[House Hearing, 108 Congress]
[From the U.S. Government Publishing Office]
IMPROVING WOMEN'S HEALTH: UNDERSTANDING DEPRESSION AFTER PREGNANCY
=======================================================================
HEARING
before the
SUBCOMMITTEE ON HEALTH
of the
COMMITTEE ON ENERGY AND COMMERCE
HOUSE OF REPRESENTATIVES
ONE HUNDRED EIGHTH CONGRESS
SECOND SESSION
__________
SEPTEMBER 29, 2004
__________
Serial No. 108-133
__________
Printed for the use of the Committee on Energy and Commerce
Available via the World Wide Web: http://www.access.gpo.gov/congress/
house
__________
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------------------------------
COMMITTEE ON ENERGY AND COMMERCE
JOE BARTON, Texas, Chairman
W.J. ``BILLY'' TAUZIN, Louisiana JOHN D. DINGELL, Michigan
RALPH M. HALL, Texas Ranking Member
MICHAEL BILIRAKIS, Florida HENRY A. WAXMAN, California
FRED UPTON, Michigan EDWARD J. MARKEY, Massachusetts
CLIFF STEARNS, Florida RICK BOUCHER, Virginia
PAUL E. GILLMOR, Ohio EDOLPHUS TOWNS, New York
JAMES C. GREENWOOD, Pennsylvania FRANK PALLONE, Jr., New Jersey
CHRISTOPHER COX, California SHERROD BROWN, Ohio
NATHAN DEAL, Georgia BART GORDON, Tennessee
RICHARD BURR, North Carolina PETER DEUTSCH, Florida
ED WHITFIELD, Kentucky BOBBY L. RUSH, Illinois
CHARLIE NORWOOD, Georgia ANNA G. ESHOO, California
BARBARA CUBIN, Wyoming BART STUPAK, Michigan
JOHN SHIMKUS, Illinois ELIOT L. ENGEL, New York
HEATHER WILSON, New Mexico ALBERT R. WYNN, Maryland
JOHN B. SHADEGG, Arizona GENE GREEN, Texas
CHARLES W. ``CHIP'' PICKERING, KAREN McCARTHY, Missouri
Mississippi, Vice Chairman TED STRICKLAND, Ohio
VITO FOSSELLA, New York DIANA DeGETTE, Colorado
STEVE BUYER, Indiana LOIS CAPPS, California
GEORGE RADANOVICH, California MICHAEL F. DOYLE, Pennsylvania
CHARLES F. BASS, New Hampshire CHRISTOPHER JOHN, Louisiana
JOSEPH R. PITTS, Pennsylvania TOM ALLEN, Maine
MARY BONO, California JIM DAVIS, Florida
GREG WALDEN, Oregon JANICE D. SCHAKOWSKY, Illinois
LEE TERRY, Nebraska HILDA L. SOLIS, California
MIKE FERGUSON, New Jersey CHARLES A. GONZALEZ, Texas
MIKE ROGERS, Michigan
DARRELL E. ISSA, California
C.L. ``BUTCH'' OTTER, Idaho
JOHN SULLIVAN, Oklahoma
Bud Albright, Staff Director
James D. Barnette, General Counsel
Reid P.F. Stuntz, Minority Staff Director and Chief Counsel
______
Subcommittee on Health
MICHAEL BILIRAKIS, Florida, Chairman
RALPH M. HALL, Texas SHERROD BROWN, Ohio
FRED UPTON, Michigan Ranking Member
JAMES C. GREENWOOD, Pennsylvania HENRY A. WAXMAN, California
NATHAN DEAL, Georgia EDOLPHUS TOWNS, New York
RICHARD BURR, North Carolina FRANK PALLONE, Jr., New Jersey
ED WHITFIELD, Kentucky BART GORDON, Tennessee
CHARLIE NORWOOD, Georgia ANNA G. ESHOO, California
Vice Chairman BART STUPAK, Michigan
BARBARA CUBIN, Wyoming ELIOT L. ENGEL, New York
JOHN SHIMKUS, Illinois GENE GREEN, Texas
HEATHER WILSON, New Mexico TED STRICKLAND, Ohio
JOHN B. SHADEGG, Arizona DIANA DeGETTE, Colorado
CHARLES W. ``CHIP'' PICKERING, LOIS CAPPS, California
Mississippi CHRIS JOHN, Louisiana
STEVE BUYER, Indiana BOBBY L. RUSH, Illinois
JOSEPH R. PITTS, Pennsylvania JOHN D. DINGELL, Michigan,
MIKE FERGUSON, New Jersey (Ex Officio)
MIKE ROGERS, Michigan
JOE BARTON, Texas,
(Ex Officio)
(ii)
C O N T E N T S
__________
Page
Testimony of:
Blocker, Carol............................................... 16
Fredenburg, Michaelene, President, Life Resource Network..... 37
Shadigian, Elizabeth, Department of Obstetrics and
Gynecology, Mott Hospital.................................. 41
Stotland, Nada L., Professor of Psychiatry and Professor of
Obstetrics and Gynecology, Rush Medical College............ 20
Material submitted for the record by:
American Cancer Society, prepared statement of............... 55
American College of Obstetricians and Gynecologists, prepared
statement of............................................... 62
Alzheimer's Foundation of America, prepared statement of..... 59
(iii)
IMPROVING WOMEN'S HEALTH: UNDERSTANDING DEPRESSION AFTER PREGNANCY
----------
WEDNESDAY, SEPTEMBER 29, 2004
House of Representatives,
Committee on Energy and Commerce,
Subcommittee on Health,
Washington, DC.
The subcommittee met, pursuant to notice, at 1:09 p.m., in
room 2123, Rayburn House Office Building, Hon. Michael
Bilirakis (chairman) presiding.
Members present: Representatives Bilirakis, Pickering,
Pitts, Barton (ex officio), Brown, Towns, Green, DeGette,
Capps, and Rush.
Staff present: Cheryl Jaeger, majority professional staff;
Chuck Clapton, majority counsel; Eugenia Edwards, majority
legislative clerk; and John Ford, minority counsel.
Mr. Bilirakis. Good afternoon, the hearing will come to
order. Today's hearing, ``Improving Women's Health:
Understanding Depression After Pregnancy,'' addresses
depression in women, an important issue that is often
overlooked.
Depression is a disease that many people feel uncomfortable
discussing. It is often dismissed because there is a thought
that this condition is personal weakness, or you should just be
able to snap out of it. However, this is a potentially serious
and debilitating condition for those who experience depression.
Depression affects your body, your mood and your thoughts. It
is different from being in a bad mood.
Without treatment, a depressed individual can suffer from
symptoms such as hopelessness, fatigue, lack of appetite, and
thoughts of suicide, to name a few. It can last weeks, months
or years.
Appropriate treatment, however, can help most people who
suffer from depression.
It's extremely disconcerting that women experience
depression about twice as often as men. While we don't know all
of the causes of depression, we do know that hormonal factors
may contribute to the increased rate of depression in women,
and many women are also particularly vulnerable after a
pregnancy.
In today's hearing, we will discuss two aspects of
depression in women, postpartum depression and post-abortion
depression. These are sensitive matters in an area where we
really don't have a lot of conclusive answers, and that's why
I'm interested in hearing from our witnesses and learning more
today. While each member has his or her own views on some of
the issues that we'll be discussing today, none of us is an
expert in the field of depression. So, I believe we will really
be able to learn from today's hearing.
I'd like to thank our witnesses for being here today,
especially Carol Blocker and Michaelene Fredenburg, who will
share their personal experiences with us today. Ms. Blocker
lost her daughter who suffered from postpartum depression. Ms.
Blocker, I'm so sorry for your loss. No parent should have to
go through what you experienced with the loss of your dear
daughter, Melanie. Ms. Fredenburg, being willing to share your
personal experience with abortion is extremely brave, and I'm
so glad to have you here today.
I'd also like to thank, of course, our other two witnesses
today, Doctor Nada Stotland with the American Psychiatric
Association, and Doctor Elizabeth Shadigian, with the
Department of Obstetrics and Gynecology at Mott Hospital. I
look forward, as we all do, to hearing from you.
Again, thank you for being here today, and I'm pleased to
yield to the ranking member of the subcommittee, my friend, the
gentleman from Ohio, Mr. Brown, for an opening statement.
Mr. Brown. Thank you, Mr. Chairman, and thanks to our
witnesses for joining us this morning. Ms. Blocker, thank you
for your courage and your willingness to share your story with
us.
Postpartum depression is a clinically proven, alarmingly
prevalent women's health condition. Postpartum depression is a
mental health threat that affects, we believe, at least 10
percent of new mothers, 400,000 women, every year. It causes
tremendous suffering, and in its most severe form it can
jeopardize the lives of new mothers, as well as their children.
It affects women without regard to race, or age, or
socioeconomic status. It affects new mothers and women with
more than one child equally, and no one knows for sure what
causes this debilitating condition.
Despite that, important innovations are being made in
understanding and treating postpartum depression. It's
appropriate and vitally important for this subcommittee to
learn more about this condition. Unfortunately, my Republican
colleagues chose to politicize today's hearing.
I'm sorry that one of our witnesses has dealt with
depression that she attributes to the circumstances surrounding
her abortion. I'm not surprised, though, that the majority
chose to introduce the topic of abortion in this debate. Had
the majority truly been interested in expanding the focus of
this hearing to look at the mental health of women who have
been pregnant, then where are the witnesses who have
experienced miscarriage, or stillbirth, or adoption for that
matter? Where is the witness who is currently facing an
unintended pregnancy who didn't know about birth control
because her high school couldn't get funding for comprehensive
sex education?
Anti-choice Members of Congress have every right to promote
their agenda, but it's a shame they chose to turn this
important public health hearing into yet another attack on the
reproductive rights of women. This hearing should promote the
well-being of women, not compromise it. Postpartum depression
is a serious mental health threat. Its impact on women and
families is enormous. We should keep our eye on the ball.
Thank you, Mr. Chairman.
Mr. Bilirakis. I thank the gentleman. We try to do some
good in terms of learning up here, and it always seems to
always turn negative.
Mr. Pitts--well, Mr. Chairman, I'm sure you would like to
make an opening statement. Proceed.
Chairman Barton. Thank you, Chairman Bilirakis, for holding
this hearing, and before I read my prepared statement, let me
say that the reason that we are doing this hearing is twofold.
Former Congressman Tauzin, the chairman of this committee, had
promised Mr. Rush that we would do a hearing, and Mr. Tauzin
had also promised Mr. Pitts that we would do a hearing. And
when I became Chairman, both of those gentlemen told me that
they had that promise and I kept it, and that's why we are
having the hearing today.
We have two panels, because they are, while they are
similar issues they are separate, and we wanted to have each
panel, basically, Mr. Rush's panel first, and then Mr. Pitts'
panel, and I felt that it was acceptable to do that. There's
nothing at all where we are trying to be partisan, just the
opposite, we are trying to be fair and get two issues that are
important, dissimilar in some ways, similar in some ways, on
the table for the American people. But, if there is angst and
frustration to be expressed, it should be expressed at me,
because I'm the one who honored the commitment that the former
Chairman had to both the distinguished members of this
committee, and I think that we should keep our promises even
when we are not the individual who made the initial promise,
and that's why we are doing it.
I do want to thank you two women for being here, and our
second panel also. This is a serious issue. Depression is very
serious. We've got a series of hearings going on right now in
the Oversight Subcommittee where we are looking at
antidepressant drugs that are being prescribed to children. One
out of every six U.S. children is on some sort of an
antidepressant. For women who have given birth, postpartum
depression is a real illness, there's no question about that.
Research that's been conducted, with the support of the
National Institutes of Health, has uncovered a variety of
issues about this particular subject that's going to be
important in this hearing. We know that for women the risk of
depression increases after puberty, indicating possible
hormonal links. We also know that new imaging tools have helped
researchers better understand how the brain works, enabling
them to highlight brain functions with respect to depression in
women.
The mapping of the human genome has allowed for the first
time scientists to identify and explore potential genetic
triggers. This is all basic information, we combine it,
hopefully, in a way that can lead to an improved targeted
treatment for depression. The more information we collect and
analyze, the better off we'll be.
So I'm happy to have this hearing, Mr. Chairman, and I look
forward to it, and I'm going to stay for as much of it as
possible, and hopefully have a chance to ask some questions.
[The prepared statement of Hon. Joe Barton follows:]
Prepared Statement of Hon. Joe Barton, Chairman, Committee on Energy
and Commerce
Thank you, Mr. Bilirakis, for holding this hearing today.
There is one thing that everyone in this room should agree on:
depression is a serious illness that we need to better understand.
Statistics tell us that women are roughly twice as likely to develop
depression than men. That's powerful information. With this fact,
scientists can target their research efforts in areas that are unique
to women, like reproductive, hormonal, genetic, and other biological
factors.
Research conducted with the support of the National Institutes of
Health has uncovered a variety of useful information. We know that for
females, the risk of depression increases after puberty, indicating
possible hormonal links. New imaging tools are helping researchers to
better understand how the brain works, enabling them to highlight brain
functions with respect to depression. The mapping of the human genome
allows, for the first time, scientists to identify and explore
potential genetic triggers. All of this basic information combined
together will ultimately lead the way to improved, targeted treatments
for depression. The more information we collect and analyze, the better
off we will be.
I am concerned that some have suggested that it's unnecessary to
even evaluate the impact of abortion and its relationship to
depression. We need to know more information about depression, not
less. Right now, scientists are still evaluating the impact of
depression screening and intervention tools to improve health outcomes.
When there are still outstanding questions about the incidence and
prevalence of perinatal depression, it's obvious to me that we still
need to learn a lot more.
Patients look to their doctors to provide them with the latest
information about treatments and options. This is the case in every
medical situation: whether it is a wife seeking advice about pregnancy
or a young woman contemplating an abortion. Medical procedures are
risky. They often have permanent consequences. I want the patient to be
able to make a truly informed decision.
I would like to thank all of the witnesses for taking the time to
participate in this hearing today. I look forward to the testimony.
Mr. Bilirakis. The Chair thanks the chairman.
Mr. Rush is recognized for 3 minutes for an opening
statement.
Mr. Rush. I want to thank you, Mr. Chairman, for
recognizing me, and I certainly want to thank the chairman of
the full committee for keeping his promise, or keeping the
promise of the former chairman. I want to thank him for all
that he has done on behalf of the suffering--women who suffer
from postpartum psychosis, disease and depression.
I want to certainly welcome two constituents of mine who
are at the panel. First of all, I want to welcome my friend for
many years, Ms. Carol Blocker, who is the mother of Melanie
Stokes Blocker. She is a person who we are quite proud of in my
city and my district, and she's someone who has remarkable
courage and strength in that her tragic and heartbreaking
tragedy that happened to Melanie Stokes Blocker is--Melanie
Blocker Stokes--she's taken that and she's really become quite
a fighter on behalf of countless other women who suffer from
postpartum psychosis, and postpartum depression, and postpartum
diseases, mental diseases.
And I want to also thank Doctor Stotland, who is renowned
in this field of mental health. She is a former--she is a
professor, practicing psychiatrist and a professor right now in
Chicago, renowned in her capacity, and also in her public
works, published works rather, in this particular area, and I
certainly welcome her testimony.
I want you to, Mr. Chairman, to understand, as I know you
do, that postpartum depression is a very real mental illness
that affects and afflicts millions of women nationwide. and
what we used to naively and thoughtlessly refer to as the
``baby blues'' is a real psychological phenomenon that can lead
to severely destructive behavior on the part of the mother.
Ever since my constituent, the late Melanie Blocker Stokes,
committed suicide after the birth of her child due to
postpartum psychosis, I have become a passionate advocate for
the aggressive treatment of this disease. Because of my
commitment to eradicate this disease, in each of the last 3
years I have introduced H.R. 846, the Melanie Blocker Stokes
Postpartum Depression Research and Care Act. Given the severity
of this issue, Mr. Chairman, I would like to thank you again
and Chairman Barton for holding this important hearing.
It is my opinion that while both issues are important, Mr.
Chairman----
Mr. Bilirakis. Please finish up.
Mr. Rush. [continuing] Mr. Chairman, I ask for unanimous
consent that I be granted a minute of Mr. Towns time.
Mr. Bilirakis. I've heard them all, but I'm not sure I've
heard that one.
Mr. Rush. Yes, well you heard it----
Mr. Bilirakis. Without objection, you have an extra minute.
Mr. Rush. All right.
Mr. Chairman, as you know, nearly 80 percent of new mothers
experience the baby blues, and over 400,000 women suffer from
postpartum mood changes. And, Mr. Chairman, my bill, in a
nutshell, my bill is aimed at addressing this severe problem,
this extreme problem, and my bill, Mr. Chairman, is meant to
expand and intensify the research at the National Institutes of
Health, the National Institutes of Mental Health, and, Mr.
Chairman, I look forward to this hearing, I look forward to the
views of the panelists, and, Mr. Chairman, I look forward to
congressional action on support and passage of the bill that
exists in this subcommittee.
Thank you, and I yield back.
Mr. Bilirakis. The Chair thanks the gentleman.
Mr. Pitts is recognized for 3 minutes.
Mr. Pitts. Thank you, Mr. Chairman, and thank you for
holding this hearing today.
As you know, we talked a long time ago about the importance
of this issue, and I'm glad to see the hearing finally come to
fruition, and I appreciate the Chairman keeping the commitments
made previously.
I'm going to keep my comments short, focus them on the
post-abortion depression, since that is what my bill, H.R.
4543, the Post-Abortion Depression Research and Care Act,
addresses. However, this statement should not be construed as
opposition to the other topic being discussed today.
Mr. Chairman, women have a right to know about the long-
term effects of abortion on their mental and emotional well-
being. There are not many resources on the impact that abortion
has on women, which is a big part of the problem. Abortion has
been done 45 million times in this country since 1973, but
there's very little study on the topic.
Abortion is a medical procedure. Women need to know as much
information about this procedure as they do about any other
medical procedures. We would never tolerate restricted access
to information about other medical procedures we are about to
undergo.
Also, most post-abortion counseling, whether conducted at
an abortion clinic, a pregnancy center, or in a counselor's
office, is not long term. I fear that unless more research is
done on the long-term emotional impact of abortion it will be
difficult for many women to have access to post-abortion
counseling and treatment if they decide they want it.
While the physical impact of abortion has been documented
since Roe v. Wade, the long-term emotional impact to women has
remained largely unexplored. Research on the emotional impact
of giving birth, that is, postpartum depression, and
miscarriage, has been very helpful in developing compassionate
responses and treatment for women who are experiencing these
changes in their lives, and I strongly support continued
research on postpartum depression and miscarriage-related
depression.
However, I believe that we also need to devote better
resources to the research and treatment of post-abortion
depression. No matter what pregnancy outcome a woman chooses,
there should be help made available that speaks to the
emotional issues that she may be encountering.
Mr. Chairman, I would like unanimous consent to insert for
the record Doctor Shadigian's Senate testimony from the March
3, 2004 hearing, on the topic of abortion's impact on women,
plus the studies she references in that testimony.
Mr. Bilirakis. Without objection.
Mr. Pitts. I notice that Doctor Shadigian's prepared
testimony for today focuses on stress related to postpartum
depression, and I'm grateful that we will be hearing one of
those voices of women who have actually had abortions today,
and I want to thank our witnesses, Michaelene Fredenburg and
Doctor Elizabeth Shadigian for testifying today on this very
important issue, and I look forward to their testimony, as well
as the first panel, and yield back the balance of my time.
[The prepared statement of Hon. Joe Pitts follows:]
Prepared Statement of Hon. Joe Pitts, a Representative in Congress from
the State of Pennsylvania
Mr. Chairman, thank you for holding this hearing today. As you
know, we talked long ago about the importance of this issue, and I am
glad to see the hearing has finally come to fruition today.
I am going to keep my comments short and focus them on post
abortion depression, since that is what my bill, HR 4543, The Post
Abortion Depression Research and Care Act, addresses. However, this
statement should not be construed as opposition to the other topic
being discussed today.
Mr. Chairman, women have a right to know about the long-term
effects of abortion on their mental and emotional well-being.
There are not many resources on the impact abortion has on women,
which is a big part of the problem. Abortion has been done 45 million
times in this country since 1973, but there is very little study on the
topic.
Currently, there is no comprehensive system of data collection of
psychological complications resulting from pregnancy, delivery or
abortion.
Although the Centers for Disease Control (CDC) operate an abortion
surveillance program that gathers information from state health
departments and individual hospitals and clinics, these statistics are
not comprehensive. I am sure our witnesses will comment on that further
during their testimony.
