Postpartum disorders draw attention but not coverage by insurers
Seattle Times staff reporter
If only Martha Silano had been feverish when she began talking with the devil and the Unabomber, when she was certain she'd been shot in the stomach by a serial killer, when she became convinced her alert, adorable baby was dead — and that it was all her fault.
If only her delirium had been the result of a massive infection contracted after delivering Riley, the much-anticipated outcome of a difficult pregnancy. Then her health insurance would have paid for her month-long hospitalization.
But Silano didn't have a fever. She had postpartum psychosis, a sometimes deadly disorder that strikes as many as two in 1,000 women who give birth.
Postpartum depression, a chronic complaint of many new mothers, has only recently been recognized as a disorder than can range from a treatable, short-term case of the blues to severe psychosis.
The condition has drawn new attention since Andrea Yates of Houston drowned her five children last month; she had been diagnosed with postpartum psychosis.
News of the Yates' case chilled Silano. While she still finds it unthinkable for a mother to kill her own children, she knows firsthand how dramatically reality can become warped.
Researchers are trying to pinpoint the cause of postpartum psychosis. Theories range from changes in hormones to decreased blood flow to the brain during delivery. But most agree the disorder is biologically based and triggered by childbirth.
Silano stayed at Harborview for a month. Her HMO, Group Health Cooperative, agreed the time was "medically appropriate." But since her condition was classified as "psychiatric," her policy limited hospital coverage to 10 days.
Most group insurance policies place strict limits on psychiatric hospitalization. And no individual policies now sold in Washington state cover mental-health care, inpatient or out.
Silano's husband, Langdon Cook, says someone mentioned mental-health coverage limits when his wife was sick. But he assumed Group Health would cover the disorder as a physical complication of childbirth.
The couple have depleted their savings and used money from their parents to pay $14,000 for Silano's treatment.
Psychiatrists worry that patients without a financial cushion or family support leave treatment prematurely.
"It's so dangerous," says Dr. Rex Gentry, a private psychiatrist in Bellevue and former director of psychiatry at Overlake Hospital Medical Center.
Postpartum depression, which occurs in an estimated 15 to 20 percent of new mothers, can be treated without hospitalization, experts say. But postpartum psychosis presents a medical emergency.
"Anybody with active postpartum psychosis should not be home alone," Gentry said. "And certainly not home alone with their babies."
The Yates' case in Houston raised new concerns about how postpartum cases are treated.
"People are being discharged much sooner than anybody is comfortable with," in large part because of cost concerns, says Dr. Paul Appelbaum, president-elect of the American Psychiatric Association.
Silano is back home, in Seattle's Mount Baker neighborhood, delighting in 9-month-old Riley, who likes to thump the rhythm of some silent song on his highchair tray as he slurps strained carrots. She is training for a triathlon, feels like her old self and — crucial to a poet — is again able to laugh and cry.
She's had months of therapy, mostly at her own expense, and takes four medications to maintain her stability.
Group Health's well-regarded prenatal program informs prospective mothers about postpartum symptoms. But at the time, Silano and Cook didn't give them much thought.
Midway in her pregnancy, Silano was ordered to bed for six weeks to recover from a torn placenta and infection; she remained upbeat and otherwise healthy.
"I'd always felt I'd been a really lucky person," she says. "I'd always escaped everything."
Nor had the couple worried much about insurance coverage. Silano was insured through a teaching job at Edmonds Community College; he through his job at Amazon.com.
And they weren't aware of the battle in Washington and other states to make insurers provide "parity" coverage for mental and physical health.
Group Health, in a letter to Silano denying her claim, said it didn't matter that Silano was involuntarily committed, or that the HMO agreed the hospitalization was appropriate.
In a statement to The Seattle Times, Group Health officials said they support parity of mental-health benefits in principle.
But the HMO says providing parity while controlling costs is a matter for public debate.
"The real question is whether the current standard for mental-health benefits ... is right or fair," said Cheryl Scott, Group Health president and chief executive. "If the answer is no, then we should be talking about mental-health parity at the state and federal levels."
Group Health's handling of the Silano case was standard industry practice: If diagnosis and care fit "mental-health" codes in accepted professional manuals, coverage falls under mental health, which is typically limited by cost-conscious employers.
Chris Bruzzo, spokesman for Regence BlueShield, says a typical group policy insures for eight to 12 days of inpatient psychiatric care per year. Premera Blue Cross, the state's other large insurer, covers about 10 days.
