Why Screening of Postpartum Moms is Important and Who Can and Should Do the Screening

Today’s post was inspired by a March 19, 2018 NPR article by April Dembosky titled “Lawmakers Weigh Pros and Cons of Mandatory Screening for Postpartum Depression,” as well as a June 2018 Romper article by Karen Fratti titled “Moms Should be Screened for Postpartum Depression in the ER, New Study Suggests, & It Makes Perfect Sense,” a June 30, 2018 News Medical article titled “Screening mothers for PPD in emergency setting,” and a June 29, 2018 Austin360 article by Nicole Villalpando titled “Who should be screening moms for postpartum depression? More doctors now can.

Screening moms for postpartum depression (PPD) serves multiple purposes.  Screening will help ensure moms get the help they need and avoid suffering unnecessarily.  In case you weren’t aware, screening educates women on what PPD is, why it happens and just how common it is (1 in 7 new moms experience it), and helps them avoid what I and so many other mothers have gone through (PPD makes you feel alone, like you’re losing your mind and will never return to your previous self).  It will ensure fewer moms will ultimately fall through the cracks.  It will ensure fewer tragedies involving mothers and their babies.  And I’ve said this many times before, but a mother who is not well cannot care for her baby the way a healthy mother can.  This is pure logic.  Unfortunately, logic takes a back seat because our capitalist society places more priority on what benefits the pocket over what benefits the people’s well-being.

So…..question is WHO should screen new moms for PPD?

Her OB/GYN?  This should be a given, period, hands down, no questions asked!  In May 2018 the American College of Obstetricians and Gynecologists recommended that, in addition to the standard 6-week postpartum visit, OB/GYNs perform a follow-up visit within the first three weeks postpartum.  This new recommendation is due to the fact that symptoms of PPD often begin before the 6-week appointment.   See second half of my blog post on the issues many OB/GYNs are faced with in terms of screening.

Her baby’s pediatrician (but here the patient is the baby, not the mother)?  The American Academy of Pediatrics (click here and here) recommends doctors screen mothers for PPD when they bring their newborns in for wellness visits, since they occur numerous times in the baby’s first year; whereas, the mother only gets the one wellness check at postpartum week six.  Pediatricians who realize that the baby’s development can be negatively impacted when the mother is ill with PPD will try to screen the mom for PPD.  Problem is, most pediatricians as far as I’m aware are not prepared to screen and refer mothers since the mother is not a patient.

An ER physician?  While you will no doubt raise your eyebrows, doctors like Dr. Lenore Jarvis, an emergency medicine specialist with the Children’s National Emergency Department at United Medical Center in Washington, DC, have been seeing moms bring their babies to the ER, and it turns out the baby is fine but it’s the mother who is highly anxious and feeling overwhelmed.  In these cases, it’s logical to try to determine if it’s the mother who needs help.  In fact, Dr. Jarvis and several colleagues conducted a research study with several colleagues on screening moms for PPD in an ER setting.  A Eureka Alert release dated June 29, 2018 explains the results of the research study. Moms who participated were screened using the Edinburgh Postnatal Depression Scale supplemented by other questions.  The great thing about the research study is that, when moms scored positive for PPD, they received information about PPD and were offered–or if they had a strong positive score from screening, they were required to have–a consultation with a social worker.  Additionally, the researchers followed up with mothers who screened positive one month later to see how they were doing.  This is akin to case management programs we have in place when patients check out of hospitals (I explain all this in my post below). Now THIS is the way it SHOULD be!

Dr. Jarvis refers to the ER as a “safety net  for people who are not routinely accessing regular checkups for themselves and their children. If a mother is having an acute crisis in the middle of the night and feeling anxious and depressed, they often come to the emergency department for help.”  Because American policymakers have been so resistant to instituting policies that would require insurance companies to work with doctors to ensure PPD is caught early through screening and subsequent referrals–researchers/subject matter experts on PPD are left to make recommendations for what Dr. Jarvis referred to as a “safety net” approach of having emergency rooms screen for PPD when moms come in either for their babies (for colic, fevers, etc.) or even for themselves (symptoms of a postpartum mood disorder).