Abortion is a medical procedure. Women need to know as much
information about this procedure as they do about any other medical
procedures.
We would never tolerate restricted access to information about
other medical procedures we are about to undergo. Nor should we
tolerate a lack of empirical evidence concerning the potential side-
effects of an abortion.
It is widely acknowledged that medical procedures can affect not
only the patient's physical state but the patient's mental state as
well. We need to be able to document the potential emotional impact of
abortion.
Also, most post-abortion counseling--whether conducted at an
abortion clinic, a pregnancy center, or in a counselor's office--is not
long term.
The limited follow-up that can be provided by an abortion clinic or
pregnancy center is not a comprehensive source of non-anecdotal
information about the emotional effects of abortion.
While using anecdotal information in a peer counseling session may
be helpful, it does not provide the same benefits as empirical
research. The nature of informed consent, now considered standard
procedure, implies that a patient be informed of the potential side-
effects of the procedure based on objective data, not anecdotal
information.
Mr. Chairman I fear that unless more research is done on the long-
term emotional impact of abortion, it will be difficult for many women
to have access to post-abortion counseling and treatment, if they
decide they want it.
Most of the advances in mental health in recent years have been
preceded by an increased awareness of a specific mental health problem.
Accurate research can foster awareness because it makes a problem
concrete.
For instance, by comparing women with different pregnancy outcomes
(miscarriage, live birth/biological mother raising child, live birth/
adoption and abortion), we can better determine what potential
emotional impact abortion produces relative to other pregnancy related
decisions. This information may 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 and not have to struggle alone
for a long period of time.
I am hoping some of our witness will address this very issue today.
Further, Mr. Chairman, While the physical impact of abortion has
been documented since Roe v. Wade, the long-term emotional impact of
abortion has remained largely unexplored.
In recent years, the federal government has called for an increased
focus on the issue of mental health. Now more than ever good mental
health is part of the public debate. Why should women considering
abortion deserve anything less than accurate information concerning the
potential impact of abortion on their mental health? Why should women
who have experienced abortion deserve any less than compassion--and
even treatment--for whatever emotions they may be feelings in
connection with their abortion?
And finally, research on the emotional impact of giving birth (i.e.
post-partum depression) and miscarriage have been very helpful in
developing compassionate responses and treatment for women who are
experiencing these changes in their lives.
I strongly support continued research on post-partum depression and
miscarriage-related depression. However, I believe that we also need to
devote federal resources to the research and treatment of post-abortion
depression. No matter what pregnancy outcome a woman chooses, there
should be help made available that speaks to the emotional issues that
she may be encountering.
Mr. Chairman I would like unanimous consent to insert for the
record Dr. Shadigian's Senate testimony from the March 3, 2004 hearing
on the topic of abortions impact on women plus the studies she
references in that testimony. I noticed that Dr. Shadigian's prepared
testimony for today focuses on stress related to post-partum
depression.
I suspect that those who promote abortion do not want an honest
study on this topic, but those who care about women should be demanding
that we take a look at how abortion impacts women.
The way to start is to hear from women who have actually had
abortions because their voice has not been heard.
I am grateful that we will be hearing one of those voices today. I
want to thank our witnesses Michaelene Fredenburg and Dr. Elizabeth M.
Shadigian, for testifying today on this very important issue.
I look forward to their testimony and yield back the balance of my
time.
______
Emotional impact of abortion, miscarriage varies
By Amy Norton
NEW YORK (Reuters Health)--Although women who have an abortion may
have a lesser immediate emotional reaction than those who miscarry, the
long-term impact may be stronger for some, a new study suggests.
Researchers in Norway found that women who'd had an abortion two
years earlier were more likely than those who'd miscarried to be
suppressing thoughts and feelings about the event--although most women
did not show this reaction.
Overall, nearly 17 percent of 80 women who'd had an abortion scored
highly on a scale measuring such ``avoidance'' symptoms, compared with
about three percent of those who'd miscarried.
That's in contrast to responses 10 days after the miscarriage or
abortion, when nearly half of those who miscarried and 30 percent of
those who had an abortion scored highly on measures of avoidance or
``intrusion,'' which includes symptoms such as flashbacks and bad
dreams.
The findings suggest that women who have an abortion or miscarriage
should be encouraged to talk about their feelings instead of holding
them inside, according to study leader Dr. Anne Nordal Broen.
``We know that suppression of thoughts and feelings connected to an
event is not a healthy way to deal with difficult psychological
responses,'' Broen, a specialist in psychiatry at the University of
Oslo, told Reuters Health.
``It is better to talk about what happened, let the natural
feelings come out,'' she said.
Broen and her colleagues report their findings in the journal
Psychosomatic Medicine.
The study included 120 women between the ages of 18 and 45 treated
at one Norwegian hospital; 80 had an abortion before the 14th week of
pregnancy, and 40 miscarried in the first or second trimester. The
women completed standard questionnaires on avoidance and intrusion
symptoms 10 days, six months and two years after the miscarriage or
abortion.
Broen's team found that women with strong feelings of shame, grief
or loss at the first time point were more likely than others to have
continuing symptoms of avoidance or intrusion two years out.
Broen said this suggests that doctors should be ``extra observant''
of such women over the long term, and be ready to provide them with
more follow-up care. Family and friends, she noted, should also be
prepared to give support.``Women with a miscarriage or an induced
abortion should be encouraged to talk and allow themselves to have
feelings about what happened,'' she said.
SOURCE: Psychosomatic Medicine, March/April 2004.
______
Prepared Statement of Dr. Elizabeth Shadigian, Given at a Science,
Technology, and Space Hearing: Impact of Abortion on Women, Wednesday,
March 3, 2004
M.D., Clinical Associate Professor, Department of Obstetrics and,
University of Michigan Most of the medical literature since induced
abortion was legalized has focused on short-term surgical
complications, surgical technique improvement, and abortion provider
training.
Long-term complications had not been well studied as a whole, until
now, due to politics--specifically, the belief that such studies would
be used either to limit or expand access to abortion. The two
commissioned studies that attempted to summarize the long-term
consequences of induced abortion concluded that future work should be
undertaken to research long-term effects.
The political agenda of every researcher studying induced abortion
is questioned more than in any other field of medical research.
Conclusions are feared to be easily influenced by the author's beliefs
about women's reproductive autonomy and the moral status of the unborn.
Against this backdrop of politics is also a serious epidemiological
concern: researchers can only observe the effects of women's
reproductive choices, since women are not exposed to induced abortion
by chance. Because investigators are deprived of the powerful tool of
randomization to minimize bias in their findings, research must depend
on such well-done observational studies. These studies depend on
information from many countries and include legally mandated registers,
hospital administrative data and clinic statistics, as well as
voluntary reporting (or surveys) by abortion providers.
Approximately 25% of all pregnancies (between 1.2-1.6 million per
year) are terminated in the United States, so that if there is a small
positive or negative effect of induced abortion on subsequent health,
many women will be affected.
A recent systematic review article critically assesses the
epidemiological problems in studying the long-term consequences of
abortion in more detail. It should be kept in mind that: 1) limitations
exist with observational research; 2) potential bias in reporting by
women with medical conditions has been raised and refuted; 3) an
assumption has been made that abortion is a distinct biological event;
4) inconsistencies in choosing appropriate comparison groups exist; and
5) other possible confounding variables of studying abortion's effects
over time also exist.
Nonetheless, given the above caveats, my research, which included
individual studies with no less than 100 subjects each, concluded that
a history of induced abortion is associated with an increased long-term
(manifesting more than two months after the procedure) risk of: 1)
breast cancer 2) placenta previa 3) preterm birth and 4) maternal
suicide.
Outcomes Not Associated with Induced Abortion
Induced abortion has been studied in relation to subsequent
spontaneous abortion (miscarriage), ectopic pregnancy, and infertility.
No studies have shown an association between induced abortion and later
spontaneous abortion. An increase in ectopic or tubal pregnancies was
seen in only two out of nine international studies on the topic, while
only two out of seven articles addressing possible subsequent
infertility showed any increased risk with induced abortion.
OUTCOMES ASSOCIATED WITH INDUCED ABORTION
1. Breast Cancer
Based upon a review of the four previously published systematic
reviews of the literature and relying on two independent meta-analyses,
(one published and one unpublished ), induced abortion causes an
increased risk of breast cancer in two different ways. First, there is
the loss of the protective effect of a first full-term pregnancy
(``fftp''), due to the increased risk from delaying the fftp to a later
time in a woman's life. Second, there is also an independent effect of
increased breast cancer risk apart from the delay of fftp.
The medical literature since the 1970s has shown that a full-term
delivery early in one's reproductive life reduces the chance of
subsequent breast cancer development. This is called ``the protective
effect of a first full term pregnancy (fftp).'' This is illustrated in
Figure 1 which uses the ``Gail Equation'' to predict the risk of breast
cancer for an 18 year-old within a five-year period and also within a
lifetime. The Gail Equation is used to help women in decision-making
regarding breast cancer prevention measures.
In the first scenario, the 18 year-old decides to terminate the
pregnancy and has her fftp at age 32, as compared to the 18 year-old in
the second example who delivers at term. The individual risk of these
women is then assessed when the risk of breast cancer peaks. As figure
1 shows, having an abortion instead of a full-term pregnancy at age 18
can almost double her five-year and lifetime risk of breast cancer at
age 50, regardless of race.
An independent effect of increased breast cancer risk apart from
the delay of first full-term pregnancy has been controversial. Four
published review articles have been written. Two of the reviews found
no association between induced abortion and breast cancer, while one
paper found a ``small to non-significant effect.'' The sole published
meta-analysis reported an odds-ratio (``OR'') for breast cancer of 1.3
(or 95% CI=1.2, 1.4) in women with a previous induced abortion. One yet
unpublished independent meta-analysis found the OR=1.21 (95% CI=1.00,
1.45). Brind et al. used older studies and translated non-English ones.
He did not exclude any studies and used a different statistical
approach. The unpublished study used exclusion criteria and only
English language studies. Another finding was that breast cancer is
increased if the abortion is performed before a first full term
pregnancy. Brind found an OR=1.4 (95% CI=1.2, 1.6), while the
unpublished study showed an OR=1.27 (95% CI=1.09-1.47). The two meta-
analyses used different methodologies, but reported nearly equivalent
results, which are statistically significant, and do show that induced
abortion is a independent risk factor for breast cancer.
Some other findings from individual research papers included in my
review concluded that the risk of breast cancer increases with induced
abortion when: (a) the induced abortion precedes a first full term
pregnancy; (b) the woman is a teen; (c) the woman is over the age of
30; (d) the pregnancy is terminated at more than 12 weeks gestation; or
(e) the woman has a family history of breast cancer. One researcher
(Daling) also reported, in her study, that all pregnant teens with a
family history of breast cancer who aborted their first pregnancy
developed breast cancer.
2. Placenta Previa
``Placenta previa'' is a medical condition of pregnancy where the
placenta covers the cervix, making a cesarean section medically
necessary to deliver the child. In general, this condition puts women
at higher risk, not just because surgery (the c-section) is necessary,
but also because blood loss is higher, and blood transfusions may be
necessary. There is also a higher risk of hysterectomy (the loss of the
uterus), and therefore the need for more extensive surgery.
Three studies with over 100 subjects each were found examining
induced abortion and placenta previa, as well as one meta-analysis. The
three studies found a positive association, as did the meta-analysis.
Induced abortion increased the risk of placenta previa by approximately
50%.
3. Pre-Term Birth (``PTB'')
Twenty-four studies explored associations between abortion and pre-
term birth or low birth weight (a surrogate marker for pre-term birth).
Twelve studies found an association which almost doubled the risk of
preterm birth. Moreover, seven of the twelve identified a ``dose
response effect'' which means a higher risk for pre-term birth for
women who have had more abortions.
``Also notable is the increased risk of very early deliveries at
20-30 weeks (full-term is 40 weeks) after induced abortion, first noted
by Wright, Campbell, and Beazley in 1972. Seven subsequent papers
displayed this phenomenon of mid-pregnancy PTB associated with induced
abortion. This is especially relevant as these infants are at high risk
of death shortly after birth (morbidity and mortality), and society
expends many resources to care for them in the intensive care unit as
well as for their long-term disabilities. Of particular note are the
three large cohort studies done in the 1990s, 20 to 30 years after
abortion's legalization. Each shows elevated risk and a dose response
effect. Because these studies were done so long after legalization, one
would assume that the stigma of abortion that might contribute to
under-reporting would have waned.''
4. Suicide
Two studies have shown increased rates of suicide after induced
abortion, one from Finland and one from the United States. The Finnish
study (by Gissler et al.) reported an OR=3.1 (95%CI=1.6,6.0) when women
choosing induced abortion were compared to women in the general
population. The odds ratio increased to 6.0 when women choosing induced
abortion were compared to women completing a pregnancy. The American
study (by Reardon et al.) reported recently that suicide RR=2.5
(95%CI=1.1, 5.7) was more common after induced abortion and that deaths
from all causes were also increased RR=1.6 (95%CI=1.3, 7.0).
In addition, self-harm is more common in women with induced
abortion. In England psychiatric hospital admissions because of suicide
attempts are three times more likely for women after induced abortion,
but not before.
Maternal Mortality
There is no mandatory reporting of abortion complications in the
U.S., including maternal death. The Centers for Disease Control (CDC)
began abortion surveillance in 1969. However, the time lag in CDC
notification is greater than 12 months for half of all maternal deaths.
Maternal deaths are grossly underreported, with 19 previously
unreported deaths associated with abortions having been identified from
1979-1986. The CDC quotes approximately one maternal death for every
100,000 abortions officially, which is death between the time of the
procedure and 42 days later. Therefore, statements made regarding the
physical safety of abortion are based upon incomplete and inaccurate
data.
Many women are at much higher risk of death immediately after an
induced abortion: for example, black women and minorities have 2.5
times the chance of dying, and abortions performed at greater than 16
weeks gestation have 15 times the risk of maternal mortality as
compared to abortions at less than 12 weeks. Also, women over 40 years
old, as compared to teens, have three times the chance of dying.
Late maternal mortality, which includes deaths occurring after the
first 42 days following abortion are not reflected in CDC numbers, nor
are data from all 50 states, because reporting is not currently
mandatory. To accurately account for late maternal mortality, maternal
suicides and homicides, breast cancer deaths and increased caesarian
section deaths from placenta previa and pre-term birth would also be
included with other abortion-related mortality.
Informed Consent
Health care providers are obliged by law to inform patients of the
benefits and risks of the treatment being pondered before a medical
decision is made. In the case of a woman deciding to terminate a
pregnancy, or undergoing any surgery or significant medical
intervention, informed consent should be as accurate as possible.
Induced abortion is associated with an increase in breast cancer,
placenta previa, pre-term birth and maternal suicide. Maternal deaths
from induced abortion are currently underreported to the Centers for
Disease Control. These risks should appear on consent forms for induced
abortion, but currently are not.
American College of Obstetricians and Gynecologists (ACOG)
In the most recent edition of medical opinions set forth by the
American College of Obstetricians and Gynecologists (Compendium of
Selected Publications, 2004, Practice Bulletin #26), ACOG inexplicably
states:
``Long-term risks sometimes attributed to surgical abortion
include potential effects on reproductive functions, cancer
incidence, and psychological sequelae. However, the medical
literature, when carefully evaluated, clearly demonstrates no
significant negative impact on any of these factors with
surgical abortion.'' (Italics added for emphasis)
I am a proud member and fellow of ACOG. Because of groups like ACOG
American women enjoy some of the best health, and health care, in the
world. However, I am deeply troubled that ACOG makes assurances to
their membership, and to women everywhere, claiming a lack of long-term
health consequences of induced abortion. Instead, ACOG should be
insisting that these long-term health consequences appear on abortion
consent forms.
Why doesn't ACOG insist that long-term health consequences of
induced abortion be included?
ACOG seems to claim that they have adequately evaluated the medical
literature, but they do not consider our study nor the many older
studies we evaluated. This situation is akin to the early studies that
indicated that cigarette smoking was linked to heart disease and lung
cancer in the 1950's and 1960's. Eventually, larger, improved studies
were funded that could thoroughly assess the health effects of smoking.
We are at a similar crossroads for women today--just as we were
regarding smoking and long-term health effects in the 1950's and
1960's.
Conclusion A clear and overwhelming need exists to study a large
group of women with unintended pregnancies who choose--and do not
choose--abortion. If done properly, a dramatic advance in knowledge
will be afforded to women and their health care providers--regardless
of the study's outcome. A commitment to such long-term research
concerning the health effects of abortion including maternal mortality
would seem to be the morally neutral common ground upon which both
sides of the abortion/choice debate could agree.
In the meantime, there is enough medical evidence to inform women
about the long-term health consequences of induced abortion,
specifically breast cancer, placenta previa, pre-term birth, and
maternal suicide. They should also be informed of the inadequate manner
in which maternal death is reported to the government, thus grossly
underestimating the risk of death from abortion.
I applaud this subcommittee for taking on such a politically
difficult topic in an effort to show women the respect they deserve by
supplying them with accurate medical information.
Mr. Bilirakis. The Chair thanks the gentleman.
The gentlelady from Colorado, Ms. DeGette, for an opening
statement.
Ms. DeGette. Thank you, Mr. Chairman.
I would like to at least thank the Chairman for agreeing to
two separate panels today, for what are clearly two very
separate issues.
At first, I was perplexed why these two bills were being
lumped together at one hearing. But then I realized, well, they
both deal with women, pregnancy and depression, so what the
heck, I guess they must be the same.
Unfortunately, though, what the hearing does, it conflates
one issue on which there is broad scientific evidence, and that
one is postpartum depression, and it conflates it with a highly
specious topic with almost no scientific basis, that of so-
called post-abortion syndrome.
Now, I can understand attempts to muddy the waters, but
let's not mistake and confuse these two issues. To do so would
be to fall victim to the worst sort of rhetorical folly and
political theater, and I know that that is not in the best
interest of this committee or this Congress.
As my colleagues have pointed out, professional medical
associations have concluded that so-called post-abortion
syndrome does not exist. Neither the American Psychological
Association, nor the American Psychiatric Association's DSM IV,
the definitive manual of mental illnesses and psychological
phenomena, recognize so-called post-abortion syndrome or any
related category as an identifiable mental health condition.
Further, the American Psychological Association assembled a
panel of experts in 1989 to review the evidence of
psychological risks of abortion. The panel unanimously
concluded that legal abortion, ``does not create psychological
hazards for most women undergoing the procedure,'' and that
there is no evidence of such an epidemic. That was in 1989.
Since that time, there has been no significant change in this
point of view.
By way of contrast, of course, postpartum depression, has
been widely recognized in the medical profession. Every year
over 400,000 women suffer from postpartum mood changes with
baby blues affecting up to 80 percent of new mothers.
Postpartum mood and anxiety disorders impair around 10 to 20
percent of new mothers, and postpartum psychosis strikes one in
1,000 new mothers. This is a serious problem.
I'd like to thank my colleague, Mr. Rush, for bringing it
to our attention. I think that we should really be looking as a
Congress for ways that we can help all of these women with an
identifiable medical problem that really needs to be solved.
And, in conclusion, as the Co-Chair of the Pro Choice
Caucus in Congress, I know we work on these difficult and
complex issues. And so, therefore, I do look forward to hearing
the testimony, but I think we should keep our eye on scientific
reality and avoid political rhetoric.
Thank you.
Mr. Bilirakis. The Chair recognizes the gentleman from
Mississippi, Mr. Pickering, for an opening statement.
Mr. Pickering. Mr. Chairman, I thank you for having this
hearing, and I think the issues of postpartum depression, as
well as post-abortion depression, are something that we need to
understand as a Nation and as a people, to be able to address
those needs both emotionally, psychologically, and from a
health perspective. There must be policies and forms of
assistance to mothers at this critical time.
So, I thank you for this hearing, I look forward to hearing
the testimony today.
Mr. Bilirakis. The Chair thanks the gentleman.
Mr. Towns, the gentleman from New York, for an opening
statement.
Mr. Towns. Thank you very much, Mr. Chairman.
Let me begin by thanking you for holding this hearing, and
thanking my good friend and colleague, Bobby Rush, for pushing
for the hearing, and to thank the chairman of the full
committee for also agreeing that the hearing should take place
after the commitment was made by the former chairman. So, I
want to thank all of you for that.
And also, I encourage us to move forward with an open mind,
let's move forward in a team approach, because this is a
serious problem, and we have to recognize that. And, I think
that if we have an open mind that we can listen to our
witnesses, Doctor Stotland, and, of course, Ms. Blocker, and
maybe we can learn something and be able to do something that
might be able to save a lot of people, because as you know this
issue is out there, and we need to address it in a very strong
and professional manner.
