$34,000 to save mothers and their children from postpartum depression

$34,000 to save mothers and their children from postpartum depression

A swimming pool. Most of a Tesla. Not nearly enough to have your kid swapped out during their sham SAT test. Nor would an ICU bill for a stay that resulted in survival — $48,744 is the cost of that. What costs an alarming amount more is the bill the US Government pays annually on erectile dysfunction medications for servicemen — a whopping $8.7 million according to a 2016 Rand report.

In May of 2014, I admitted a patient to our inpatient hospital within Twin Towers Correctional Facility. A Los Angeles County facility that’s notoriously notorious for it seems everything — not the least being what’s called the largest psychiatric hospital within the world’s largest jail that houses between 14 to 17 thousand inmates at any time. This is probably my 800th admission that year. The prison churns over 100 thousand inmates through its doors per year. It was perhaps one of the 50 peripartum cases I would care for that year. Yet, this one would impact my life in the most jarring way. Its reverberations I have quietly carried for years, until now when it is appropriate to speak up on her behalf and those she may one day represent. I can now as she lost her appeal, and I am free to be judged by non-judges.

I chose now as the time to bring this difficult case up again because I have been dismayed by responses to the new FDA approved drug to treat PPD, Brexalone, which costs $34 thousand and is infused over four and a half days, has a fast therapeutic response time — days, not weeks as we see are used to, and the results appear to be highly effectively. The degree of naysayers rejecting it outright with comments such as: “I’ll stick SSRI’s with that price tag,” prompted this article. Maybe it was time I finally spoke about Carol.

In my five years having been a prison doctor, I can say, I have seen just about everything, heard it all, imagined it all, been caught in the middle of the worst, seen people at their absolute lowest points of humanity.

I have cared for those society loves to hate and rallies for tougher sentences for them. “An eye for an eye.” And when you have walked the rows housing over 700 inmates on death row at San Quentin and have seen the licensed 55-bed psychiatric state hospital built to care for those who are condemned to death, it is not so easy to see anything as “evil or holy.” “An eye for an eye” seems as nonsensical as the gang’s own code of ethics. Perhaps the most degrading illusion is the one DAs consistently rely on as the “other” explanation for psychosis: “true evil.” The most complicated cases are boiled down to these simple, digestible categories. There is nothing left for us as a society to gain or grow from. Just a simple label. A concrete punishment. No need to look backward. Evil has been captured. The world is now safe again.

Yet what we lose is understanding the simple things we could have done before we have 700 people on death row — or a postpartum psychotic woman murder her children.

Upon receipt of this patient who had been at after four days of treatment at LA County USC’s trauma center following a self-inflicted stab wound to the chest, she was deemed stable for transfer to our medical ward at Twin Towers Correctional Facility as her chest tube had been removed. I knew what medications she had been given already from the sign out provided by the psychiatrist at LAC USC who had seen her and also knew what she was given upon her initial transfer to Torrance Memorial. She had been receiving antipsychotics since her presentation to the hospital, including emergency injections for agitation, psychosis, and confusion for the previous four days. But she was now calm, almost catatonic.

I said very little to her except that I was her doctor and everything would be between us. She’d get the same care from me on the inside as she would on the outside. I would do my best to help her. She could trust me. She had already been riddled with dozens of questions in the previous days. She didn’t appear capable of hearing much of what I said, let alone being able to answer a series of questions. Those would need to be asked, slowly, over time. I was surprised by her physical appearance. She was gaunt, almost cachectic. Not like a postpartum mom. She responded minimally. She had sunk herself as deeply as possible into her suicide gown, like a cocoon from which she mumbled a “thank you” and that she was tired, couldn’t think, wanted to sleep but would try to talk to me another day. She didn’t make eye contact, no facial expressions. Like a person who had expected to be dead but found herself alive inside a shroud of a suicide gown.

