SCOM1 PsN: SCOM1
6

fessionals 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 postabortion 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 cosponsored 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 feelVerDate 11-SEP-98 10:39 Feb 29, 2008 Jkt 000000 PO 00000 Frm 00011 Fmt 6633 Sfmt 6633 Q:\DOCS\110-38 SCOM1 PsN: SCOM1
7

ing—and most fulfilled, this disorder can have immediate and longterm 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

8

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 selfworth 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.

9

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

10

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.

11

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 thirdtime 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.

12

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

13

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.

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20

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25

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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 BlockerStokes 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.

28

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

29

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:]

30

1 Henshaw, C. Mood disturbance in the early puerperium: a review. Archives of Women’s

Mental Health. 2003 Aug; Suppl 2:S33–42.

2 Gaynes, BN, Gavin N, eta l. Perinatal Depression: Prevelence , Screening Accuracy, and

Screening Outcomes.

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

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

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

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

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

31

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 ComVerDate 11-SEP-98 10:39 Feb 29, 2008 Jkt 000000 PO 00000 Frm 00036 Fmt 6633 Sfmt 6633 Q:\DOCS\110-38 SCOM1 PsN: SCOM1
32

pany 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 hollowedeyed 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

33

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.

34

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 antipsychotic 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.

35

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 inVerDate 11-SEP-98 10:39 Feb 29, 2008 Jkt 000000 PO 00000 Frm 00040 Fmt 6633 Sfmt 6633 Q:\DOCS\110-38 SCOM1 PsN: SCOM1
36

stitution 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:]

37

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.

38

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 livein 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.

39

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 deVerDate 11-SEP-98 10:39 Feb 29, 2008 Jkt 000000 PO 00000 Frm 00044 Fmt 6633 Sfmt 6633 Q:\DOCS\110-38 SCOM1 PsN: SCOM1
40

pression. 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

41

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. Wellmeaning 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.

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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

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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:]

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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

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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 socalled 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 postabortion 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 illVerDate 11-SEP-98 10:39 Feb 29, 2008 Jkt 000000 PO 00000 Frm 00064 Fmt 6633 Sfmt 6633 Q:\DOCS\110-38 SCOM1 PsN: SCOM1
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ness 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.

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order, 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.

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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 selflimited. 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.

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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

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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 nondiscriminatory 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

65

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.

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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.

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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 21⁄2 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,

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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 pubVerDate 11-SEP-98 10:39 Feb 29, 2008 Jkt 000000 PO 00000 Frm 00073 Fmt 6633 Sfmt 6633 Q:\DOCS\110-38 SCOM1 PsN: SCOM1
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lished 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?

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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

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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.

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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 antipsychotics 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.

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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.

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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——

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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.

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Mrs. CAPPS. The one that has to do with is this the same as postabortion?

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.

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[Whereupon, at 2:25 p.m., the subcommittee was adjourned.]

[Material submitted for inclusion in the record follows:]

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