You know, I am very concerned about it. I'm a trained
social worker by profession, so I have a real interest in this,
because I know that there's a lot of people out there that are
suffering and that we can do something about it by having the
proper legislation here in the House.
And, I think that Mr. Rush's legislation will be able to
assist us in that, but here again we need to hear from our
witnesses with an open mind and be in a position to take that
information and try and make the bill as strong as we possibly
can, because we are dealing with families. A lot of people are
hurting. And, of course, we need to try to eliminate pain
whenever we can.
I think that's why people send us here, I think they send
us to Congress to do that. I think that we need to sort of keep
that in mind, and we should not make this political. I mean,
this is more than that. I think that to try and jump on from a
political point of view, would be providing a great disservice
to so many people in this country.
So, I'm hoping that on both sides of the aisle that you
will hold your powder and open your ears and listen.
Thank you, and I yield back.
Mr. Bilirakis. And, I thank the gentleman for his very wise
statement, and I, too, am appreciative to Mr. Rush for bringing
this. I mean, this is a real world problem, and he has been a
strong proponent of the issue for a long, long time. We should
appreciate the fact that he's making us much more aware of it
than maybe we were before.
I will say that in the past we have often held hearings
where we mixed issues, if you will, and in the interest of time
and that sort of thing, so I don't know why, you know, there
happens to be a problem here that we've decided to put these
two issues together. They are both involving, obviously, post
pregnancy depression and both involve women. So, yes, this is
why we've done what we have.
Mr. Green, for an opening statement.
Mr. Green. Thank you, Mr. Chairman and Ranking Member
Brown, for holding this hearing to examine depression and
mental health after pregnancy.
My statement and witness questions today are focused
primarily on postpartum depression, the pervasive condition
that deserves the full attention of this subcommittee, without
being clouded by politically motivated discussion about
abortion.
Postpartum depression affects a majority of American
families in one way or another, whether it's in the form of the
baby blues, clinical depression or psychosis.
In my hometown of Houston, we learned all too well the
dangers as a result of undiagnosed or mistreated postpartum
depression. In 2001, Andrea Yates drowned her five children and
was sentenced to life in prison in Texas. A native Houstonian,
and valedictorian of Milby High School in my district, Andrea
had everything going for her and a bright future as a
registered nurse at the top cancer center in the country. Yet,
Andrea's adult years were filled with warning signs about her
tendencies toward depression and psychosis. Because of her
history of suicide attempts, hospitalizations, drug therapies
for her depressive episodes, doctors warned her that additional
children would 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 my community in Houston, but our nation. Sadly,
families all across America are dealing with effects of
postpartum depression and psychosis, and they 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, and I
would suggest that also to their husbands, 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 the subcommittee, however, we can take
action, not only with this legislation today, but a majority of
this Congress has co-sponsored Representative Kennedy's bill to
provide equal insurance coverage for mental health benefits,
and we know the support is there, so let's pass this bill and
put our money where our mouths are, 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. These thoughts resulted, not
only from the 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.
I want to thank our witnesses for appearing today, and
particularly appreciate Ms. Blocker's willingness to share her
family's story with the subcommittee. I can only imagine the
pain that you must relive each time you tell your daughter's
story. However, please know that you are doing a world of good
in educating us and the public about this important issue.
Thank you, Mr. Chairman, I yield back my time.
Mr. Bilirakis. I thank the gentleman.
Ms. Capps, for an opening statement.
Ms. Capps. Thank you, Mr. Chairman. I appreciate the
opportunity to look at the issue of postpartum depression.
Approximately, 400,000 women will experience postpartum
depression this year. So many of them don't even know that they
need help. A condition that can put such terrible strain on
families just at the time when they expect to be able to revel
in the joy of the birth of a child.
As a nurse for many years, I've seen firsthand how much
women, their families, and their partners, struggle with this
difficult condition. Unfortunately, it's been noted there is a
great stigma associated with postpartum depression, as many
women feel so ashamed of the feelings that they are
experiencing, which mainly comes about because so many of us
don't fully understand the condition.
In the 106th Congress, I worked with Congressman Jack
Kingston to pass a resolution in the Congress to bring more
attention to this condition, and I want to publicly acknowledge
a constituent of mine, Jane Honiquan, who founded, a couple
decades ago, Postpartum Depression International, and has
worked so tirelessly to remove the stigma from the situation.
The resolution we passed here called on hospitals to
provide new mothers with information on this problem before
their discharge. I'm so proud this year to co-sponsor Mr.
Rush's bill to instruct NIH and the National Institutes of
Mental Health to expand their research into postpartum
depression and to provide grants for support services, and I
commend Mr. Rush's constituent for being willing to talk about
this issue today.
However, this hearing seems to be equating the documented
illness of postpartum depression with that of a so-called post-
abortion depression. It's so unfortunate, because there is
little, if any, evidence in the scientific literature that
post-abortion depression exists.
For example, Surgeon General C. Everett Koop conducted an
exhaustive review of the science on this issue, despite intense
political pressure and his own views opposing choice, he found
that the psychological effects of abortion are minuscule from a
public health perspective.
The American Psychological Association, the Journal of
American Medical Association likewise, has found no evidence of
post abortion depression, and the American Psychological
Association's DSM-IV, the definitive manual on mental illness,
does not have a category, does not even recognize post abortion
depression. That's not to say that women facing a troubled or
unwanted pregnancy, including those who choose termination, do
not suffer great anguish, and many of them, some of them may
have pre-existing depression.
Despite anti-choice rhetoric to the contrary, choosing an
abortion, choosing to have an abortion, is not a decision that
women take lightly. Indeed, it is precisely the gravity with
which women approach this issue that should give politicians
and anti-choice activists pause before they choose to dictate
the choices that should be made for women.
Like the unsubstantiated claims linking breast cancer to
abortion, the claims of abortion causing mental illness are
just another weapon, a political ploy, in the fight to make all
abortions illegal. It's truly unfortunate because there are
women who do need our help, whether they choose to carry their
pregnancies to term or not. Our time would be much better spent
helping them, rather than looking for another reason to take
the right of choice away from them.
Thank you.
Mr. Bilirakis. The Chair thanks the gentlelady.
[Additional statement submitted for the record follows:]
Prepared Statement of Hon. Charlie Norwood, a Representative in
Congress from the State of Georgia
Thank you Chairman Bilirakis for calling this subcommittee hearing
to discuss issues concerning ``women's health.'' Of course, we all know
that women's health is everyone's health.
Pregnancy is a powerful event in every woman's life--and it can
have lasting effects. Unfortunately, some the effects can be negative,
such as depression or postpartum psychosis. I believe today's hearing
will be extremely enriching because the aforementioned diseases afflict
many women during and after their pregnancy. For instance, many don't
know that most mothers fight a bout with ``baby blues;'' one in ten
mothers are diagnosed with postpartum depression; and an estimated one
to 500 to 1,000 mothers are diagnosed with postpartum psychosis. The
most unfortunate fact is that these diseases are often terribly under-
diagnosed. I am pleased that we are doing our part to discuss these
issues and advance the issues of women's health. I am sure that all of
here would agree that in order to have a health society, we must have
healthy women.
I look forward to hearing from the witnesses before this committee
today, and I yield back the balance of my time.
Mr. Bilirakis. Let's move on to our panel now.
Ms. Blocker and Doctor Stotland, your written statement is
a part of the record, we would hope that you would sort of
supplement it, complement it, if you will, orally.
Ms. Blocker, we'll start off with you, and we'll set the
clock at 5 minutes. Please proceed, Madam. And again, thank you
for having the courage to be here.
STATEMENTS OF CAROL BLOCKER; AND NADA L. STOTLAND, PROFESSOR
OF PSYCHIATRY AND PROFESSOR OF OBSTETRICS AND GYNECOLOGY, RUSH
MEDICAL COLLEGE
Ms. Blocker. Okay.
Mr. Chairman and members of the subcommittee, my name is
Carol Blocker, and I am the mother of Melanie Blocker Stokes.
My daughter took her life on June 11, 2001, less than 5 months
after giving birth to her first daughter, my grandchild, Sommer
Skyy. I am here this afternoon to ask for the committee's
support for H.R. 846, the Melanie Blocker Stokes Postpartum
Depression Research and Care Act, introduced on February 13,
2003 by Congressman Bobby Rush, a distinguished member of this
committee.
Congressman Rush introduced this legislation after hearing
my daughter's story, which I would like to share with the
members of the committee today.
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 Doctor Sam Stokes.
Sam and Melanie were so happy in their marriage and their
lives together, and 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, and my daughter's
pregnancy was normal.
But, 6 weeks after my daughter 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 normally. 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, and he said, well, she's
suffering from postpartum depression.
Over the next 7 weeks Melanie was hospitalized three times,
and each time the doctors prescribed different combinations of
anti-depression, anti-anxiety and anti-psychotic medications,
but Melanie's depression had deepened to the point that she
wouldn't or couldn't take the pills. She talked about suicide
and looked for ways to harm herself. Once she even asked her
brother to buy her a gun. Another time she took the screens out
of my high-rise apartment windows while visiting me.
And another time we found that she had snuck away from her
home and tried to drown herself in Lake Michigan. Each time we
went back to the doctor sand 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, on the news,
pleading, ``Melanie, please come home. I need you. You baby
needs you.'' But Melanie didn't answer.
While we searched, Melanie went to a hotel in Chicago and
talked a clerk into letting her 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 window on the twelfth floor
of a hotel to her death. And I think my heart died that day.
After hearing my daughter's story, Congressman Rush, a
member of this distinguished committee, 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 to recognize, understand and treat this terrible
syndrome--postpartum psychosis--that affects about one in 1,000
new mothers. The symptoms, many which my daughter exhibited,
including losing touch with reality, distorted thinking,
delusions, hyperactivity and mania. The psychosis became like a
monster that entered my daughter's brain, and it could not be
controlled.
Even in the milder forms of postpartum depression, this
disease manifests itself with lack of interest in a newborn
child, fear of harming the child, fatigue, sadness,
hopelessness, guilt, inadequacy and worthlessness. Some
research indicates that between 50 percent and 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.
From our discussions, and from discussions with many
physicians and health practitioners, he developed and
introduced the Melanie Blocker Stokes Postpartum Depression
Research and Care Act. The legislation 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. The bill will also provide money to deliver services
to individuals and their families who suffer from a postpartum
depression and postpartum psychosis.
Mr. Chairman, if this legislation had been in place in
2001, maybe we would have been able to recognize my daughter's
trouble and prevent her death. Maybe my granddaughter would
have her mommy today. My granddaughter calls both me and her
aunt, ``Mama,'' and we are mothering her with all of the love
and energy that we have. But I notice that when other people
look at Sommer, and they know her story, there is sadness in
their eyes. They know, like I know, that Sommer deserved to
have a mother, and her mother deserved to have her daughter.
Mr. Chairman and members, I hope and pray that this
committee will finally act on this legislation to spare
countless of other women and their families from the horrible
consequences of this disease.
Thank you.
[The prepared statement of Carol Blocker follows:]
Prepared Statement of Carol Blocker
My name is Carol Blocker and I am the mother of Melanie Blocker
Stokes. My daughter took her life on June 11, 2001, less than five
months after giving birth to her first child--my granddaughter, Sommer
Skyy. I am here this afternoon to ask for the Committee's support for
H.R. 846, the Melanie Blocker Stokes Postpartum Depression Research and
Care Act, introduced on February 13, 2003 by Congressman Bobby Rush, a
distinguished member of this Committee.
Congressman Rush introduced this legislation after hearing my
daughter's story, which I would like to share with the members of the
Committee today.
My daughter, Melanie, was born and raised in the city of Chicago.
As both a child and adult, she was beautiful and accomplished and the
light of my life. We educated her at St. George private school in Hyde
Park, Immaculata High School in Chicago, and Spelman College in
Atlanta. 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 married Dr. Sam Stokes.
Sam and Melanie, were so happy in their marriage and their lives
together and even happier when they learned, in 2000, that a child was
on the way. The whole family, Sam's family and ours, where ecstatic
when my granddaughter--who Melanie named Sommer Skyy--was born on
February 23, 2001, after my daughter's normal pregnancy.
But, six weeks after my daughter gave birth, at the routine six
week postpartum checkups, she said that she felt ``hopeless'' and
retreated to her room. We couldn't get her back to the doctor, back to
her job or back to the world.
One day, I found her in her bedroom, hollow-eyed and gaunt, rocking
in her glider. Her lips and tongue were peeling from malnutrition,
because Melanie was not eating or sleeping normally. When I went to her
bathroom to get her a cold towel, I found a butcher knife. I asked
Melanie, ``What are you going to do with this?'': she looked at me and
said she didn't know, but thought she would have to die.
At that moment, I knew that something was very, very wrong with
Melanie and I called her doctor, who said that she was suffering from
postpartum depression--two words that I had never heard before.
Over the next seven weeks, Melanie was hospitalized three times--
each time the doctors prescribed different combinations of
antidepressant, anti-anxiety and anti-psychotic medications. But,
Melanie's depression had deepened to the point that she wouldn't--or
couldn't--take her pills. She talked about suicide and looked for ways
to harm herself. Once, he 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 sneaked away from her home
and tried to drown herself in Lake Michigan. Each time, we went back to
her doctors 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 still I was worried, and my fears were
founded.
On the night before Melanie disappeared, I told her husband Sam,
``Don't 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 six 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 us.
While we searched, Melanie went to a hotel in Chicago and talked a
clerk into letting her into a room on the twelfth floor. There she
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 the 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 window on the twelfth floor of a hotel, to
her death. My own heart died that day.
After hearing my daughter's story, Congressman Bobby Rush, a member
of this distinguished Committee, 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 to recognize, understand and
treat this terrible syndrome--a postpartum psychosis--that affects an
estimated one in 1,000 new mothers? The symptoms, many which my
daughter exhibited, include losing touch with reality, distorted
thinking, delusions, hyperactivity and mania: the psychosis became like
a monster that entered my daughter's brain, and could not be
controlled.
Even in its milder forms, postpartum depression 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 percent and 75 percent of all
new mothers suffer with these ``baby blues,'' yet little is known about
how we, as families, can prevent the tragic consequences that fell on
my family.
From our discussions, and from discussions with many physicians and
health practitioners, he developed and introduced the Melanie Blocker
Stokes Postpartum Depression Research and Care Act. The legislation
will expand and intensify research at the National Institutes of Health
and National Institutes of Mental Health on the causes, diagnoses and
treatments of postpartum depression and postpartum psychoses and
provide money to deliver services to individuals and their families who
suffer from a postpartum depression and postpartum psychosis.
Mr. Chairman, if this legislation had been in place in 2001, maybe
we would have been able to recognize my daughter's trouble and
prevented her death. Maybe my granddaughter would have her mother
today. My granddaughter calls both me and her aunt, ``Mama,'' and we
are mothering her with all of the love and energy that we have. But, I
notice that when other people look at Sommer, and they know her story,
there is sadness in their eyes. They know, like I know, that Sommer
deserved to have a mother--and her mother deserved to have her
daughter.
Mr. Chairman and members, I hope--I pray--that this Committee will
finally act on this legislation to spare countless of other women and
their families from the horrible consequences of this disease.Thank
you.
Mr. Bilirakis. Thank you so much, Ms. Blocker.
Doctor Stotland, proceed.
STATEMENT OF NADA L. STOTLAND
Ms. Stotland. Good afternoon, Chairman Bilirakis and
members. I am Nada Stotland, M.D. I'm a psychiatrist speaking
today on behalf of the American Psychiatric Association and
Physicians for Reproductive Choice and Health. And, as was
mentioned, I'm Professor of Psychiatry and Obstetrics and
Gynecology at Rush Medical College in Chicago.
My written testimony addresses the general epidemiologic
data about mental illness in women. As you know, this is a
major national health problem. I commend the subcommittee for
focusing in general on post-pregnancy mental health in women,
and particularly, I greatly appreciate the leadership of my own
Congressman, Representative Bobby Rush, in calling attention to
the consequences of untreated postpartum depression.
We tend to use psychiatric terms, such as depression and
psychosis, imprecisely, so let me briefly discuss these
illnesses in the context of the Diagnostic and Statistical
Manual of Mental Disorders, the internationally recognized
standard for the diagnosis of mental disorders. Depression is
classified in DSM by severity, recurrence and association with
mania. Major depression is a serious illness typified by a
depressed mood most of the day, nearly every day, for at least
2 weeks, markedly diminished interest or pleasure in nearly all
activities, weight loss or increased appetite, insomnia or
hypersomnia, fatigue and recurrent thoughts of death or
suicide.
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.
With those definitions in mind, I'd like to say a quick
word about postpartum disorders before discussing ``so-called
post-abortion depression and psychosis.''
Today we know that disturbances can occur in the postpartum
period in the form of transeunt baby blues, or much more
seriously as postpartum depression and psychosis. As you have
heard today, left undiagnosed or untreated, the consequences of
postpartum psychosis can be horrific. We need more attention to
these illnesses, particularly in populations that traditionally
have restricted access to health and mental health care. So-
called ``post-abortion depression and psychosis'' are, however,
created designations by those who believe that abortions can
have a long-term impact on the mental health of humans who
elect to terminate a pregnancy.
In fact, data clearly shows that the vast majority of women
have abortions without psychiatric sequelae. Even C. Everett
Koop, M.D., who was President Reagan's Surgeon General and was
personally very much opposed to abortion, found that, ``The
psychological effects of abortion are minuscule from a public
health perspective.'' This is clear. Abortions are not a
significant cause of mental illness.
The psychological outcome of abortion is optimized when
women are able to make decisions on the basis of their own
values, beliefs and circumstances, free from pressure or
coercion, and to have those decisions supported by their
families, friends and society in general.
This is not to say that there aren't any women who feel
deeply distressed about having abortions, but it does not
follow that there is a causal link between abortion and severe
mental or physical illness. Self-selected accounts of post-
abortion distress, however personally compelling, are not
scientific studies. Unwanted pregnancy is a major stressor in a
woman's life. The strongest predictors of poor post-abortion
psychological outcomes is a pre-pregnancy history of
depression. Other factors can include whether the pregnancy is
terminated because of medical or genetic risks or
complications, or a feeling that the decision to abort was not
freely made.
Let me make a few specific observations about many of the
primary arguments put forward by some who support this
unscientific nomenclature of ``post-abortion depression'' and
so-called ``post-abortion psychosis.'' First of all, the terms
confuse emotions with psychiatric illnesses. Sadness, grief and
regret follow some abortions for very understandable reasons.
These are not diseases. Again, the literature shows that
abortion does not result in post-abortion psychopathology.
Second, supporters of this nomenclature do not distinguish
women who terminate unwanted pregnancies from those who have to
terminate wanted pregnancies because of threat to their own
health, or serious malformations in their fetuses. These
circumstances are stressors independent of the abortion itself.
Next, the arguments overlook an obvious reality: only
pregnant women have abortions. These arguments fail to compare
the aftereffects of abortion with the aftereffects of
pregnancy, labor and child birth. Full-term pregnancy is
associated with considerably greater medical and psychiatric
risk than with abortion.
Next, assertions that abortion causes mental illnesses do
not take into account the reasons women become pregnant when
not intending to have babies, and the reasons pregnant women
decide to have abortions, nor do they acknowledge that pre-
existing mental health issues can have a significant impact on
post-abortion outcomes, the most powerful impact.
And last, some articles I've seen assume that all women who
have abortions require mental health intervention. There is
simply no evidence that women seeking abortions need more
mental health intervention than people facing other medical
procedures.
With regard to general health issues, there is much
misinformation about medical sequelae of abortions. Breast
cancer is a good example. The most highly regarded, and
methodologically sound study, on the purported link between
abortion and breast cancer, indicates that there is no
relationship between induced abortion and breast cancer.
Mr. Chairman, as a woman, as a physician, and particularly
as a psychiatrist, I have great sympathy and compassion for all
of my patients, women and men, adults and adolescents, who
struggle with mental illnesses, but we don't do women any
favors when we encourage the representation as psychiatric
disorders, those alleged conditions which data show have little
basis in fact. Confusing feelings of sadness and regret with
psychosis is not helpful to the profession or to the millions
of women coping with mental illness.
Today, too many women, men and children, needing treatment
for mental illnesses lack access to adequate mental health
services. If this Congress wants to take one single action that
would make a world of difference for all women, for all
persons, needing mental health care, I respectfully suggest
that Congress should promptly pass legislation to end
discriminatory coverage of treatment of mental illnesses.
Thank you again for the opportunity to speak with you
today. I would be happy to answer any questions you or other
members of the subcommittee may have. Thank you.