Carol Coronado was charged and found guilty not by reason of insanity for the murders of her three young children, ages one, two and 13 weeks. The usual questions surfaced first: No, she did not have a drug abuse history, and her tox screen was negative. No, she never had a DCFS report. In fact, she was described as being a “loving mother” who worked as an X-ray tech to support her family. She was poor, with little to no support as her husband Rudy was the first to publicly admit his role in being absent often and unsupportive, not understanding what PPD even was. Money was tight without her working as Rudy worked selling used car parts at the swap meet. He had started to use some of the welfare benefits to get cash for marijuana leaving Carol with fewer diapers and formula than she needed. She knew she felt “bad” and “not happy,” at times “hopeless,” but she also felt this way the first two times after her pregnancies and never managed to find help. “My OB said I was OK, and I guess I was and so I went back to work and kept busy.” I asked her about three kids in two and a half years — did anyone discuss birth control? “I didn’t want them so soon.” It seems Rudy was present at the hospital during the discussions and he wanted her to have multiple children. She wasn’t empowered to go about this on her own. She was already pregnant by her six-week postpartum visit each time when they were supposed to address it.

I cared for Carol for over a year in our inpatient psychiatric forensic unit, then testified in her criminal trial as the treating psychiatrist. I have thought about her case in more ways and through more angles than may be humanly possible.

It is not the sheer tragedy of it, which is the greatest tragedy of them all: the murder of children. Unfortunately, I have seen that many times. And while those cases have a particularly ingrained place in my psyche, it is Carol in this case that does as she was my patient. I recall a social worker asking me how I could care for as a patient given the fact that I have children. She went on, “I could never look her in the eye knowing what she did to those babies. I could only see my own baby.”

That made me sad for Carol. The ball had been dropped so many times before this tragedy, and now, it had turned into a game of dodgeball.

I thought night and day about how we failed Carol. Rudy already admitted how. Next would be her mother who testified that Carol left her multiple desperate messages on the day of the crime asking for help, saying, “Please help me, I think I am going crazy.” She decided to finish her shift as a bus driver at a school then head over in the evening, at which time it was too late. Presumably, Carol always had it “together.” She wasn’t the “type.”

And she visited her well-meaning OB/GYN just a week before the murders. He testified that he didn’t ask her about depression or suicide because she seemed “fine.” I can see how he wouldn’t think of Carol as at risk. She is the epitome of not wanting to be a “problem” or seeming like she is a “problem” for anyone. She isn’t a complainer, and patients like her can seem “fine” when they aren’t. We have 10 minutes, a patient says they are “fine” they want to go back to work — it seems straightforward.

What do we miss in those tight 10-minute appointments? Where are those vitals signs again? Are they in the chart already, or is the MA holding on to them? Who knows, and I can’t blame the OB for not noticing that Carol weighed less 12 weeks postpartum after three kids in two and a half years than she did before her first pregnancy. For one, robotic AI EMRs don’t flag such things: weight loss is a green flag! Whoo hoo! The doctor would have to have a reasonable suspicion of a problem to go back and compare weights that far back (easier for me to say from a forensic vantage point). Or maybe those data points just aren’t available on his clunky overly data-filled EMR that has her pulse-ox dating back to 2005 but not her weight changes. Who knows? All I know is that I can miss practical things more readily now with EMR than I used with simple documentation because practical information that requires a physician’s brain to connect the dots is a challenging task in an EMR with glowing alerts and tasks and hard stops to answer meaningless questions.

And more than all of those people who had the opportunity to see Carol, what about me? How was I complicit in her crime?

I testified that, in fact, we all were. All of us who make up Carol’s community, and that includes me, a physician who trained at a hospital that provided 24-hour psychiatric care on a walking basis and in a county where all residents can receive free psychiatric care and medications — and can set that up 24 hours a day by calling 1-800-854-7771. How did Carol never leave the hospital with a 24-hour access line? How, when the prevalence of PPD is 1/10.

And even if Carol had that information — would she have acted on given the stigma of getting psychiatric help as a new mom?