The problem, says Bruzzo, is affordability: Expanding mental-health coverage "becomes a question of `at the expense of what else?' "
A bill before Congress sponsored by Sens. Pete Domenici, R-N.M., and Paul Wellstone, D-Minn., would require parity. Some studies predict parity would increase premiums 2 to 4 percent; Appelbaum of the American Psychiatric Association estimates the increase would be only 1 percent.
Health experts worry that any increase in premiums causes people to lose insurance.
"It's the sleeping dog that the insurance industry wants to leave alone," Gentry says. "If it wakes up, we'll all pay for it."
When health insurance was established a half-century ago, psychiatry was "pre-medical" — a dichotomy that lingers, Gentry says.
But even Sigmund Freud, the father of modern psychotherapy, suggested in the early 1900s that a physical basis would eventually be found for most mental disorders. And in the last 30 years, brain imaging and other procedures add to an increasing body of evidence that "mental" disorders are simply physical problems in the brain.
Diabetes, for example, can produce psychological changes, including confusion or difficulty concentrating. The flu manifests itself in lack of appetite and a general malaise, not unlike depression. At the same time, physical conditions such as high blood pressure may be caused as much by stress as by high cholesterol.
"Any mental disorder is grounded in some dysfunction of a physical system in the brain in the same way that any liver disorder is grounded in a physical dysfunction of the liver," says Applebaum.
Gentry believes postpartum psychosis may be brought on by a precipitous drop in estrogen. In the six months after delivery, women are 14 times more likely to be hospitalized for psychiatric conditions, he says.
In a recent study of 10 women with the psychosis, all recovered quickly when given estrogen and without traditional psychiatric medicines.
Dr. Ty Erickson, an Idaho Falls, Idaho, obstetrician-gynecologist, thinks postpartum psychosis is a complication of pregnancy caused by decreased blood flow to parts of the brain.
"A responsible (insurer) would say if a woman has a condition that has a clear relationship to delivery, it should be covered as a complication of pregnancy," he says.
But Dr. Robert Small, behavioral health medical director for Premera Blue Cross, says the science is far from clear.
"No one has ever established a direct physical cause of postpartum psychosis," he says. "What you're hearing is a lot of supposition, but none of it has been proven."
Even so, say parity advocates, cancer treatments are covered even though it's not always clear what caused the cancer.
And lack of coverage parity perpetuates the stigmas attached to mental illnesses, they say.
In part because of that stigma, and in part because of costs, there is little widespread pressure on insurers to expand coverage into an area as murky as mental health.
"If everybody really felt strongly about this, like they feel about breast cancer or other conditions, (the disparity) wouldn't last for a year," predicts Dr. Peter Roy-Byrne, chief of psychiatry at Harborview.
Silano and Cook appealed Group Health's decision last Wednesday. The appeal was denied the next day.
Group Health declined to comment on the specifics of the case, citing confidentiality. But the couple wants other families to be better informed than they were.
Relegating postpartum psychosis to the "netherworld of psychiatric coverage" ignores the realities of pregnancy and childbirth, Cook says. "It is anti-woman, anti-child, and anti-family."
As Riley naps nearby, his voracious baby brain ready for life to imprint its lessons, Silano and Cook recall how it all began. Silano was rocking 3-week-old Riley and crooning a Beatles' song, "Maxwell's Silver Hammer." Cook had gone out.
"All of a sudden, I started to leave the room a little bit," Silano remembers. "I started getting really, really anxious." She called Group Health and found a birthing midwife.
"I need to get out of here, I need help — Don't hang up the phone!" she begged.
Cook came home to find an ambulance and two police cars in front of their house. At Group Health's emergency room, Silano was diagnosed as sleep deprived.
"I really wanted to believe that's all it was," Silano says. "I went home that night thinking it's all over. And we're fine, we're a family again."
But she had another attack a week later, during an appointment with a behavioral-health specialist at Group Health. She grabbed at him, begging, "Help me!" She was prescribed an anti-depressant for postpartum depression.
She grew worse, until one day, she told her husband, "I've figured out what's going on."
Relieved, he turned to her.
"I'm dead!" she told him.
Cook's heart sank. "I realized, `Oh, my God, we're in for something that I don't understand, and I don't know where this is going to lead.' "
By then, Silano was unable to nurse or hold Riley. When she was committed, she was unable to talk or blink.
Over the next month, Silano heard voices and saw God outside the hospital window. For the first part of her stay, she refused to take her medications, believing they were poison.
"It was the scariest four weeks of my life," Cook says.
Carol M. Ostrom can be reached at 206-464-2249, by fax at 206-464-2261 or by e-mail at firstname.lastname@example.org.