[The prepared statement of Nada L. Stotland follows:]
Prepared Statement of Nada L. Stotland, Professor of Psychiatry and
Professor of Obstetrics and Gynecology, Rush Medical College
Good afternoon, Chairman Bilirakis, Ranking Member Brown, and
members of the Health Subcommittee. Thank you for allowing me 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 am also Professor of Psychiatry and Professor of Obstetrics and
Gynecology at Rush Medical College. I have devoted most of my career 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
35,000 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. I also speak
today as a Board member of Physicians for Reproductive Choice and
Health (PRCH), which represents more than 6,300 physician and non-
physician members nationally. PRCH is a national not-for-profit created
to enable concerned physicians to take a more active and visible role
in support of universal reproductive health. PRCH is committed to
ensuring that all people have the knowledge, access to quality
services, and freedom of choice to make their own reproductive health
decisions.
By way of personal background, my interest began with the
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.
I commend the Subcommittee for holding this important hearing and
for attempting to keep the focus on a general discussion of post
pregnancy mental health in women. Let me say at the outset that I
appreciate the Chairman's stated hope that we can explore the frank
differences between some of the witnesses with a mutually respectful
examination of the facts.
Before I begin my testimony, I want to take a brief moment to say
that I was delighted to meet with my Congressman--Representative Bobby
Rush--before today's hearing, and I was pleased to have been invited by
Representative Rush to speak before the Congressional Black Caucus
symposium on postpartum depression in 2001. I greatly appreciate his
leadership on this vital issue, particularly with respect to the impact
of untreated depression in minority populations, including minority
women. This is an important and sorely neglected issue.
Mental Health Issues and Women:
Before focusing on post-pregnancy depression, it would be useful to
discuss some general issues related to women's mental health. Burt and
Hendrick, writing in their ``Concise Guide to Women's Mental Health,''
put it succinctly, noting that ``Women use more health care services
than any other group in the United States. They make more visits to
doctors' offices than do men, fill more prescriptions, have more
surgeries . . . and spend two out of every three health care dollars.''
Specific gender differences in the prevalence of mental illnesses
in the United States are well recognized. This is true of prevalence
rates for some disorders, but also in the way in which some disorders
present at the diagnostic interview, and also in comorbidities. For
example, not only are depression and dysthymia (a chronic form of
depression) more common in women than men, but both are more likely to
be accompanied by anxiety disorders in women than men. And the features
of psychiatric illnesses present in women are likely to be different
than when present in men.
The landmark Surgeon General's Report on Mental Health, issued by
then-Surgeon General David Satcher, M.D., in 1999, provides much
valuable information. Anxiety disorders (panic disorder, phobias,
obsessive compulsive disorder, panic disorder, PTSD, etc.) are the most
prevalent disorders in adults and are found twice as often in women as
in men. Panic disorder is about twice as common among women as men,
with the most common age of onset between late adolescence and mid-
adult life. In the general (non-military) population, the one-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.
Time does not permit a more detailed discussion of gender-based
differences in the prevalence, course and treatment of mental disorders
in women. I hope this brief summary helps frame the questions before
you today: What do we know about post-pregnancy depression? and What
can we do about it?
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. Even the Centers for Medicare and Medicaid Services (CMS)
require mental health care professionals to use the DSM codes for the
purposes of Medicare reimbursement.
DSM and Depression and Psychosis:
One of the more unfortunate aspects of our culture is that we tend
to toss around diagnostic criteria in commonplace 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 the lack of understanding and the
stigmatic way in which we approach serious illnesses that happen to be
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, and association with mania.
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:
I was asked to focus most of my testimony on the question of post-
abortion depression and psychosis, which I will do. Although others
have addressed postpartum disorders, let me briefly talk about them.
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 unrelated to past history, but the disorder is self-limited.
Women with baby blues benefit from reassurance that the symptoms are
common and will quickly disappear, but should be advised to seek help
if symptoms are severe or persist for more than two weeks.
Postpartum depression is an affective disorder lasting more than
two weeks, typically with an onset beginning two to four weeks
postpartum, the severity of which meets criteria for DSM-IV
designation. Special attention to postpartum depression is warranted
because--in addition to the impact on maternal health 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.
The literature shows risk factors including 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.
``Post-Abortion Depression and Psychosis:''
Advocates of a created designation of ``post-abortion depression
and psychosis'' typically argue without foundation that abortions can
have a long-term impact on the mental health of women who elect to
terminate a pregnancy. Alleged symptoms include recurring sadness,
persistent feelings of guilt and a host of other factors including
eating disorders, substance abuse, suicidal ideation and promiscuity,
to name a few.
In fact, the vast majority of women have abortions without
psychiatric sequelae, or secondary, consequences. A study of a national
sample of more than 5,000 women in the U.S. followed for eight years
concluded that the experience of abortion did not have an independent
relationship to women's well-being.
The most powerful predictor of a woman's mental state after an
abortion is her mental state before the abortion. The psychological
outcome of abortion is optimized when women are able to make decisions
on the basis of their own values, beliefs and circumstances, free from
pressure or coercion, and to have those decisions, whether to terminate
or continue a pregnancy, supported by their families, friends and
society in general.
As a practicing psychiatrist, I have seen a 15-year-old girl who
was pregnant as a result of being raped by a family friend, her grades
falling and depression descending as she and her mother sought funds to
pay for an abortion to avoid compounding the trauma of the assault. I
have seen a young woman who had an abortion in her teens without
support from family or friends, and who did not have the opportunity to
talk about her feelings until entering psychotherapy for other reasons
later in her life. There, she concluded that the decision had been
painful but correct and went on to have and cherish several healthy
children. I worked with a woman who had an abortion early in her life
and had to come to grips, decades later, with the fact that she might
never have a child, and in the process, reaffirmed that she had made
the right decision when she was younger.
My professional experience reflects the scientific findings: women
do best when they can decide for themselves whether to take on the
responsibility of motherhood at a particular time, and when their
decisions are supported. No one can make the decision better than the
woman concerned. Mental illnesses can increase the risk of unwanted
pregnancy, but again, abortion does not cause mental illness.
President Ronald Reagan appointed C. Everett Koop, M.D., as the
Surgeon General of the United States and asked him to produce a report
on the effects of abortion on women in America. Dr. Koop was known to
be opposed to abortion, but he insisted upon hearing from experts on
all sides of the issue. The American Psychiatric Association assigned
me to present the psychiatric data to Dr. Koop. I reviewed the
literature and gave my testimony. Later, I went on to publish two books
and a number of articles based upon the scientific literature.
Dr. Koop, though personally opposed to abortion, testified that
``the psychological effects of abortion are miniscule from a public
health perspective.'' It is the public health perspective which with we
are concerned in this hearing, and Dr. Koop's conclusion still holds
true today.
Despite the challenges inherent in studying a medical procedure
about which randomized clinical trials cannot be performed, and despite
the powerful and varying effects of the social milieu on psychological
state, the data from the most rigorous, objective studies are clear:
abortions are not a significant cause of mental illness.
I am submitting for the record under separate cover some of the
excellent scientific articles, published in the world's most
prestigious medical journals, upon which I base my professional
conclusions. These articles speak for themselves.
The fact that there is no psychiatric syndrome following abortion,
and that the vast majority of women suffer no ill effects, does not
mean that there are no women who are deeply distressed about having had
abortions. Some are members of communities that strongly disapproved of
abortion and some were unaware of or unable to access other options. It
was difficult in the past for some of these women to discuss their
negative feelings. Some are now actively organized to affirm and
underscore those feelings and to publish and publicize their accounts.
These accounts, however, are not scientific studies, which cannot rely
on self-selected populations, or those specifically recruited because
of negative feelings.
It's important to understand that an unwanted pregnancy is a major
stressor in a woman's life. According to Burt and Hendrick, research
suggests that for women ``who have undergone an elective first-
trimester abortion, the strongest predictor of poor postabortion
psychological outcome is a prepregnancy history of depression.'' Other
factors can include medical or genetic factors (that is, that the
pregnancy is terminated because of medical or genetic risks or
complications), and a feeling that the decision to abort was not freely
made. Again, the literature shows that freely chosen abortion does not
result in postabortion psychopathology. Notably, in an article
published in 2000 in the Archives of General Psychiatry assessing the
psychological consequences of first-trimester abortions, the rate of
reported posttraumatic stress disorder in the subjects was lower than
the rate in a general female population matched by age.
Some articles and statements aimed at the public have gone so far
as to claim the existence of an ``abortion trauma syndrome.'' We are
all familiar with posttraumatic stress disorder, or PTSD, a condition
tragically brought to public attention by the horrific events of
September 11, 2001. ``Abortion trauma syndrome'' does not exist in the
psychiatric literature and is not recognized as a psychiatric
diagnosis.
Let me make a few specific observations about many of the primary
arguments put forward by some who support the nomenclature of ``post
abortion depression'' and ``post abortion psychosis.''
The terms confuse emotions with psychiatric illnesses. As stated
earlier, the term ``depression'' can be used for both a passing mood
and a disease. Sadness, grief and regret follow some abortions, for
very understandable reasons. These are not diseases. There is no
evidence that women regret deciding to have abortions more than they
regret making other decisions, including having and raising children,
or allowing their babies to be adopted by others. We have a 50 percent
divorce rate in this country. One might conclude that many or most of
those 50 percent regret having gotten married, but as a nation, we are
working to promote marriage, not to make it difficult.
Supporters of the would-be created nomenclature do not
distinguish women who terminate unwanted pregnancies from those who
have to terminate wanted pregnancies because of threats to their own
health or serious malformations in their fetuses. Those circumstances
can cause terrible disappointment, a sense of failure, and concern over
the possibility of future pregnancies, all of which are stressors
independent of the abortion itself.
The arguments overlook an obvious reality: only pregnant women
have abortions. They fail to compare the aftereffects of abortion with
the aftereffects of pregnancy, labor, and childbirth. Full-term
pregnancy is associated with considerably greater medical and
psychiatric risk than is abortion. The incidence of psychiatric illness
after abortion is the same or less than after birth. One study reports
that for each 1,000 women in the population, 1.7 were admitted to a
psychiatric inpatient unit for psychosis after childbirth, and 0.3 were
admitted after an abortion.
Assertions that abortion causes mental illness do not take into
account the reasons women become pregnant when not intending to have
babies, and the reasons pregnant women decide to have abortions. Pre-
existing depression and other mental illnesses can make it more
difficult for women to obtain and use contraception, to refuse sex with
exploitative or abusive partners, and to insist that sexual partners
use condoms. Poverty, past and current abuse, incest, rape, lack of
education, abandonment by partners, and other ongoing overwhelming
responsibilities are in themselves stressors that increase the risk of
mental illness and increase the risk of unintended pregnancy.
Likewise, they do not account for the mental health of the woman
before she has an abortion. Pre-existing mental state is the single
most powerful predictor of post-abortion mental state. As we all
learned in school, association does not mean causation. Having a
serious mental illness at a given time may make some women decide that
it would not be appropriate to become mothers at that time. The
scientific literature indicates that the best mental health outcomes
prevail when women can make their own decisions and receive support
from loved ones and society whether they decide to continue or
terminate a pregnancy.
Some articles I have seen assume that all women who have
abortions require mental health intervention. There is no evidence that
women seeking abortions need counseling or psychological help any more
than people facing other medical procedures. Standard medical practice
demands that patients be informed of the nature of a proposed medical
procedure, including its risks, benefits and alternatives, and that
they be allowed to make their own decisions. Of course this applies to
abortion as well. Because the circumstances and decision can be
stressful, most facilities where abortions are performed make formal
counseling a routine part of patient care.
Over 30 percent of women in the United States have abortions at
some time in their lives, and very few of these seek or need
psychiatric help related to the procedure--either before or after. Our
role, as mental health professionals, when patients do seek our
consultation under those circumstances, is to help each patient review
her own experiences, situation, plan, values, and beliefs, and make her
own decision.
There is little attempt made to address the impact of barriers to
abortion, social pressure, and misinformation on the mental health of
women who have abortions. Imagine being in a social milieu where your
pregnancy is stigmatized and abortion is frowned upon, having to make
excuses for your absence from home, work, or school, travel a great
distance to have the procedure, endure a waiting period, perhaps
without funds for food or shelter. Imagine having to face and go
through a crowd of demonstrators in order to enter a medical facility.
Finally, imagine being told that the medical procedure you are about to
undergo is very likely to cause mental and physical health problems
``although this is not true. Any stress or trauma caused by these
external factors should not be confused with reactions to the abortion
itself.
With respect to parental consent issues, one important study
involved adolescents who had negative pregnancy tests with those who
were pregnant and carried to term and those who were pregnant and had
terminated the pregnancy. All three groups had higher levels of anxiety
than they showed one or two years later. But, the interesting result
was that two years later, the adolescents who had abortions had better
life outcomes--including school, income, and mental health--and had a
significantly more positive psychological profile, meaning lower
anxiety, higher self-esteem and a greater sense of internal control
than those who delivered and those were not pregnant. As all of us
support planned pregnancies and parenthood and healthy families, we
need to better understand and respond to issues such as postpartum and
maternal-/parenting-related depression so that women who continue their
pregnancies are not at greater risk.
With respect to health issues, there is much misinformation about
medical sequelae of abortion. Breast cancer is a good example. But
here's what the National Cancer Institute wrote in its May 2003 report,
``Abortion, Miscarriage, and Breast Cancer Risk'': ``The relationship
between induced and spontaneous abortion and breast cancer risk has
been the subject of extensive research beginning in the late 1950s.
Until the mid-1990s, the evidence was inconsistent . . . Since then,
better-designed studies have been conducted. These newer studies
examined large numbers of women, collected data before breast cancer
was found, and gathered medical history information from medical
records rather than simply from self-reports, thereby generating more
reliable findings. The new studies consistently showed no association
between induced and spontaneous abortions and breast cancer risk.''
The most highly regarded and methodologically sound study on the
purported link between abortion and breast cancer--Melbye's ``Induced
Abortion and the Risk of Breast Cancer,'' which appeared in the New
England Journal of Medicine in 1997--indicates that there is no
relationship between induced abortion and breast cancer. In contrast
with most of the studies in this area, this study contains a large
study sample (1.5 million women) and relies on actual medical records
rather than women's recollection, which can be influenced by fear and
the attitudes of their communities.
In February 2003, the National Cancer Institute, a part of the U.S.
Department of Health and Human Services, brought together more than 100
of the world's leading experts on pregnancy and breast cancer risk.
Workshop participants reviewed existing population-based, clinical, and
animal studies on the relationship between pregnancy and breast cancer
risk, which included studies of induced and spontaneous abortions. This
workshop ``concluded that having an abortion does not increase a
woman's subsequent risk of developing breast cancer.'' The World Health
Organization, which conducted its own review of the subject, came to
the same conclusion.
In plain language, there is no medical basis for the claim that
abortion increases the risk of breast cancer. This position, shared by
the National Cancer Institute and the American Cancer Society, is based
on a thorough review of the relevant body of research. Among studies
that show abortion to be associated with a higher incidence of breast
cancer, most are unreliable due to recall bias and other methodological
flaws. By contrast, studies that were designed to avoid such biases
show no relationship. It is irresponsible for politicians to develop
public policy that is based upon false medical allegations.
Conclusion:
Mr. Chairman, as a woman, as a physician, and particularly as a
psychiatrist, I have great sympathy and compassion for all of my
patients, women and men, adults and adolescents, who struggle with
mental illnesses. In order to ensure state of the art treatment, we
need to ensure that the scientific process that is the foundation of
our reference for diagnostic criteria--the DSM--is maintained at the
highest levels. Above all else, what the women I treat need is access
to mental health care.
Today, patients in our great country who seek treatment for mental
illnesses all too often find that they lack access to adequate mental
health services as a direct result of the discrimination in insurance
coverage for mental disorders. 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 to
achieve this result. On behalf of my patients, I respectfully urge you
to address the unmet mental health needs of the nation's women, and
men, children and adolescents, by enacting non-discriminatory coverage
of treatment of mental illnesses.
Thank you again for the opportunity to speak with you today. I
would be happy to answer any questions you or other members of the
Subcommittee may have.
Mr. Pickering [presiding]. Thank you, Dr. Stotland.
Mr. Pitts, do you have any questions?
Mr. Brown?
Mr. Brown. Ms. Blocker, thank you again so much for being
here.
Ms. Blocker. You are welcome.
Mr. Brown. Your appearance, obviously, means a lot to all
of us, and I'm sure it means a lot to the more than 400,000
women per year who experience depression as a result of
childbirth.
Give us, generally, your advice on what this Congress can
do, what this committee can do, to help decrease the number of
women afflicted with postpartum depression and psychosis each
year, and how we can help loved ones better recognize the
warning signs before they lead to suicide.
Ms. Blocker. Yes, sir.
First of all, I'm going to say that the illness is very
insidious. It's very sneaky, and it kind of creeps up on the
new mommy before anybody really knows what has happened to her.
Most of the women that have called me, because I have put
up a web site for my daughter to help other women, most of the
women that call me say their husbands are furious with them,
because they want them to snap out of it, and they said they
can't snap out of it because, you know, because it's a hormonal
thing first of all, and there's nothing they can do to help
themselves.
What I would like to see done, what I would like to see
done, is more information with the doctors. Every maternity
ward should have almost like large warning signs there to warn
doctors to look at these new mothers when they come back for
their 6-week checkup.
Had I not known Melanie so well, I would have thought that
Melanie was just suffering because Melanie has never had any
trauma in her life, and believe me, labor pains are awful, and
I thought the labor pains had kind of put her in a little deep
depression, or was too traumatic for her. I had no idea that
postpartum psychosis even existed.
I would love to see someplace where a woman could go
somewhere in America, we have nowhere to treat women. As you
can see by these pills that they gave my daughter, they don't
know anything about this illness and they are experimenting.
They were experimenting with her.
I would like to see some safe haven place for a mother to
go and know that she'll be safe until her hormones go back.
Mr. Brown. Thank you.
Doctor Stotland, talk to us about C. Everett Koop, what his
views about abortion are, and what his public stance and
reflection on his and other research findings are about this
whole issue in Mr. Pitts' bill.
Ms. Stotland. When Doctor Koop was selected to be Surgeon
General of the United States, he was the editor of the Journal
of Fetal Medicine, very much opposed to abortion.
President Reagan ordered him to write a report on the
mental and physical effects of abortion on women in the United
States, and he undertook to hear from every possible
constituency, expert group, advocacy group, et cetera.
And I was, at the time, the Chair of the Committee on Women
of the American Psychiatric Association, and my main interest
was, in fact, in birth. The President of the American
Psychiatric Association said this is your job, you have to do
the research on this, and you have to go and present the
findings.
And so, I did the research, eventually published a book
afterwards, but I remember being very worried, because I knew
that he was very personally opposed to abortion, and finally
someone said to me 1 day, ``It's going to be okay.'' And, I
said, it was an older colleague, and I said, ``How can you say
that?'' And, he said to me, ``I went to college with him, and
he's an honest man.''
So, Doctor Koop heard from absolutely everybody who had
something to say or information to bring, and he came out. He
refused to write the report, and he came out with a statement I
believe he wrote to Congress, anyway to the President, saying
what's been quoted here, the psychological impact of abortion
on women is minuscule from a public health standpoint, after
exhaustively reviewing all the information there was and all
the opinions and feelings there were as well.
Mr. Brown. One other quick question, what are your
methodological concerns with Doctor Shadigian's assertions, and
articles and reports that she references that abortion causes
mental illness?
Ms. Stotland. What are my problems with those? I outlined
some of them in my testimony, and more are in my written
testimony, obviously, but we have to remember why someone has
an abortion. The studies that have been published, which are
very few and not very well accepted, as opposed to a giant
literature about how women do okay after they decide to
terminate their pregnancies, is we don't know the baseline.
Most of the women who are depressed after abortion were
depressed before abortion. We don't know why someone decided to
have an abortion, because their mate deserted them and they are
upset about that, because they are terribly poor and they can't
afford to have a child because they have many children they are
struggling to take care of already, because they know they are
too young, because they were raped or coerced into becoming
pregnant in the first place, and then you look at what happens
afterwards and say, these people were upset. They were upset
because of the circumstances, not because of the medical
procedure they had.
The vast majority of women come out an abortion feeling
relieved, not because they've done something insignificant, but
because they've made a responsible, important decision for the
benefit often of children they have or want to have in the
future, so that they can give them the best possible life.
Mr. Pitts. Mr. Rush.
Mr. Rush. Thank you, Mr. Chairman.