While Carol is the one who took the life of her three young children — as a society, we are all to blame in some way for her own need to perpetuate an image of “happiness” and “normalcy” when she was experiencing anything but. As a society, we are obsessed with congratulating new moms — “Wow, you must be thrilled! What an adorable baby!” (How do you know she is thrilled? Cute babies don’t equal happy moms). We leave little to no room for mothers to say how they may really feel (“I’m tired, not sure how I feel, I’m not as happy as I thought I would be”). Next time you see a new mom, just ask her how she is doing. And if you share your own experience, no need to share that your kids slept through the night at six weeks, latched on perfectly and nursed until pre-school. Nobody actually wants or needs to hear that. Just listen.

What would I have done differently? Carol’s mother would have reached her an hour earlier; Carol would have been brought to a hospital. The psychiatrist at Torrance Memorial had already given the diagnosis of psychosis, likely PPD; thus I can presume he would have initiated a Brexalone infusion after treating her psychosis. What would $34 thousand have saved? The lives of three children are not inconsequential.

And one can, of course, argue that postpartum psychosis is rare — 1/1000, but the effects of untreated maternal depression on the baby are not benign. SSRIs which are the maintenance of treatment, take four to six weeks to work due to activation of receptors and overcoming of down-regulation by the 5HT1a autoreceptor, blah, blah, blah. All of that to say — it’s slow. Too slow when babies need their mama’s to want to hold them.

Studies show that the effects of the psychological, social and developmental toll of untreated maternal depression have on their offspring includes something detrimental we call “insecure attachment” — this is the foundation for a personality disorder later life (borderline PD, narcissistic PD). Further, those offspring have lower cognitive, language, social-emotional problems and behavioral development delay and are at risk for internalizing symptoms at 18 months as well as increased rates of internalizing disorders throughout childhood and adolescence (i.e., they also become anxious and depressed). They also have elevated rates of externalizing symptoms — physical aggression, across childhood, suggesting that PPD impacts multiple neural pathways and has sequela lasting long beyond the “four-month” postpartum window.

Lower IQ and language delays are also associated with the offspring of PPD mothers. As sad as this all is, it is not surprising, given one of the largest studies we have on this, (N=5,089), that the bottom line is not that complicated: a depressed mom is less likely to engage in enrichment activities with the infant including less reading, singing songs, telling stories and playing games.

So, let’s ask the question in a different way. Is $34 thousand worth to prevent lower IQ, lower cognitive skills, fewer behavior problems, fewer emotional problems and prevent attachment disorders in children who would otherwise need thousands upon thousands of dollars in resources throughout childhood to accommodate them?

When I think about Carol now, it is often difficult. It is a tragedy with many layers — one of whom includes me as one who feels she could have done more. I only wish Brexalone was available to me in the past, even six months ago when I had a mother like Carol sitting in m office week after week, crying non-stop, then leaving and appearing completely normal the rest of the world. I’ll never forget how the staff would comment on how pretty she was. It wasn’t how I saw her. Carol would pop into my head — she was pretty too. Do we see “pretty” mothers as happy mothers? This patient would crumble when the door closed, and we were alone. It was her time. I just let her cry. And cry. I had sleepless nights about her — every time, I struggled with should I have kept her? Was she Carol? But what about her responsibilities to her other kids and she never said anything that would justify hospitalizing her. She just seemed so depressed. But this patient’s husband was supportive at least. But how do I really know? She says she’ll call me tomorrow. On a Saturday. What if she doesn’t? What if I can’t reach her? Do I send a PET team?

If I only had Brexalone, I could have used it for that patient — who made it through eight weeks of up titrations of an SSRI and a secondary augmenting agent, but not without my intensive, ad-hoc partial day program to make sure she was OK. It was worth my time — I only wish she had not had to suffer as much for those two months. If the government believes $8 million is reasonable to spend on erectile dysfunction drugs for soldiers — than as a physician who cares for peripartum patients, I believe $34 thousand is more than reasonable to save mothers and their children from the preventable and costly sequelae of untreated postpartum depression.

Author’s note: There is no protected health information in this post as what is written is part of the court record: It has been testified during trial by this physician, and those transcripts have been reviewed to ensure this.
Torie Sepah is a psychiatrist and can be reached on Twitter @toriesepahmd.
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