Ms. Blocker, would you--I understand that Mr. Stokes, Sam
Stokes, is a physician, a trained physician.
Ms. Blocker. Yes, he's a physician and surgeon.
Mr. Pitts. And surgeon.
Can you share with this committee some of his commentary to
you after Melanie's tragic death, in terms of how he was
unaware?
Ms. Stotland. Yes, it's really sad to say this, but Sam had
never heard of the word either, and I had found this book, it
was called, ``Women's Moods,'' and I read a little part of it
and it said, unfortunately, sometimes new mothers will commit
suicide if they have postpartum psychosis, and I gave the book
to Sam and I said, ``Sam, read this little part here.'' I said,
``It sounds like the symptoms that Melanie had.'' He said,
``You know,'' they call me Bammy, he said, ``You know what,
Bammy, Melanie would never kill herself.'' He said, ``She loves
life,'' and he said, ``Especially since she's given birth to
this little girl that looks just like her.'' He said, ``Bammy,
that's preposterous, that's ridiculous,'' and that's why he
left her, and I hate to say it.
I knew my daughter, because Melanie and I were extremely
close, and I knew the minute the baby was delivered that
something happened during the delivery. I didn't know that a
woman's hormones rise extremely high during pregnancy. These
are things that we didn't know. I didn't know that during
delivery the hormones leave and sometimes, unfortunately, they
leave the brain, which is what happened to Melanie. I didn't
know that if you took the blood of a woman that was 3 months
pregnant and injected it in a man it would damn near kill him.
I didn't know that. I had never heard those things before, but
now I know.
And Sam didn't know how sick Melanie was. As a matter of
fact, a couple times he got angry at her too, and he told her,
he said, ``You know what, I am really furious that you call
yourself having postpartum depression.'' He said, ``when I'm
over here at Cook County Hospital working every day,'' he said,
``taking out guts and preparing bodies.'' He said, ``If you
want to see a depression, you come over here to Cook County
Hospital with me, that will make you really depressed.''
He tried a lot of things to try to get her to snap out of
it. He said, you know, and I'm going to just say this, he said,
``You know, Melanie, I'm going to take Sommer and I'm going to
move to Paris and you are never going to see her again if you
don't snap out of this.'' And, I was there, I heard him say it,
and it hurt me, and she said, ``See, mommy,'' she said, ``I'm a
bad, bad person.'' She said, ``The baby doesn't like me.'' I
said, ``The baby is just an infant.'' She said, ``No, mommy,
the baby likes you and Sam.'' She said, ``Sam hates me,'' and
she said, ``I'm going to have to die.''
Mr. Pitts. Doctor Stotland, how widespread is this issue of
postpartum psychosis? I know that, you know, we've indicated
one in a 1,000 women suffer from it, but those who, in our
society, who are suspected of having psychosis and, in fact,
rather than killing themselves they may kill a loved one, a
child, how does our society deal with them, how does the
criminal justice system deal with them right now? What's the
tragedy of that?
Ms. Stotland. Well, unlike in most other countries of the
world, we have no special designation for people who kill their
children in the throes of severe mental illness. In other
countries that's a separate issue.
As we saw in Houston----
Mr. Pitts. Mr. Chairman, can we suspend just for a moment
into the bill?
Mr. Pickering. Yes, and let me just real quickly say what
we are going to do here, as soon as the buzzer stops. We will
continue Mr. Rush's questions. When he completes his we will
recess. We have two votes. We will come back as quickly as
those votes are over, and then we will want to give everybody
else a chance to ask their questions.
I would ask that we are sensitive to our time, because we
need to get to the second panel as early as possible.
Mr. Rush?
Ms. Stotland. As we saw in Houston, as we saw in Texas,
Andrea Yates was pretty much treated like a common criminal,
like someone who takes out a gun at a convenience store and
shoots someone. And, it goes part and parcel with the education
that your bill is calling for, because not only does the
criminal justice system not understand, people don't
understand.
I was on CNN in the course of the Andrea Yates trial, and
you know how the little worm runs across the bottom of the
screen, and I was offsite, and people were calling in and e-
mailing in, and there were literally--and this is the case in
the United States right now, just about 50/50, there would be
one message that said, nothing is more--no punishment is bad
enough for this awful woman. My children aggravate me too, and
I didn't kill them. Okay. And then the next message would say,
nobody can know what this woman went through unless they went
through it. I suffered through this. I was a loving mother, and
I suffered through, but luckily I didn't kill my children.
So, we don't have any distinguishing factor in our penal
system, in our justice system, to differentiate a criminal who
just murders someone from a mother in the throes of horrible
delusions and hallucinations, who kills her child.
Mr. Rush. Thank you, Mr. Chairman.
Mr. Pitts. Ms. DeGette.
Ms. DeGette. Thank you, Mr. Chairman.
Ms. Blocker, I want to add my sympathy at your loss, and
also I want to add, I see a lot of testimony, and this is some
of the most moving and persuasive testimony that we've seen.
So, thank you, I know it's hard for you. Ms. Capps and I are
mothers too, and we were just sitting here saying----
Ms. Blocker. Yes, it's very hard for me, but more than that
I am determined to change, to make a change, I'm determined.
Ms. DeGette. That's why your testimony is so effective to
us.
Ms. Blocker. It's not just for Melanie, it's for all women,
because honestly men have--they don't have a clue. They don't.
And, men are wonderful people, but they do run the world, and I
have to say for my daughter she died for this illness. She did.
Ms. DeGette. Yes. We are hoping to change that.
Ms. Blocker. I hope so.
Ms. DeGette. Doctor Stotland, I wanted to ask you a couple
of questions.
You talked about Surgeon General Koop's extensive research
and conclusions. I'm wondering if you could talk to me about
any other research on the so-called post-abortion depression
issue that's been done since Doctor Koop's.
Ms. Stotland. Well, the psychiatric impact of abortion has
been continued to be studied intensively, not with the name of
a diagnosis that doesn't exist, but has been studied, and
there's been an article in Science, which is probably the most
prestigious, difficult to get into, journal in the world, about
scientific matters, again, demonstrating that abortion does not
cause psychiatric illness.
I think I've alluded to some of the small literature that
purports to demonstrate psychiatric problems after abortion,
and some of the severe methodologic problems with it, not
having a baseline, not knowing what circumstances the woman was
in, whether she was coerced, whether she was raped, et cetera.
Ms. DeGette. Are you aware of the research of Doctor
Shadigian, who will testify on the next panel?
Ms. Stotland. I'm sorry, I got distracted by the buzzer.
Ms. DeGette. Are you aware of the research of Doctor
Shadigian, who is scheduled to testify on the next panel?
Ms. Stotland. Yes, Doctor Shadigian and I have both
testified in the Senate on a similar bill, and she and I have
both reviewed the literature. Neither of us is actually in the
trenches doing the research, we are the ones keeping track of
the research.
Ms. DeGette. So, her research is not original research,
it's based on a review of existing research, as is yours?
Ms. Stotland. That's my understanding, yes.
Ms. DeGette. Now, the studies that form a basis for her
testimony, that assert a connection between abortion and
depression, do they control for the patient's previous mental
state?
Ms. Stotland. No, they don't.
Ms. DeGette. How important is that in a study?
Ms. Stotland. It's the most important determining factor in
the outcome.
Ms. DeGette. Why is that?
Ms. Stotland. It just is, because this procedure doesn't
change someone's psychiatric condition.
Ms. DeGette. Now, in her brief testimony that was submitted
to the panel, Doctor Shadigian mentions that women who choose
abortions are more likely to be victims of violent crime,
especially homicides.
How do you respond to that assertion?
Ms. Stotland. Well, there's a new study in JAMA that came
out quite recently, demonstrating that the No. 1 killer of
pregnant women is homicide. Okay? So, we have to always compare
abortion with having a baby, or continuing a pregnancy.
So again, people who choose to have abortions, and as was
indicated, after careful thought, okay, are people who have
been in difficult circumstances. They were people who were
subject to abuse before, they are subject to abuse afterwards.
Ms. DeGette. So, one might expect to find similar rates for
people who carried the baby to term or had abortions, it's not
related to whether they terminated the pregnancy or had the
baby, it's related to their pre-existing circumstances.
Ms. Stotland. Correct.
Ms. DeGette. Now----
Ms. Stotland. By the way, we've submitted a great deal of
scientific literature for the committee today.
Ms. DeGette. Mr. Chairman, I'd ask that that literature be
included. I'd ask for unanimous consent that be included.
Mr. Pitts. Is there any objection?
Hearing none, so ordered.
Ms. DeGette. I just have one last question. There's a study
that you mentioned in your written testimony that found for
each 1,000 women in the population, 1.7 were admitted to a
psychiatric in-patient unit for psychosis after child birth,
and .3 percent were admitted after abortion. Can you talk to me
about that study, the sample size, any contrary evidence that
may have been published?
Ms. Stotland. Sure. It's a little bit technical, that study
is fairly old. It's very hard, as we've all been arguing here
today, for better access to mental health care, it's very hard
to get to a hospital at all today, and that's something of what
Melanie went through as well, obviously, just having to leave
the hospital without being all well yet. But again, it
demonstrates that if you are going to talk about the condition
people are in after they have a baby, or after they have an
abortion, they are at considerably greater risk of having
severe mental illness after having a baby, unfortunately, than
after having an abortion.
Ms. DeGette. Thank you.
Thank you very much, Mr. Chairman.
Mr. Pitts. Thank you.
I believe that we have time for one more set of questions
for 5 minutes. We now have 6 minutes and 24 seconds left in a
vote.
You don't think--all right, we'll recess, we always try to
be efficient around here.
Ms. Blocker, I would like to say how much I appreciate your
courageous testimony, your story, and the powerful experience,
and this Congress has many examples of where personal stories
like yours has affected decisions, and laws, and policies, and
we hope that that's the outcome of this hearing.
Thank you, Ms. Blocker.
Ms. Blocker. Thank you.
[Brief recess.]
Mr. Bilirakis. The hearing is called to order, the Chair
apologizes to the witnesses, this is our life up here, though,
back and forth.
In any case, the Chair recognizes Mr. Towns to inquire.
Mr. Towns. Thank you very much, Mr. Chairman.
What can we do, Doctor Stotland, to encourage a team
approach in terms of getting the OB/GYN folks involved,
psychologists, social workers, psychiatrists, and all of them,
to see what we can do to overcome this barrier?
Ms. Stotland. Well, luckily ACOG, the American College of
Obstetricians and Gynecologists, has taken this quite
seriously, as have the other organizations.
Obviously, we need more support. If people can't get the
mental health care after the diagnosis is made, then it doesn't
do any good, then we just have people with a diagnosis and no
treatment. So, we need to, as has been mentioned, eliminate the
insurance barriers and the terrible things that are happening
to funding in the states as well for mental health services.
And also, there's some things we really need to understand
better. We know that postpartum depression and psychosis
exists, we can treat them, usually quite successfully. We know
very little about prevention, and that team that you mentioned
could very well come together and there is some new research,
just brand new, and a very exciting area of research, that's
what we really need to do, is prevent this terrible thing from
happening. A team approach is perfect.
Mr. Towns. If we start in terms of adolescence, is there
anything you think we might be able to do there to prevent this
from happening later on in life?
Ms. Stotland. Well, that's what we don't know. We know that
some young women are more--some women are more vulnerable to
times of hormonal change than others. Some have PMS worse than
others, can't take birth control pills, and then they may be
the ones who have trouble postpartum when there's a big change
in hormones.
But, that would be very interesting research to do, but I
don't know of any--I don't know of any way that we could do
that. I think right now what we want to do is start with the
woman when she gets pregnant, in terms of postpartum
depression, and see, especially, the ones we know are
vulnerable already, including the young ones, and then jump in
and see what we can do to prevent it.
We know now we can jump on it the minute after the woman
delivers and try and--if we were anticipating it, like someone
who had it before for example, or has had depression before,
and we can start treating that woman the minute she delivers.
But, to prevent it from ever happening in the first place while
she's still pregnant, we don't know how.
Mr. Towns. Well, let me thank both of you for your
testimony, I really think that you've provided a great service
here for us in the Congress. I want to just thank you very
much.
I also want to thank you, Ms. Blocker, for your commitment
and your dedication to get the word out, because I can imagine
the pain and the suffering that you have gone through. So
again, we salute you and hope you continue, because it's a
story that needs to be told. More people need to know about it.
Thank you so much.
Ms. Blocker. Thank you.
Ms. Stotland. Thank you.
Mr. Bilirakis. The Chair thanks the gentleman.
Ms. Capps to inquire.
Ms. Capps. Thank you, Mr. Chairman, and again, thank you to
this amazing first panel.
Ms. Blocker, you have done a beautiful thing, and are in
the process of really paying the finest tribute to your
daughter's life, as she lived it so richly when she was here on
earth, and I commend you for your bravery and your ability to
focus your grieving and your utter sadness into something that
is so positive, as judged from what you've compiled on your web
site, and so much is indicated by the testimony that you gave,
very eloquent, very moving. And, I am one who is committed in
her name to passing this legislation that you and--both of you
have such a fine representative here on our subcommittee.
And, since you nodded when I mentioned Jane Honiquan's
name, I'll be happy to let her know. I believe those who have
experience postpartum depression, or have a loved one who has,
are such marvelous advocates and really so important in moving
us forward on this, so I want to commend you for that, and also
to thank you, Doctor Stotland, for your common sense approach
to this topic, which needs the expertise that you can bring to
it, and I thank you for your continued interest, and I know
you've had to spend a lot of time in front of panels and on the
circuit, if you will, but it's part of what's needed now to
raise the awareness about a mental health condition that can be
treated and that with the kind of interest that we should do
can be prevented as well.
I want to ask you a question about statements that I've
heard floating around, and, perhaps, maybe we'll hear in the
next panel, that some have equated feelings of sadness
following an abortion with post-traumatic stress syndrome or
PTSD, which I believe is a defined disorder in which exposure
to exceptional mental or physical stress is followed by
persistent re-experiencing, flashbacks if you will, of that
event.
And, I wonder, I know it's a battlefield term that we're
now quite familiar with, and has been well documented, is that
an accurate comparison for post-abortion trauma?
Ms. Stotland. Well, let me say several things. PTSD is a
real psychiatric disorder.
You spoke about veterans, we now know that it's more common
in women and children than it is in men. There is no literature
to indicate that abortion overall is associated with post-
traumatic states of any kind.
That isn't to say that an individual woman couldn't be
under horrible circumstances, have to go through a crowd of
people screaming and yelling, have to go to another State and
not have enough money to wait the waiting period, be forced
into an abortion because her husband says I'll leave you if we
have another baby, that there can't be other circumstances
surrounding an abortion. And certainly before they were legal,
and people were not given anesthesia, and, you know, were in a
back alley, one can readily imagine that that could have been--
amounted to the level of trauma.
Ms. Capps. So, in other words, if we are going to do
studies on post-abortion situations, we can't do that without
really understanding the pre-existing conditions.
Ms. Stotland. Absolutely, and we already know that if we
make the circumstances less traumatic then the likelihood of
post-traumatic stress disorder happening would be much less.
Again, there's no recognized form of PTSD or relationship
between PTSD and abortion.
Ms. Capps. Since this is our one chance to talk about what
we could do, Mr. Towns gave you this opportunity, but I wanted
to just see if there's something more you wanted to say. It's
at a time of limited fiscal opportunities, the pressures are
great upon us here in Congress in terms of appropriating funds.
I believe strongly, as you do, in the Wellstone and Domenici
mental health parity, but how can you give this panel a bit
more of your incite and expertise as to how we could best
prioritize funds that would be-should be allotted in a way that
would improve women's mental health in general?
Ms. Stotland. Well, let me continue for a moment with the
postpartum issue.
Ms. Capps. Sure.
Ms. Stotland. Although I said very honestly that we don't
have the data yet about primary prevention, this is a disorder
that affects the whole family.
When I heard Ms. Blocker, she and I have presented together
once before, and in that, that was in a Congressional Black
Caucus, and I will never forget the sight of Melanie's bereaved
widower husband, okay. What that left him with after going
through this, we heard how he didn't understand, okay, and we
know that it has measurable effects on the baby, the mother is
depressed.
So, if there is anywhere you are going to put money, in
terms of affecting a whole family, affecting a whole society, I
mean look what the stress on Ms. Blocker, on her sister, et
cetera, et cetera. It seems to me if we are going to single out
any disorder this is a very smart disorder to single out, and,
of course, we want to make treatment available to everybody.
People who do have trouble around the time of an abortion,
people for whom it is a very upsetting circumstance, should be
able to go and get care, you know, just as women who have
trouble after having a baby. There doesn't have to be a disease
made up for people who happen to be depressed, and were
depressed before quite likely, to get care.
Ms. Capps. I wish we had more time, but thank you very
much.
Mr. Bilirakis. I thank Doctor Stotland, Ms. Blocker, I do
believe--Mr. Pitts, do you have anything further? I think that
completes the questioning of this panel.
You know, I know the interruptions hurt, hurt your
communication and what not, but what can we do, that's our life
up here.
But, we really appreciate your taking time to come here,
and, Ms. Blocker, again, what can we say? If there's any good
at all in what happened, it is helping you to communicate to us
and to the world, that this is really a very serious real world
problem. So, thank you so very much.
Ms. Blocker. Thank you, and I do want to state that I love
my daughter with all of my heart.
Mr. Bilirakis. I bet you did.
Thank you. Well, you are showing that.
Ms. Blocker. Thank you.
Mr. Bilirakis. The second panel, let's see, it's Michaelene
Fredenburg, President of the Life Resource Network from San
Diego, California, you have come a long way, and Doctor
Elizabeth Shadigian, Clinical Associate Professor with the
Department of OB/GYN, as we say, Obstetrics and Gynecology, Ann
Arbor, Michigan, University of Michigan. When you say Ann Arbor
we assume it's the University of Michigan, don't we?
We appreciate your coming here. Again, your written
statement is a part of the record, and we would hope that you
will complement it in some way. I'll set the clock at 5
minutes.
And, Ms. Fredenburg, again, I said it earlier, thanks so
much for your courage. I know it's going to be helpful to share
that with us.
Would you proceed, please?
STATEMENTS OF MICHAELENE FREDENBURG, PRESIDENT, LIFE RESOURCE
NETWORK; AND ELIZABETH SHADIGIAN, DEPARTMENT OF OBSTETRICS AND
GYNECOLOGY, MOTT HOSPITAL
Ms. Fredenburg. Mr. Chairman, good afternoon. My name is
Michaelene Fredenburg. I'm President of the Life Resource
Network, and I do live in San Diego, California, and I do want
to thank you for the opportunity to testify before this
committee today.
Women's rights and human rights have always been a passion
of mine. As a teenager, I assumed that legalized abortion was
necessary for women, so it's not surprising that when I became
pregnant at 18 I thought about having an abortion. I also
considered adoption, but when I told my boyfriend he said he'd
kick me out if I didn't have an abortion.
I turned to my employer for advice. She agreed that
abortion was the only logical option and offered to arrange one
for me.
My experience at the abortion clinic was painful and
humiliating. I met briefly with a counselor who characterized
my 8-week pregnancy as ``a couple of cells'' and the ``products
of conception.'' When the abortion provider entered my
procedure room, I began to have second thoughts and asked her
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 also completely unprepared for the emotional fallout
after the abortion. 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. While living
in Hawaii, I was shocked to learn that an 8-week embryo is at
least a \1/2\ inch long with a head, arms and legs, a beating
heart and functioning brain. I sank even deeper into depression
and self-hatred as I realized that I had destroyed my child. I
would experience 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 to be able to pull myself
together.
I saw a number of doctors for the fatigue and weight loss.
They tested me for everything from lupus, to cancer, to AIDS. I
did not tell them about the feelings I was having as a result
of the abortion, because I did not see a connection between the
abortion and my physical symptoms.
This continued for the next few years until suicidal
thoughts began to scare me. This is when I finally went to see
a therapist. With the help of counselors and supportive friends
the time of self-condemnation and self-punishment came to an
end.
In addition to grieving the loss of my child, I suddenly
became aware the impact my choice had on other members of my
family. My parents believe that somehow they failed me and that
they are partly responsible for the death of their grandchild.
When I first told my sister she cried and said she wished she
didn't know. My oldest son found out 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, who is nine,
hasn't been told yet, and it breaks my heart that he will have
to deal with the loss that I inflicted.
In addition to coping with the fallout the abortion has
caused to my family, there are still times that are painful for
me. After all, healing doesn't mean forgetting. The year that
my child would have graduated from high school was very
difficult. My best friend's daughter was graduating that year,
and each time she talked about senior activities I was reminded
that my child would not be participating. I agonized for weeks
after I received an invitation to attend the graduation. In the
end, I had to decline. I didn't want to spoil her celebration
with my sorrow.
At one time I thought that my abortion experience was
unique, but over the years I have found that it is not. There
is mounting evidence, both anecdotal and in published studies,
that women suffer emotionally after an abortion, but since
abortion is held hostage to politics and special interest
groups there are too few reliable studies that have been done.
Abortion continues to be an unchecked and unstudied experiment
on American women.
It's normal to grieve after a pregnancy loss, whether the
loss is caused by a miscarriage, still birth, adoption,
infertility or an abortion. Most of us know someone who has
suffered a 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 done in secret.
An important part of grieving is talking. Since an abortion
is typically a secret, the woman is unable to talk. Even when
she is able to talk about the abortion experience, her efforts
are often met with resistance. Her partner typically doesn't
want to discuss it. Well-meaning family and friends may try to
help her by encouraging her to move on with her life and forget
about the abortion. She may fear that pro-life individuals will
condemn her and pro-choice individuals deny her feelings. With
no safe place to deal with her emotions, she may need to
repress or numb them in order to cope. This repressed grief can
lead to prolonged feelings of sadness, nightmares, loss of
self-esteem, eating disorders, substance abuse, destructive
relationships, an inability to bond with future children, or
even attempted and completed suicides.
If the abortion's loss is followed by additional pregnancy
losses, such as miscarriage or infertility, the multiple losses
will only increase the inner chaos and pain.
Although much has changed in the 19 years since my
abortion, not much has changed for women experiencing an
untimely pregnancy. They undergo abortion, not so much out of
choice, but as a desperation or as a last resort. I believe
women deserve better than this.
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's time to stop the noise and start listening to
women who have experienced abortion and other pregnancy losses.
I'm grateful that you've taken the time to listen, and I
urge you to continue to take steps to understand the impacts
abortion and other pregnancy losses have on women.
Thank you.
[The prepared statement of Michaelene Fredenburg follows:]
Prepared Statement of Michaelene Fredenburg, President, Life Resource
Network
Mr. Chairman, good afternoon; my name is Michaelene Fredenburg, I
am President of the Life Resource Network, and I live in San Diego,
California. I thank you for the opportunity to testify before this
Committee today.
Women's issues, women's rights and human rights have always been a
passion of mine. As a teenager I assumed that 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, but when I told my
boyfriend, he said he would kick me out if I didn't have an abortion. I
turned to my employer for advice. She agreed that abortion was the only
logical option and offered to arrange one for me.
My experience at the abortion clinic was painful and humiliating.
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.''
When the abortion provider entered my procedure room, I began to
have second thoughts and asked her 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 also completely unprepared for the emotional fallout after
the abortion.
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.
While living in Hawaii I educated myself about fetal development. I
was shocked to learn that an 8-week embryo is at least a half-inch long
with a head, arms and legs, a beating heart and functioning brain. I
sank even deeper into depression and self-hatred as I realized that I
had destroyed my own child.
I would experience 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 to be able to pull myself together and at least
outwardly lead a normal life.
I saw a number of doctors for the fatigue and weight loss. They
tested me for everything from lupus to cancer to AIDS. I did not tell
them about the feelings I was having as a result of the abortion
because I did not see a connection between the abortion and my physical
symptoms. This continued for the next few years until suicidal thoughts
began to scare me. That is when I finally went to see a therapist.
With the help of counselors and supportive friends the time of
self-condemnation and self-punishment came to an end allowing me to
enter into a healthy grieving process. In addition to grieving the loss
of my child, I slowly became aware of the impact my choice had on other
members of my family.
Although I have repeatedly assured my parents that I never doubted
their support and assistance if I had decided to carry the baby to
term, they continue to believe that somehow they failed me and that
they are 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 that is missing. My oldest son found out
quite young and still struggles with the loss of a sibling and the
reality that his mother was the cause of the loss. My youngest son who
is 9 hasn't been told yet, and it breaks my heart that he will have to
deal with a loss that I inflicted.
In addition to coping with the fallout the 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 that my child would have graduated from high school
was also filled with pain. My best friend's daughter was graduating
that year and each time she talked about Senior activities I was
reminded that my child would not be participating. I agonized for weeks
after I received an invitation to attend the graduation ceremony. I
wanted so badly to attend and show my support, but in the end I had to
decline. I didn't want to spoil her celebration with my sorrow.
At one time I thought that my abortion experience was unique, but
over the years I have found that it is not. There is mounting
evidence--both anecdotal and in published studies--that women suffer
emotionally after an abortion. But since abortion is held hostage to
politics and special interest groups there are too few reliable studies
that have been done. Abortion continues to be an unchecked and
unstudied experiment on American women.
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 done in
secret. An important part of grieving is talking. Since an abortion is
typically a secret, the woman is unable to talk about it.
Even when she does want to talk about the abortion experience, her
efforts are often met with resistance. Her partner typically doesn't
want to talk about it. Well-meaning family and friends may try to
``help'' her by encouraging her to move on with her life and forget
about the abortion. She may fear that pro-life individuals will condemn
her and pro-choice individuals deny her feelings. With no safe place to
deal with her emotions, she may need to repress or numb them in order
to cope.
This repressed grief can lead to prolonged feelings of sadness,
nightmares, loss of self-esteem, eating disorders, substance abuse,
destructive relationships, an inability to bond with future children or
even attempted and completed suicides. A woman suffering from a past
abortion often feels isolated--as if she is the only one feeling this
way. 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.
It has been nineteen years since my abortion. Although much has
changed in nineteen years, not much has changed for women experiencing
an untimely pregnancy. They still face unsupportive partners and
employers and are often unaware of the community resources available to
them. They undergo abortion not so much out of choice, but out of
desperation or as a last resort. I believe women deserve better than
this.
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 abortion and other 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 pregnancy losses have on women.
Mr. Bilirakis. Thank you very much.
Doctor Shadigian.
STATEMENT OF ELIZABETH M. SHADIGIAN
Ms. Shadigian. I want to thank this whole Committee on
Energy and Commerce and the specific Subcommittee on Health,
and especially Congresspersons Barton and Bilirakis for
inviting me here. I feel proud to be here on several accounts.
I am a mother. I'm a researcher. I'm a medical doctor. I just
delivered two babies 2 days ago, and every day of my life I
work for women's health.
One of the things I research is violence against women, and
another area that is very important to me is women's mental
health and pregnancy complications as well. I support ongoing
research on how depression affects women, and support
furthering our understanding of why some women experience
significant depression, some to the point of suicide,
especially after pregnancy.
I have worked at the University of Michigan over 10 years
now, and I've been a doctor for almost 15 years. Depression is
generally viewed--and because I'm a fairly young doctor, over a
lifetime, I got to study in Baltimore, so I know a lot of the
people around here as well--depression is generally viewed in
the medical community like other diseases, like diabetes, like
hypertension, like cancer. Theories explaining the cause of
postpartum depression typically include changing hormone and
brain receptor levels, with research indicating that women at
the highest risk for postpartum or depression after pregnancy
are those that have been diagnosed prior to pregnancy or even
in pregnancy with depression or bipolar disorder.
But, we also know women who have troubled marriages, women
who have poor social supports, are also at higher risk.
We also know that about 10 to 15 percent of women
experience mild to severe postpartum depression, which is
clinically under-diagnosed.
In our own clinic in Michigan, we now are doing pregnancy
screens for depression two times in prenatal care and once at
the postpartum visit, and so this has been instituted with a
liaison with the Psychiatry Department, the OB/GYN Department,
and Family Practice, including our Midwife Department, so it's
something that can be instituted to try to screen for women
during and after pregnancy.
In the past, research has failed to systematically
incorporate an analysis of the effects of violence in women's
lives as an important contributor to depression. When I was a
student at Hopkins, that whole thing about violence against
women was never talked about once for all the years I was
there. We didn't talk about women being abused as children,
women being beaten at home by their partners, or being raped as
a teenager. Those things never came up, and it was never even
constructed as part of what we should be screening for for
depression. So, this is all very new, to think about violence
and depression being related in any way at all.
But, we also have not, until recently, realized, and Doctor
Stotland actually said this already, that homicide is probably
the leading killer of women in pregnancy and the year after
pregnancy, homicide, and not far behind is suicide. And that
also is some research I've been working on.
Newer research has indicated that the risk of becoming an
attempted or completed homicide victim was three times higher
for women abused versus not abused during a pregnancy, and that
black women have a threefold increased risk as compared to
white women.
And, other studies have shown that homicide is very common
among postpartum teenagers, as compared to adult women.
This same research on homicide and suicide after pregnancy
reveals that women who terminate their pregnancies, as compared
to women delivering a term baby, are twice as likely to die
from homicide and two to six times as likely to die from
suicide. These associations were not seen with other pregnancy
losses, such as still birth or miscarriage.
Violence histories are several fold higher for women who
seek termination of their pregnancies as well.
The important thing, this research is not just about
abortion, this is research about all kinds of pregnancies and
all kinds of death.
Concentration on biology to the exclusion of culture and
sexual and physical violence in examining differences in
depression creates a misleading picture of risk factors and
eventual outcomes. Studying depression, while ignoring physical
and sexual violence against women, is like searching for a
child hiding in a house without looking in the closets.
In the same manner, research studying only depression after
child birth ignores the difficulty millions of women have in
this country and what they are faced with following pregnancy
losses, depression after miscarriage, still birth and
termination of pregnancy.
We must also focus considerable energy on the safety and
mental health of women who terminate their pregnancies. They
deserve just as much research as women who carry their babies,
both deserve it, and remember, we are talking about the same
women. Many women choose abortion at some time in their life
and then they choose to carry their babies later on.
Improving women's health must include improving mental
health and physical and sexual safety. Therefore, improving our
understanding of depression after pregnancy is imperative. It's
important to save women's lives, to save women like Melanie
Blocker Stokes, and the only way we can do that is by getting
better research, and we must be looking for that child in the
closet.
Thank you.
[The prepared statement of Elizabeth M. Shadigian follows:]
Prepared Statement of Elizabeth M. Shadigian, Clinical Associate
Professor of Obstetrics and Gynecology, University of Michigan Medical
School
Thank you Congressperson Barton and Congressperson Bilirakis for
the opportunity to address this Subcommittee.
I am a medical doctor who specializes in obstetrics and gynecology
with a special interest in violence against women, women's mental
health issues and pregnancy complications. I support ongoing research
on how depression affects women and support furthering our
understanding of why some women experience significant depression, some
to the point of suicide, especially after pregnancy. I am a clinician
who sees depressed women everyday in my practice, have co-authored
clinical depression guidelines at the University of Michigan and have
published research on depression and suicide after pregnancy.
Depression is generally viewed by the medical community like other
diseases such as diabetes, hypertension and cancer. Theories explaining
the cause of much of postpartum depression typically include changing
hormone and brain receptor levels and thyroid disorders, to name a few,
with research indicating that women at highest risk for depression
after pregnancy are those who have been diagnosed with prior major
depression and/or bipolar disorder, marital difficulties and a general
lack of social support. About 10 to 15 percent of women experience mild
to severe postpartum depression, which is clinically under-diagnosed.
In the past, research has failed to systematically incorporate an
analysis of the effect of violence in women's lives as an important
contributor to depression. Equally important, but routinely overlooked
and ignored, is the data that homicide is a leading cause of pregnancy-
associated death (the death of a woman from any cause while pregnant
and during the year after pregnancy) and that suicide is also a
significant cause of death.
Newer research has indicated that the risk of becoming an attempted
or completed homicide victim was three times higher for abused women
versus non-abused women during pregnancy and that black women have a
three-fold increased risk as compared to white women. Other studies
report higher rates of homicide among postpartum teenagers as compared
to adult women.
This same research on homicide and suicide after pregnancy reveals
that women who terminate their pregnancies, as compared to women
delivering a term baby, are twice as likely to die from homicide and
almost two to six times as likely to commit suicide. These associations
were not seen in other forms of pregnancy loss. Violence histories are
several-fold higher in these same women who seek termination of their
pregnancies.
In addition, self-harm and psychiatric hospital admission because
of suicide attempt is more common in women who terminate their
pregnancies, while rates of suicide and suicide attempt are half or
less for women with full term pregnancies compared to the general
population.
The concentration on biology to the exclusion of culture and sexual
and physical violence in examining differences in depression creates a
misleading picture of risk factors and eventual outcomes. Studying
depression while ignoring sexual and physical violence against women is
like searching for a child hiding in a house without looking in the
closets. In the same manner, research studying only depression after
childbirth ignores the difficulties that millions of women in this
country are faced with following pregnancy losses--depression after
miscarriage, stillbirth and termination of pregnancy.
We must also focus considerable energy on the safety and mental
health of women who terminate their pregnancies. Not doing so is to
ignore an important area of women's mental health research. A number of
studies note the association between the termination of pregnancy and
either suicide or suicide attempt. This is an objective outcome which
is seen only after termination of pregnancy rather than before and
indicates either common risk factors for both choosing termination of
pregnancy and attempting suicide such as depression or the harmful
effects of termination of pregnancy on mental health.
Improving women's health must include improving mental health and
physical and sexual safety. Therefore, improving our understanding of
depression after pregnancy is imperative. We must look for the child in
the closet.
Mr. Bilirakis. Well, there's so much here. I am gathering,
when were you last in medical school?
Thank you so very much, Doctor.
Ms. Shadigian. I finished, I completed medical school in
1990.
Mr. Bilirakis. 1990, and at that time, apparently, they
were not focusing at all on this type of a problem, so far as
teaching is concerned, is that right?
Ms. Shadigian. Correct, and, in fact, the Chair of
Psychiatry, I took extra courses from him, because I wanted to
know more about things, and we never discussed those kinds of
things. It just wasn't even the things we looked at at that
time.
Mr. Bilirakis. Do you know, has that changed now? Have they
improved in this regard, do you know?
Ms. Shadigian. I think in general people are becoming more
aware, but I think it's something that takes a long time to
seep into the consciousness to actually change an outlook of a
whole field like psychiatry.
Of course, you know, now post-traumatic stress disorder is
in the DSM-IV, so things are starting to change, but I think
just looking at the long view of things, in general it's not
mandatory in psychiatric research around depression, around
suicide, around homicide, to actually screen for violence, and
that has to be mandatory for us to understand the situation
women are in in their homes.
Mr. Bilirakis. Thank you, Doctor.
Do you--it would be interesting to try to figure out what
we could do about that, I suppose, making the medical
profession more aware of the problem.
How about NIH, if you know, are they adequately researching
postpartum depression?
Ms. Shadigian. I know that it's an important issue for many
researchers, and we know it's important for women and families.
I think some of the things that they need to focus on is
making sure, no matter what the study is, is that we take an
adequate violence history from all women in these studies, that
that should be a mandatory part of each and every study, to
understand the violence history and understand what their
obstetrical history is, which means that we know how many
miscarriages, how many abortions, in what trimester, how many
times their babies were born early but fine, and at term and
fine. I mean, we need to understand all those things before we
can put these pieces together, and we need to look forward, not
just backwards, we need to do studies that start with 15, 16
year olds, and follow them throughout their lifetime so we can
see which of those girls and then young women have problems
like Melanie Stokes did.
Mr. Bilirakis. So, are you saying then that you feel that
we would be short changing our research efforts on depression
if we ignore research of all sorts of depression as related to
pregnancy, which would include abortion?
Ms. Shadigian. I think what we have to do is stop worrying
about the politics part of it and start thinking about women in
general, that we need to focus research to help women, and
women are going to make those choices or not, depending on
their individual situation.
So, I want to be pro information. I want to be pro science,
and I think women deserve that in America.
Mr. Bilirakis. All right.
Well, but again, you are not familiar then with the extent,
if at all, that NIH is spending on research on this particular
subject.
Ms. Shadigian. No one has briefed me on the exact number of
dollars spent in which kind of research.
Mr. Bilirakis. Do you know if that research is taking place
at all?
Ms. Shadigian. Oh, yes, yes, there are, and, in fact, I
have many colleagues at the Depression Center at the University
of Michigan who, in fact, have NIH grants, and they are trying
to not just look at postpartum depression, but look at what the
effects are on small children whose mothers are depressed.
So, I know there's research ongoing, I'm just not the
financial expert.
Mr. Bilirakis. Well, Ms. Fredenburg, do you know, I don't
know whether you've thought about taking the opportunity to
check in terms of what research has taken place or what
educational aspects might be taking place soon. Do you know,
can you add anything as far as your knowledge is concerned,
because as a result of your experience you've become very much
involved in this issue.
Ms. Fredenburg. I have, and while I'm certainly not an
expert in that area, I think the hearing today has already
highlighted that there certainly is a lack of knowledge,
because of a lack of statistical data and a lack of studies on
the effect of pregnancy losses and, in particular, abortion
losses upon women.
And, since we have millions of women who do undergo
abortions each year, we need to know that information, and
after 30-some years of legalized abortion, to me as a woman's
health advocate it's shocking and disturbing that we don't have
that type of information where we can be assisting women.
Mr. Bilirakis. Thank you.
I certainly understand you to say, and would agree, that
rather than try to downplay the effect that abortion would have
on depression, that we should be looking at depression in all
women as a result of pregnancy, regardless of whether it might
be abortion or whatever the case might be.
Thank you.
Mr. Rush has left. That being the case, Ms. Capps is
recognized.
Ms. Capps. Thank you, Mr. Chairman.
I was a bit surprised to learn that this panel who was part
of the hearing today. To the best of my knowledge, so-called
post-abortion syndrome has never been shown to exist by any
legitimate scientific or medical study, and we've heard in the
last panel about the study that C. Everett Koop, the Surgeon
General, was asked to conduct, and his acknowledgment that even
though he was anti-choice he could find no direct correlation
between an abortion and a situation of having physical or
psychological harm to a woman.
I do see a connection between this panel and the one
previous, in that, Ms. Fredenburg, your eloquent testimony to
your personal experience, and, Doctor Shadigian and the two who
preceded you in the panel, certainly give testimony to the fact
that mental health services for women are very important, and
that we do not have parity in our country, and that there are
efforts that we really should champion in the House as are
being pushed to the degree that they are in the Senate, to make
sure that there is opportunity for women, no matter what their
story, to have access to mental health.
I do want to question, I want to get at a couple of things.
Just one specific thing, because I'm concerned about statements
made without verification. Doctor Shadigian, in your testimony
on March 3 before the Senate you said this, and this is a
quote, ``Induced abortion is associated with increased risk in
maternal suicide,'' and today you also referenced that topic,
saying that women who terminate their pregnancies compared to
women who deliver a baby to term are twice as likely to die
from homicide and almost 2 to 6 times as likely to commit
suicide, and I want to ask you what research you have to back
up that statement?
Ms. Shadigian. That's a great question, I'm glad you asked
that, and I appreciate getting the opportunity to discuss that.
What I got to help was something called a systematic review
of the literature, and what we do when we want to learn more
about a specific topic is actually go to the library, or the
libraries, and do searches of all the different----
Ms. Capps. Excuse me, I don't want to cut you off, but I
have some other questions, too, and I just want to know, would
you cite the source for that particular study, please?
Ms. Shadigian. Yes, it's cited in my review article,
``Long-Term Physical and Psychological Health Consequences of
Induced Abortion: Review of the Evidence.'' It's in table
number----
Ms. Capps. What source is given at the bottom of that table
then, if you would, so that I can have it on record?
Ms. Shadigian. Absolutely, I will give you the three
different studies, so you can know that. There are ten studies
that look at it in Table 7, and the specific ones that I'm
talking about are cited in this table. There's actually ten of
them, and three of them show an increased risk in suicide----
Ms. Capps. Is there an author? Is there an author to the
study that you could just list for the record so we could
verify it?
Ms. Shadigian. Yes, I'd be glad to. It's Reardon.
Ms. Capps. Okay.
Ms. Shadigian. And, it's ``Fetal Deaths Associated With
Pregnancy Outcome: A Linkage-Based Study in Low-Income Women.''
Ms. Capps. Okay, so I'd like to have that entered into the
record if I could.
Mr. Bilirakis. Would you like to put your entire article
into the record?
Ms. Shadigian. I think that would be helpful, because it
actually goes over each and every study. The important thing is
also, this has all been since Koops'----
Mr. Bilirakis. Yeah, I don't mean to take up Ms. Capps'
time, I just thought maybe you might just prefer to have the
entire article put into the record.
Ms. Capps. That's fine, I would like to be able to get back
at this article.
Mr. Bilirakis. Without objection, that will be the case.
Please continue.
Ms. Capps. I'm concerned--I want to get to something
further. I have been aware of a climate in this administration,
and also in the House, that has a politicizing actually of
women's reproductive health from my perspective, based on an
anti-choice format, and coming from that vantage point.
One example of it is the Food and Drug Administration
ignoring recommendations from its top scientists and not
allowing an emergency contraceptive to be sold over the
counter, which actually would have the net result of reducing
the number of abortions. And so, this is part of the context, I
believe, in which even this hearing today is coming from, not
that particular issue, but I cite it as an example.
And I'm very concerned also that you are trying to get at
documentation coming from personal lives that would be shared,
that would become then a part of a story, and how we can mesh
that with the desire and the ultimate requirement that we allow
women to have privacy over their personal lives, and that
eliciting information for studies such as these that you are
citing, and also are being proposed, would be one way to get to
document that personal and private information that then could
be used in harassing and held against people.
If you could comment on that, please, Doctor Shadigian.
Ms. Shadigian. I'd be glad to.
The question is, are these women who are going to be in
part of studies obtaining informed consent?
Ms. Capps. Yes.
Ms. Shadigian. So, whenever we have studies and review
boards, they have to look and make sure women are being
properly told what the risks and benefits of participating in
studies are.
And, in fact, that's why they have institutional review
boards and they are all ones that have to talk to Federal
agencies to get funding.
So, in all these studies that maybe be proposed in the
future, these are all people who can voluntarily give their
information, no one is being coerced to give it. I think women
in America want to know, is there an increased risk of
anything.
Ms. Capps. Just could I add that there's also the opposite
side that one can state, if you look outside an abortion clinic
and you see people standing there with signs of protest, there
is a climate today, I would posit, that would really send a
chill down for many women before they would want to come forth,
though they are desperate and needing help, and though we want
to get information, because there is this underlying bias that
would want to use it for a particular----
Mr. Bilirakis. Time is long expired.
Did you want to respond very quickly to Ms. Capps' comment?
Ms. Shadigian. I just think we need to change the climate.
We need to say that this is about women's health and not about
anything but that, and I think what we have----
Mr. Bilirakis. Not about abortion, not about anything else,
it's women's health as a result of depression, resulting from
pregnancy, is that right?
Ms. Shadigian. I think we just need to get above the fray
of, this isn't about is abortion legal or not, it is legal in
America, so let's forget that for a moment and start talking
about women's health, mental health and physical health, and
how can we improve it. I think we need to just get the
discussion somewhere other than at the legal part.
Mr. Bilirakis. Thank you, Doctor. That's what some of us
are trying to do.
Mr. Pitts to inquire.
Mr. Pitts. Thank you, Mr. Chairman.
We've heard a lot about Doctor Koop and the statement in
the testimony was, ``The psychological effects of abortion are
minuscule from a public health perspective.'' The staff has
given me his letter to President Reagan, dated January 9, 1989,
when he was asked to prepare a comprehensive report on health
effects of abortion on women. I don't find that sentence in the
letter at all, in fact, it concludes, ``I regret, Mr.
President, that in spite of a diligent review on the part of
many in the public health service, and in the private sector,
the scientific studies did not provide conclusive data about
the health effects of abortion in women. I recommend that
consideration be given to going forward with appropriate
prospective studies.''
So, Mr. Chairman, just for the record, I would like to
submit that letter for the record.
Mr. Bilirakis. Without objection, that will be the case.
[The information referred to follows:]
[GRAPHIC] [TIFF OMITTED] T6101.001
[GRAPHIC] [TIFF OMITTED] T6101.002
[GRAPHIC] [TIFF OMITTED] T6101.003
Mr. Pitts. I don't know how much time--I'd like to go on
quickly, Doctor Shadigian, you've heard the questions of the
previous panel characterizing your testimony before you even
had a chance to testify. Would you like to respond in any way
to set the record straight?
Ms. Shadigian. Well, I think that what I try to do is to
look at hard outcomes. What I try to do is to promote good
science, and I think that that's where this whole issue of
appropriations needs to go to, is we need to do well-designed
studies, and we need to be able to make good conclusions. And I
believe Doctor Koop was actually asking for that in 1989, that
there just weren't very good studies at that point so he
couldn't draw any conclusions.
Mr. Pitts. Now, have you ever witnessed, or yourself
experienced, the hostility within the medical community toward
those who research the possible negative effects of abortion on
women?
Ms. Shadigian. Well, I think what's hard in the medical
community, it's hard to even talk about it because everyone is
afraid of looking one way or the other. Everyone wants to
pigeonhole somebody else as to being biased about one thing or
another, and everyone doesn't want to actually talk about the
science as much.
And, I think, again, if we can just elevate our discussion
to the scientific level, rather than stay at the personal or
political level, then I think that that's where we all want to
go to, and I think it's the higher ground that everyone can
agree with, is that we all are concerned about women's health
and women's mental health, and want to prevent suicides like
Ms. Blocker-Stokes. I mean, we all are on the same page on
that, and I think whether a woman is hurting herself after a
termination of pregnancy or after a full-term birth, we all
want to help that woman, and I don't think that that's
something that's hard to see.
Mr. Pitts. In your opinion, are we shortchanging our
research efforts on depression if we ignore research with
respect to abortion, you know, what steps should scientists
take to better understand this whole issue of either postpartum
or post-abortion depression?
Ms. Shadigian. Well, I think what we need to do is actually
to put all the pieces in order. We need to be able to put
women's violence histories in our research. We need to put
women's obstetrical histories in our research, and we need to
know who does have a prior history of depression and mania, and
all the other kinds of psychiatric diagnoses, which women have
those histories.
You know, most women won't even talk about their prior
history because they are scared. So, I think we have to pull
away the stigma of mental health issues before we can do the
research, and we are doing that on a day-to-day basis.
But, until we can do that, it's going to be hard to do the
research, and we have to all sort of get on the same page, and
I think we can do it. I'm not depressed about that at all, I
think we are very positive here.
Mr. Pitts. Ms. Fredenburg, you testified about the ways in
which you reacted negatively to abortion. Are there other ways
in which women react? And you talked about your 9 year old son,
how the prospect of telling him about your abortion breaks your
heart. It seems like the easiest thing to do would be not to
tell him, and avoid the pain, you know, why tell him? Would you
like to respond?
Ms. Fredenburg. Yes, because of my own experience, but
beyond that, because of just the vast number of women and other
family members involved in abortion experiences, I made the
decision to be public about my abortion experience, so that
women who may be experiencing similar things would know that
they are not alone, they would know that there is help, and
because I think that in this highly politicized environment on
this issue that we need to actually see real people and what
they go through.
And so, that's a decision that I have made, but I do
realize that that then has consequences for my family and, in
particular, my children, because he will eventually find out,
and he will then have to cope and to deal with this, but I do
believe that it is for the greater good.
Mr. Pitts. Thank you, Mr. Chairman.
Thank you very much.
Mr. Bilirakis. Mr. Rush to inquire.
Mr. Rush. Yes. Thank you, Mr. Chairman.
I have I believe one question, I'm not sure, it might lead
to some additional questions.
First of all, Ms. Fredenburg, I want to say to you that we
thank you so much for sharing your experiences, and we
certainly--I've tried to listen to your experiences with the
empathy that I could muster, and I want you to know that I
appreciate you appearing as a panelist before this
subcommittee. Thank you so very much.
I want to ask Doctor Shadigian, from the data that you've
been able to observe, is there any similarities, and what are
the similarities, if any, between what you call postpartum-
post-abortion depression and postpartum depression?
Ms. Shadigian. Well, it's funny, that's a great question.
You know, depression is depression. You know, depression has
certain signs and symptoms. Depression affects mood and how
people think about themselves, and so we've added those other
terms onto the word depression, okay? So, whether depression is
after childbirth, or after abortion, or after a car accident,
or after something else, we put these sort of adjectives ahead
of the word depression. And so, that's the real question, are
there triggers for major depression and what are they, because,
you know, people who are pregnant do have hormone levels, you
know, and then they do drop, and we know that, but we are not
sure if they are completely related or not.
So, there are similarities, but the problem is, people are
afraid to do that other research, and that's why I'm saying we
can't just look at one thing, we've got to look at the whole
thing around pregnancy, and if there is losses, if there is,
you know, normal birth, you know, we do know that a subset of
women feel awful afterwards, and it's not something that they
can ``will themselves out of,'' that it is a metabolic and
receptor level kind of thing, but we don't know what the
predisposing factors are.
So, we have to be really clear that, you know, we need to
study depression, in general and depression in women, and
depression in and around pregnancy, to answer those questions
well.
Mr. Rush. There is, I'm trying to locate here, is there any
data or any census that you might have heard about or might
have in your possession, of violent incidences that have been
attributed to what you call postpartum, I mean, post-abortion
depression, that you can identify?
Ms. Shadigian. Are you asking about suicide or homicide?
Mr. Rush. Both.
Ms. Shadigian. Okay. The studies that are in my review of
the ten studies did show that women who'd had abortions in the
year after their abortion had a higher rate of suicide, and
that is controlling for prior psychiatric history, unlike what
Doctor Stotland said, they actually--that was why these are so
powerful, these studies, because they actually controlled for
prior psychiatric history and prior depression.
And so, I'm not saying I understand why that subset of
women killed themselves, I don't know why, but we need to look
at it, and that's why I'm trying to take this out of the realm
of just looking at a procedure like abortion and get it out
into the realm of women's health and what women's risk factors
are.
So I think there are data out there, and they are pretty
decent data, but it's not completely explanatory why, and
that's why I think, you know, focusing the direction of money
in that direction to see what the differences are and what the
risk factors are will help women not feel so bad that they feel
like they want to hurt themselves for whatever reason, for
psychotic reasons, or for reasons of feeling they have shamed
their family, or for whatever reason they are feeling that way.
Mr. Rush. I yield back, Mr. Chairman.
Mr. Bilirakis. I thank the gentleman.
Doctor, you co-authored the Clinical Depression Guidelines
for use at the University of Michigan.
Ms. Shadigian. That's correct, two times.
Mr. Bilirakis. Two times.
Have you submitted those to any of the medical journals,
you know, as usually researchers would do and what not? I mean,
have you made that available so that it might be, you know, a
resource for physicians around the country?
Ms. Shadigian. It's actually available on our University of
Michigan home page, so it's available for people to look at and
log in on, and it actually has tables of all the common drugs
used for depression, how much they cost, how do you diagnose
depression in different groups of people, and what special
circumstances are. So, they are not just about women, they're
like all depression, it's a big 30-page document. So, it's an
actual very big resource. I'd be glad to give a copy of that
for the committee, if that would be helpful.
Mr. Bilirakis. I think that would be great to have that,
but you know what, I'm so much concerned about education, what
we find in our hearings here, we will disagree on
technicalities and political, and we all have biases because we
are human beings and God has placed biases into us, but at the
same time I think we all agree that more often than not more
education for the general public and for medical doctors,
nurses, et cetera, is so very important.
Anything that will be helpful in that regard.
Is there, and I don't know, maybe Ms. Capps knows, is there
an expert anywhere in the country who is kind of the authority
on depression in women, particularly, as it involves pregnancy,
or after pregnancy, but still depression in women?
Ms. Capps. Doctor Stotland.
Mr. Bilirakis. Well, all right, I know she testified, is
she the--do you agree, Doctor Shadigian, that she should be
considered the authority? She's still in the room.
Ms. Shadigian. Well, I don't think there's one authority on
this whole issue. I think that, you know, we all come from our
own biases and perspectives.
I think that OB/GYN physicians see pregnant women
constantly, and are the ones who follow them in pregnancy and
afterwards, but are not exclusive. Family practice physicians
do deliveries, and so do midwives.
But, in terms of depression, it's a very good question. The
whole thrust has been to actually educate primary care
physicians to identify depression and to identify people at
higher risk, and only refer, in fact, the most serious cases,
people who actually have psychosis and all those more serious
symptoms to psychiatrists.
And, in fact, most depression is treated by primary care
physicians, internal medicine, OB/GYN, family practice, et
cetera, and even pediatricians for their kids with depression.
Mr. Bilirakis. And yet, you tell us that medical schools
are not emphasizing that adequately.
Ms. Shadigian. No, I said violence against women, that's
before, but they are trying to do that more and more, and I
think the emphasis is to see that it's the generalist
physician, who is treating the bulk of depression in America.
Mr. Bilirakis. Well, all right, thank you.
I thank you both. Ms. Fredenburg, you came a long way, and
it took a lot of courage for you to be willing to do it, and we
really are very grateful to you. And, Doctor, you are quite a
witness, and we are all grateful that you're still an OB/GYN.
There aren't too many of you around anymore unfortunately, as a
result of----
Ms. Capps. Mr. Chairman, is there time for another round of
questions?
Mr. Bilirakis. No, I'd rather-well, I'd rather not go
through another round, but they have to make a flight, as I
understand it, that's what I was told earlier, but I mean if
you have something for a minute or so, go ahead.
Ms. Capps. I'd love to follow up on some of the things you
brought up, if the panel is willing and can stay for a couple
minutes.
Would you mind if I ask a couple questions?
Mr. Bilirakis. Well, you can take a couple minutes.
Ms. Capps. Okay.
Mr. Bilirakis. Don't ask a couple questions, because that
could take 10 minutes.
Ms. Capps. I wanted to, because, Mr. Chairman, you turned
to me and said is there one authority, and I think everyone
cringes at the thought of being--having one authority on
women's mental health issues. But, we do have one Federal
agency, which is the National Institutes of Mental Health, and
I just wanted to make sure that when Doctor Shadigian says that
the studies that she's citing do take into account prior
conditions before studying the ten studies that you referenced
in your literature, that study post-abortion depression or
symptoms, that there is a body of evidence to the contrary that
those studies do not adequately explain and bring to light pre-
pregnancy conditions that would certainly have a bearing on the
outcome of any procedure, whether coming to term or termination
of a pregnancy. So, I think that needs to be part of the
documentation today.
And, if there is time I wanted to ask you a question,
Doctor Shadigian, because you have mentioned a couple of times,
and I think today as well, that abortion is associated with
breast cancer, that in your testimony before the Senate, and I
want to get your answer on the fact that I'm under the
impression that this has been contraindicated by a major group
of health experts.
Have you made the assertion that abortion is associated
with breast cancer?
Mr. Bilirakis. Well, you know, I gave you an extra couple
of minutes, and now you are changing the subject.
Ms. Capps. Well, we are talking about----
Mr. Bilirakis. The subject of the hearing is depression
after pregnancy.
Ms. Capps. [continuing] physical and-breast cancer is a
pretty big topic.
Mr. Bilirakis. Do you have a very brief quick answer to
that?
Ms. Shadigian. Well, I think the problem that--a quick
answer is that we are not going to see the big picture. I think
the problem around even answering that question is it's going
to be, you know, a short, one-sentence answer to a very complex
issue.
And, I think the bottom line of that issue is, we need to
do a good study, a prospective study of women, you can include
women's health issues like depression, breast cancer, just
whole--you can go down a list of things that are important, and
do a prospective study and then, instead of just quoting other
studies that are retrospective or look backwards, and maybe
aren't as well designed, we'll be able to answer that question
more definitively----
Ms. Capps. But we don't have an association at the moment.
There's a lot of literature out there in clinics and other
places that if you have an abortion your chances of getting
breast cancer are very high. Do you agree with that?
Mr. Bilirakis. Well, now----
Ms. Capps. That could be a yes or no answer.
Mr. Bilirakis. [continuing] you know, that's why we can't
get anything done around here. You know, we are concerned about
depression in women after pregnancy. It's a wide enough subject
as it is, and yes we are concerned about cancer, whether
there's any effect of abortion on cancer and that sort of
thing, but that's not the subject matter of our hearing. And,
instead of concentrating on what the doctor said so many times,
which the concern is depression in women after pregnancy, we
keep going back to our bias insofar as abortion is concerned,
and I'm not sure what good that is doing as far as the hearing
goes.
Well, all right, if there's nothing more, I think I am
deeply----
Ms. Capps. If I could have an answer, because it came up in
the testimony. I mean, I just would like to--I didn't hear it
clearly enough, but the association was made in your testimony.
Ms. Shadigian. I think there's a large body of literature
that shows both sides, and that the studies are incomplete, and
that we will be able to answer that question more definitively
when a good prospective study, or several ones around the
world, are conducted.
And so, therefore, it is important that, you know, this
Congress actually think prospectively and try to help the
researchers design these studies by funding them.
Ms. Capps. In the meantime it's used as a scare tactic. I
appreciate your answer, though.
Mr. Bilirakis. The hearing is thus concluded. We, as we
always do, furnish you written questions, and we would hope
that you will respond to those questions in writing, you know,
as timely as you might.
And again, our gratitude for your being here. It's turned
out to be a pretty good hearing. I just wish we could have kept
it more on subject, but that's the way it goes.
Thank you so very much, both of you.
The hearing is adjourned.
Ms. Shadigian. Thank you, sir.
[Whereupon, at 3:46 p.m., the subcommittee was adjourned.]
[Additional material submitted for the record follows:]
Prepared Statement on Behalf of The American Cancer Society
The American Cancer Society would like to thank Congress and
particularly Chairman Biliraiks and the House Energy & Commerce
Committee for their strong support of an initial physical for Medicare
beneficiaries, which resulted in Section 611 of the Medicare
Modernization Act (MMA), otherwise known as the ``Welcome to Medicare''
visit. The Society--along with our partners in the Preventive Health
Partnership (PHP), the American Diabetes Association and the American
Heart Association--has been a strong advocate for the initial physical
because we believe this new benefit will help promote prevention and
early detection and will result in lives saved and improved quality of
life for our nation's seniors.
Now that Section 611 has been enacted as part of the MMA, we have
been working with the Centers for Medicare & Medicaid Services (CMS) on
the implementation and with the PHP on outreach initiatives. While we
would have liked to testify, the Society appreciates this opportunity
to communicate our interest in and perspective on this critical new
benefit to the House Energy & Commerce Committee's Subcommittee on
Health.
The Society Supports a Comprehensive Physical
Recognizing the strong value of early detection, Congress has
already provided Medicare coverage for breast, cervical, colon, and
prostate cancer screenings. While screening rates have increased since
the coverage became effective, they are still below their optimum
levels. Studies have shown that a physician's recommendation is key to
increasing screening rates; however, before Section 611 was enacted,
Medicare did not cover a routine physical or other type of ``wellness
visit'' where a conversation between a doctor and patient about cancer
screening can easily take place. The American Cancer Society advocated
for an initial ``Welcome to Medicare'' visit for new Medicare
beneficiaries so that patients and their health care providers could
have time dedicated to discussing the patient's health risk as well as
recommended disease prevention strategies, such as smoking cessation,
better nutrition and increased physical activity, and needed cancer
screenings that could either be performed as part of the physical or,
if needed, scheduled through a referral. We recognize the challenges
Congress faced in creating the benefit and the challenges CMS is now
facing with respect to implementation. Overall, the Society is pleased
with the completeness of the new physical as outlined in CMS' recent
proposed regulation, in particular that it will include a review of a
patient's comprehensive medical and social history, which will include
reviewing their family history, tobacco use, diet, and exercise. We
also appreciate the inclusion of several health measurements, including
the patient's height, weight, blood pressure, visual acuity and other
factors deemed appropriate by the health care provider based on the
patient's examination. While we recognize that patients fill out paper
work that captures some of this information prior to their enrollment
in Medicare or when they visit a new provider, we feel it is important
to use the opportunity presented by the physical for the physician and
patient to have a specific discussion about the patient's medical and
social history. Many physician practices ask patients to fill out a
survey before their first visit. Our hope is that physicians will be
able to use the information collected on these types of forms as a
discussion tool during the visit.
The need for such a visit is underscored in medical literature. For
instance, in a study of 2,775 primary care patients, the strongest
factor in whether or not an individual had undergone screening, was
whether or not they had a specific visit for a health check-up in the
previous year.1 In other words, relying on a doctor to
mention screening during their sporadic contact with patients is not
practical--and does not work. Furthermore, an analysis in the Annals of
Internal Medicine found that planned visits dedicated to prevention are
one of the most effective ways to get people screened.2
Dedicated check-ups provide the opportunity to plug cracks in the
system and assure that patients get their necessary preventive care.
---------------------------------------------------------------------------
\1\ Sox CH, Dietrick AJ, Tostenson TD, Winchell CW, Labaree CE.
Periodic health examinations and the provision of cancer prevention
services, Arch Fam Med. 1997:6:223-30.
\2\ Stone EG, Morton SC, et al. Interventions that Increase Use of
Adult Immunization and Cancer Screening Services: A Meta-Analysis.
Annals of Internal Medicine. 2002;136:641-651.
---------------------------------------------------------------------------
It is our understanding from conversations with Committee staff and
CMS that cancer screenings that can be performed by the health care
provider during the physical (such as pap smears and prostate-specific
antigens) may in fact be performed during the visit instead of
requiring a referral. We applaud this approach, as it ensures that
patients and physicians can make the most of this visit. However, we
feel that there is some ambiguity in the proposed regulatory language
regarding this point and have therefore sought clarification from CMS
on this specific issue.
Ways in Which the Physical can be Improved
Allow CMS to Add New Preventive Services
As a leading source of cancer screening guidelines, the Society is
well-aware that science advances quickly and therefore frequently
reviews and updates our guidelines. Currently, Medicare covers the
following cancer screening tests, which are inline with the Society's
recommendations:
Breast Cancer Screening: annual mammograms and regular clinical
breast exam
Prostate Cancer Screening: annual digital rectal exam and annual
prostate-specific antigen test (PSA)
Cervical Cancer Screening: pelvic exam every two years and pap smear
(either a conventional pap test, or a liquid based-pap cytology
tests such as Thin Prep) every two years
Colorectal Cancer Screening: beneficiaries have the choice of one of
five options annual Fecal Occult Blood Test (FOBT)
Flexible Sigmoidoscopy every four years
Flexible Sigmoidoscopy every four years + annual FOBT
Colonoscopy every ten years for average risk individuals and every
two years for those at high risk
Double Contrast Barium Enema as an alternative to flexible
sigmoidoscopy or colonoscopy
The Society was very pleased that Congress included a provision in
Benefits Improvement and Protection Act of 2000 (BIPA) that not only
expanded colonoscopy coverage to include average risk individuals, but
also included language that gave the Secretary the authority to update
Medicare coverage for colorectal cancer screening ``in consultation
with appropriate organizations.'' Congress recently also gave CMS this
specific authority through the MMA to update cholesterol screening.
This type of language wisely gives the Secretary the authority to
ensure that Medicare screening benefits are in line with the current
state of the science and guideline recommendations.
Recently, a new FOBT test--an immunochemical test, or an iFOBT,--
was added to the Society's colorectal cancer screening guidelines,
since it was found to be more patient friendly, and likely to be equal
or better than guaiac-based tests in sensitivity and specificity. We
were very pleased that the BIPA language allowed CMS to update the
colorectal cancer screening coverage in a timely and similar fashion to
include iFOBT. Given the success that we have had with this language in
relation to improving the colorectal cancer screening benefit, we feel
that it is important that CMS be given the authority to update other
Medicare coverage for preventive services in a similar fashion and
would be pleased to work with Congress to this end.
In giving CMS the authority to add preventive services, we would
ask that the language regarding with whom CMS consults be kept
consistent with the existing colorectal cancer and cholesterol
screening language. Congress has previously considered directing CMS to
rely solely on the recommendations of the United States Preventive
Services Task Force (USPSTF). While USPSTF serves an important function
and is widely respected in their guidelines recommendation process,
their limited resources have in the past prevented them from being as
responsive to current evidence as such organizations as the American
Cancer Society.
The USPSTF is known for conducting comprehensive assessments of
clinical prevention services; however, the timeliness of these
assessments has been cited as a concern by the Institute of Medicine
(IOM) in its 2003 report, ``Fulfilling the Potential of Cancer
Prevention and Early Detection.'' While the USPSTF updated its
prostate, breast, and colorectal cancer screening guidelines in 2002
and its cervical cancer screening guidelines in 2003, the IOM noted
that the previous USPSTF guidelines for these vital tests were last
issued in 1996--a time lag spanning six to seven years. The IOM report
concluded that ``assessments of prevention services are needed on a
continual basis to ensure that public health recommendations are
current and incorporate the latest scientific evidence.'' 3
The report also acknowledged that a significant barrier to USPSTF
issuing more timely guidelines is that it has limited resources and
that this would have to be rectified before the Task Force could
improve its responsiveness
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\3\ Institute of Medicine. Curry S., Byers T. and Hewitt M., eds.
2003. Fulfilling the Potential of Cancer Prevention and Early
Detection. Washington, DC: National Academy Press, p. 429-430.
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Further, the Society notes that there are screening tests we
currently recommend and are covered by Medicare that are not yet
recommended by the USPSTF (e.g., liquid based-pap cytology tests such
as Thin Prep). The American Cancer Society feels strongly that existing
coverage for cancer screening tests should remain intact. Rolling back
coverage for tests such as Thin Prep would be a step backwards in
bringing the Medicare program up to date with proven disease prevention
and early detection strategies.
Remove Cost-Sharing for Preventive Services
The Society also has an interest in removing cost-sharing for the
physical and all Medicare covered preventive services. Under MMA, the
new physical will be subject to the standard co-insurance and
deductible. Since studies have shown that cost-sharing has the effect
of reducing the probability of patients using preventive services, we
have long advocated for the elimination of cost-sharing for all cancer
screenings. The Society is very interested in continuing to work with
Congress on efforts to reduce or eliminate cost-sharing for the
physical and other covered cancer prevention and early detection
services.
Increase Physician Payment
As the Society has noted in our recent comments to CMS on the
proposed Physician Fee Schedule, we are concerned that the payment for
this benefit may not be sufficient to compensate physicians for the
services provided under the examination. Under the proposed value for
the new HCPCS code, G0XX2, a physician must provide several services,
including an electrocardiogram, within approximately 45 minutes.
Payment for this new HCPCS code will be based on CPT code 99203, new
patient, office or other outpatient visit, and CPT code 93000,
electrocardiogram, complete. We would like to see this physical paid
using the higher level new visit code, CPT code 99205. We are concerned
that the current payment may not adequately compensate physicians for
their time and could result in shortened visits or visits that fail to
include all of the appropriate education, counseling, and referrals.
The Society has asked CMS to reconsider the payment for the physical
and raise it to a level that will not act as a disincentive for
physicians.
Broaden Tobacco Cessation Resources
The Society also has a long-standing interest in tobacco use
cessation and strongly advocates for the availability of and access to
both cessation counseling and appropriate drug therapies for all of the
reported 70 percent of smokers who want to quit. Currently, Medicare
does not cover cessation counseling nor does it cover nicotine
replacement therapies (NRT). Medicare will begin to cover NRTs
available by prescription only once the new prescription drug coverage
goes into effect on January 1, 2006. Given the limited cessation-
related resources that will be available to patients--at least
initially, we have asked CMS for clarification on what physicians will
be able to do for patients during the first year of the benefit and
later after the prescription drug benefit goes into effect. We
appreciate that the new physical presents an opportunity for the
physician and patient to begin the discussion about tobacco cessation,
and we will continue our work with you to secure coverage for a full
cessation counseling benefit. Furthermore, the Society devotes
extensive resources to tobacco cessation, including the operation of a
quitline in a number of states, and would be pleased to serve as a
resource to physicians seeking cessation services for their patients.
We note that the report on the Medicare cessation demonstration,
``Medicare Stop Smoking Project,'' should be released shortly, and we
look forward to working with Congress and CMS to address its
recommendations.
The Importance of Outreach
The Society recognizes that securing coverage for the physical is
only half of the battle--we must also do our part to ensure that
patients know about the new benefit and use it appropriately.
Therefore, the Society is currently focused on using our organization-
wide resources to get the word out to patients and physicians that this
new benefit exists. We have already begun working on a variety of
initiatives on our own and were also recently invited by CMS to begin
an outreach partnership with them and our partners in the PHP.
The PHP's ultimate goal is to stimulate improvements in chronic
disease prevention and early detection. Together, we strive to raise
public awareness about healthy lifestyles and enhance the focus on
prevention among health care providers. The PHP has begun a
comprehensive public awareness campaign, ``Everyday Choices For A
Healthier Life,'' which includes television and radio PSAs sponsored by
The Ad Council, a joint website, an 800-number and educational
materials.
With respect to the physical, the Society's education efforts are
beginning now so that we can reach as many of those who will become
Medicare beneficiaries in the beginning phases of this new benefit as
possible, but these efforts will be on-going. Some of the things the
Society is already working on include:
Beginning educating physician memberships and our staff and
volunteers by sharing a fact sheet on the physical that we
prepared from statutory language. The fact sheet has already
been distributed at the American Society of Clinical Oncology's
annual meeting and the Primary Care Advisory Meeting, and will
be distributed at the American Academy of Family Practitioners
annual meeting.
Sharing Society expertise with CMS by arranging a meeting between CMS
staff and our Director of Cancer Screening to discuss the
implementation of the physical and to discuss the possibility
of helping CMS create a checklist that physicians can use
during the physical. The Society has also submitted comments to
CMS on the proposed Physician Fee Schedule's implementation of
the physical.
Working to raise media attention about the physical prior to the
release of the regulation and again after the proposed
regulation was released. The Society will continue to do
outreach with reporters as the January 1 implementation date
approaches.
Conducting on-going discussions with CMS about partnership
opportunities with the Society and the PHP such as potential
joint events with the CMS Administrator that publicize the
physical and encourage patients to schedule the visit.
Other resources the Society plans to use to educate beneficiaries
include the following:
Using our ``direct channels'' such as our website, call center and
the cancer survivors network
Drafting articles on the benefit for our CA Journal and working with
various other groups to publicize the physical at other
professional meetings in the fall.
Exploring other possibilities such as creating a Continuing Medical
Education course on the physical and considering other ways in
which we can work with the American Diabetes Association and
the American Heart Association through the PHP to create joint
activities.
Conclusion
The Society appreciates the leadership of this Committee in
securing coverage for the ``Welcome to Medicare'' physical and
Congress' bipartisan support for the provision. We look forward to
working with you and CMS to ensure that new Medicare beneficiaries and
their providers are aware of and utilize the opportunity for prevention
the physical represents. On behalf of the Society, and the more than
1.3 million Americans who will be newly diagnosed with cancer this
year, we thank you for your time and the opportunity to present
testimony.
______
Prepared Statement of Eric J. Hall, CEO, Alzheimer's Foundation of
America
Chairman Bilirakis, Ranking Member Brown, and distinguished
Subcommittee members: On behalf of the Alzheimer's Foundation of
America (AFA), thank you for holding this important hearing on
preventive benefits enacted as part of the Medicare Modernization Act
of 2003 (MMA).
AFA believes the preventive benefits enacted under the MMA
represent an important step forward in improving the health of our
nation's Medicare beneficiaries. In particular, Mr. Chairman, we
support and applaud your efforts to establish an initial preventive
screening examination under Medicare.
AFA's Mission
An estimated five million Americans currently suffer from
Alzheimer's disease, and the number is expected to rise to 16 million
by mid-century. It is therefore critical that we all stand together for
care as the incidence of this devastating disease continues to rise.
AFA was founded as a nonprofit 501(c)(3) organization to fill a gap
that existed on the national front for advocacy of ``care . . . in
addition to cure'' for individuals affected by Alzheimer's disease and
related dementias. AFA and its members provide direct services to
millions of Americans living with Alzheimer's disease and related
disorders nationwide, as well as their caregivers and families. Our
goals include improving quality of life for all those affected and
raising standards for quality of care.
AFA operates a national resource and referral network with a toll-
free hotline, develops and replicates cutting-edge programs, hosts
educational conferences and training for caregivers and professionals,
provides grants to member organizations for hands-on support services
in their local areas, and advocates for funding for social services. It
annually sponsors two national initiatives, National Memory Screening
Day and National Commemorative Candle Lighting. AFA is also working to
promote healthy aging through prevention and wellness education and to
expand screening for memory impairment as a tool to facilitate early
diagnosis and treatment.
The Importance of Memory Screening
Early recognition of Alzheimer's disease and related dementias is
essential to maximize the therapeutic effects of available and evolving
treatments, and screening for memory impairment is the only way to
systematically find treatable cases. Diagnosis in the early stages of
the disease is vital, providing multiple benefits to individuals with
the disease, families and society. Screening can also be beneficial for
individuals who do not present a diagnosis of Alzheimer's disease by
allaying fears and providing an opportunity for prevention and wellness
education.
Memory screening is a cost-effective, safe and simple intervention
that can direct individuals to appropriate care, improve their quality
of life, and provide cognitive wellness information. With no ``silver
bullet'' for dementia in the immediate future, it is essential to fully
use all preventive measures and early interventions. AFA supports a
comprehensive strategy that involves both research for a cure, as well
as a national system of care that includes cognitive wellness, early
detection and intervention, and disability compression.
To advance that objective, AFA launched National Memory Screening
Day in 2003 as a collaborative effort by organizations and health care
professionals across the country. AFA initiated this effort in direct
response to breakthroughs in Alzheimer's research that show the
benefits of early medical treatment for individuals with Alzheimer's
disease, as well as the benefits of counseling and other support
services for their caregivers.
AFA's annual National Memory Screening Day underscores the
importance of early diagnosis, so that individuals can obtain proper
medical treatment, social services and other resources related to their
condition. With no cure currently available for Alzheimer's disease, it
is essential to provide individuals with these types of interventions
that can improve their quality of life while suffering with the
disease.
During National Memory Screening Day, healthcare professionals
administer free memory screenings at hundreds of sites throughout the
United States. A memory screening is used as an indicator of whether a
person might benefit from more extensive testing to determine whether a
memory and/or cognitive impairment may exist. While a memory screening
is helpful in identifying people who can benefit from medical
attention, it is not used to diagnose any illness and in no way
replaces examination by a qualified physician.
Our goal is for individuals to follow up with the next steps--
further medical testing and consultation with a physician, if the
testing raises concerns. The latest research shows that several
medications can slow the symptoms of Alzheimer's disease and that
individuals begin to benefit most when they are taken in the early
stages of memory disorder. This intervention may extend the time that
individuals can be cared for at home, thereby dramatically reducing the
costs of institutional care.
With early diagnosis, individuals and their families can also take
advantage of support services, such as those offered by AFA member
organizations, which can lighten the burden of the disease. According
to several research studies, such care and support can reduce caregiver
depression and other health problems, and delay institutionalization of
their loved one--again reducing the economic burden of this disease on
society.
In addition, with early diagnosis, individuals can participate in
their care by letting family members and caregivers know their wishes.
Thus, memory screenings are an important tool to empower people with
knowledge and support. Just as importantly, the screenings should help
allay fears of those who do not have a problem.
AFA holds National Memory Screening Day on the third Tuesday of
November in recognition of National Alzheimer's Disease Month.
Broadcast personality Leeza Gibbons is the national advocate for this
event. Ms. Gibbons founded The Leeza Gibbons Memory Foundation in
response to her own family's trial with Alzheimer's. She lost her
grandmother to the disease, and her mother now battles with the final
stages of Alzheimer's.
This year, National Memory Screening Day will be held on November
16, 2004. Individuals concerned about memory problems will be able to
take advantage of free, confidential screenings at hundreds of sites
across the country with the goal of early diagnosis of Alzheimer's
disease or related dementias. Early diagnosis is critical, because as
Ms. Gibbons has noted, ``This is not a disease that will wait for you
to be ready.''
The Need for Federal Leadership
As promising research continues in the search for a cure,
additional resources are also needed in support of efforts to delay the
progression of Alzheimer's disease and related dementias. The federal
government can play a critical role in that regard by providing
resources for a public health campaign designed to increase awareness
of the importance of memory screening and to promote screening
initiatives.
Federal support is essential to expand the scope of ongoing efforts
in the private sector. Working in partnership with AFA and other
participating organizations, the federal government can leverage its
resources cost-effectively to help overcome fear and misunderstanding
about Alzheimer's disease and related dementias, to promote public
awareness of the importance of memory screening, to expand options for
screening nationwide, and to direct Americans to the support services
and care available in their local communities.
To that end, AFA is urging the Centers for Medicare and Medicaid
Services (CMS) to provide screening for memory impairment as part of
the Medicare initial preventive screening examination. CMS included a
specific request for public comments on the scope of the exam in its
proposed rules; therefore, AFA is recommending that CMS include
screening for memory impairment within the proposed definition of a
``review of the individual's functional ability, and level of safety,
based on the use of an appropriate screening instrument.'' The proposed
rules also state that review of an individual's functional ability and
level of safety must address activities of daily living and home
safety.
In that context, unrecognized dementia can increase the likelihood
of avoidable complications such as delirium, adverse drug reactions,
noncompliance, etc. These complications reduce the autonomy of affected
individuals, thereby impeding their ability to perform activities of
daily living and compromising their safety. In addition, about one-
third of elders live by themselves, and these individuals are at
greater risks for accidents, injuries, exploitation, and other adverse
outcomes. Early identification allows safeguards and home assistance to
assure continued maximization of home placement.
For the affected individual, identification of early stage dementia
allows early aggressive use of available treatments. Early
identification allows optimal therapy with available and emerging
medications. Most FDA-approved medications can help slow the
progression of symptoms of Alzheimer's disease and related dementias
when presented in early stages of dementia.
Once dementia is identified, health care management can be adjusted
to incorporate treatment strategies that accommodate a person with
cognitive impairment. Issues such as patient education, self-
medication, compliance, and hospital care can be adjusted to meet the
needs of a mildly demented person who is at risk for common
complications such as delirium and depression. Home-based support
systems can be adjusted to maximize home placement for these
individuals. Safeguards can be taken to prevent avoidable complications
such as delirium during hospitalization.
Further, the early identification of dementia supports individual
patient rights and self-determination. Mildly impaired individuals are
capable of charting the future course of their care and making
substantial decisions on issues like end-of-life care, resuscitation,
disposition of wealth, etc. Advanced directives can be initiated that
incorporate the wishes of individuals with dementia, thereby reducing
the burden on the family of surrogate decision-making. Individuals with
the disease can also take advantage of social services and other
support that can improve quality of life. These include counseling,
verbal support groups and cognitive stimulation therapies. These
strategies may prolong activities of daily living, and promote a sense
of dignity.
Separately, family caregivers also benefit from early
identification at several levels. As noted above, early identification
reduces the family burden with regard to decision-making, because
families can follow the instructions of their loved ones. This process
allows family caregivers to benefit early on from support groups,
education and other interventions that address their unique and
pressing needs. Such knowledge and support can empower them to be
better caregivers and can reduce their incidence of depression and
other mental and physical health problems. Intervention can also help
on an economic front: lightening the burden on primary caregivers, who
are also in the workforce, could help reduce employee absenteeism and
lost productivity.
Finally, screening can be beneficial for those individuals who do
not present a diagnosis of Alzheimer's disease. These negative results
can allay fears and provide reassurance. Just as importantly,
physicians can take this opportunity to present individuals with
prevention and wellness education--a strategy that promotes successful
aging.
We would note that use of available screening instruments to
identify memory impairment during the Medicare initial preventive
physical examination is consistent with current clinical practice
guidelines. Individuals with mild cognitive impairment are at higher
risk for subsequent development of Alzheimer's disease and related
dementias. General cognitive screening instruments are available and
are useful in detecting dementia in patient populations with a higher
incidence of cognitive impairment (e.g., due to age or memory
dysfunction). Attached for Subcommittee Members' reference is a summary
of the relevant American Academy of Neurology practice guidelines for
physicians.
Inclusion of screening for memory impairment is also consistent
with the recent CMS National Coverage Decision expanding Medicare
coverage of Positron Emission Tomography (PET) for beneficiaries who
meet certain diagnostic criteria for Alzheimer's disease and fronto-
temporal dementia.
AFA believes PET and other neuroimaging devices will be a valuable
tool in predicting disease and in steering those with a diagnosis of
Alzheimer's or related illnesses to the appropriate clinical and social
service resources. Expanded reimbursement for PET studies will drive
early intervention for the increasing--and alarming--number of
Americans with Alzheimer's disease. Utilization of this technology will
become even more critical in the future, as the number of Americans
with dementia is projected to triple by mid-century.
Conclusion
Expanded screening to facilitate the early identification of memory
impairment will produce tangible benefits to society by protecting
individuals, improving quality of life, and reducing the costs of
health care. Enhancing compliance and protecting individuals with
dementia also produces tangible financial benefits to the health care
system. Intervention can enable individuals to remain independent
longer and can reduce the costs of insurance, absenteeism and lost
productivity at work for primary caregivers--currently estimated at $60
billion annually.
AFA commends the Subcommittee's leadership in striving to improve
preventive care for our nation's Medicare beneficiaries. We would
likewise welcome the opportunity to work collaboratively to improve the
quality of life for Alzheimer's patients, their families and
caregivers. Please feel free to contact me at 866-232-8484 or Todd
Tuten at 202-457-5215 if you have questions or would like additional
information.
Thank you for the opportunity to share our views.
Sincerely,
Eric J. Hall
Chief Executive Officer
______
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