While I agree we need to cover all bases and try to screen a new mother wherever and whenever possible, why do we even need to resort to waiting until a mom comes into the ER to screen them?  Why do we have to have such a safety-net, fall-back, beats-nothing-at-all, better-late-than-never approach in the first place?  Answer:  our society continues to place too much priority on conception and childbirth but once the baby is born, everyone forgets the mother.  Once the baby is born, the mother’s health falls by the wayside.  I’ve blogged about this before, but the attention from that point on will be on the baby from visitors who coo at the baby and treat the mother as invisible.  Same thing with doctor visits; the mother only gets one postpartum wellness check at 6 weeks.  That’s it.  It’s like the mother ceases to exist.  Whereas, other cultures have customs to honor and mother the mother (click here and here for past posts).  The birth of the baby is synonymous in these cultures with the birth of the new mother and they are honored for bringing new life into the world.  This, my friends, is why maternal mental health advocacy is so important.  Until American policymakers institute policies to demonstrate the importance of mothers and their health, we advocates must continue to act as “squeaky wheels to get the grease.”

The following section is an excerpt from my book.

New mothers, especially the ones at high risk for PPD, should be screened during their six-week postpartum visit, provided she doesn’t complain about symptoms up to that point. If she is symptomatic before the six-week visit, she should be screened right then. If the six-week screen doesn’t indicate PPD, she should be assessed once more at the twelve-week point—or when she weans or when her period returns, whichever comes first, since these events can trigger PPD in some women.

The following—in addition to screening tools like the Edinburgh Postnatal Depression Scale or Cheryl Beck’s Postpartum Depression Screening Scale—should be asked at the six-week follow-up visit with the OB/GYN, which can help diagnose PPD:

  1. Have you been feeling any of the following for the past two weeks?
  • Persistent and mostly inexplicable sadness/tearfulness and feeling empty inside
  • Loss of interest/pleasure in hobbies/activities you once enjoyed; inability to laugh
  • Overall impaired functioning
  • Sleep difficulties (either insomnia or sleeping too much)
  • Weight loss (usually fairly quick) associated with a decrease in appetite
  • Weight gain associated with an increase in appetite
  • Excessive anxiety about the baby
  • Restlessness/irritability
  • Detachment from and inability to bond with the baby
  • Difficulty thinking, concentrating or making decisions
  • Feelings of guilt, inadequacy, failure and/or worthlessness
  • Urge to run away
  • Onset of panic attacks
  • Sense of despair and/or hopelessness leading to thoughts of death/suicide
  1. How have you been feeling physically and emotionally?
  2. Are you feeling particularly stressed, and, if so, is it due to a major change you are experiencing, such as marital problems, death of a loved one, financial problems, a recent move, or a job change?
  3. How do you feel about the baby? Are your feelings in line with your expectations of how you’d feel about the baby?
  4. Do you feel you have adequate emotional and practical support from your partner? Do you have any relatives or any other help, like a doula, to help you with the baby during the day?
  5. Are you breast-feeding and, if so, how is it going?
  6. How do you feel the labor and delivery went? Do you feel you experienced any sort of trauma during the delivery?
  7. Do you feel your childbirth and motherhood experience are meeting your expectations?
  8. Do you feel particularly anxious about your baby’s health (colic, SIDS)?
  9. How is your appetite?
  10. How are you sleeping? Have you been able to get at least four, if not five, hours of sleep a night?
  11. Have you had any recurring thoughts/images that are disturbing?
  12. How have you been adapting to motherhood, in general?
  13. Have you returned, or will you return, to work?

I believe these types of questions should be incorporated by all OB/GYNs throughout the country. This all theoretically sounds good and fine, but in most cases, OB/GYNs are not prepared to implement. Why not? At the very least, it would require training on perinatal mood disorders (recognition of symptoms and treatment), as well as ability to provide the right referrals as needed.

This last paragraph from my book excerpt remains true to this day.  Sad because I published my book in 2011.  Seven years later, things have not really changed.

California’s screening bill, AB 2193, has yet to pass the Senate and get signed into law.  Once passed, it would be an exciting development for mothers, as it doesn’t just require screening for PPD.  It requires health insurance companies to set up case management programs (same way my mother was assigned a case manager each time she had to stay overnight at a hospital to ensure she had a plan in place to address the issues that landed her in the hospital–i.e., physical therapy in a rehab center, visiting nurse to change her bandaging, etc.) to help connect moms who screen positive for PPD with a mental health practitioner.

Case management is set up to ensure there is a treatment/referral plan in place.  I sincerely hope that this means health insurance companies are prepared and able to carry out the new requirements.   And I sincerely hope that California will lead the way for other states to follow suit in setting up similar screening bills that will actually require health insurance companies to set up case management programs.

It goes without saying that screening moms for PPD serves no purpose if you can’t help those who test positive for PPD.  So far, as the first state that put mandatory screening in place, New Jersey has not had any reason to be excited ever since its initial groundbreaking “first-state-to-mandate-screening” announcement.  New Jersey, as well as 3 other states— Illinois, Massachusetts, and West Virginia — have tried mandated screening, and it did not result in more women getting treatment, according to a study published in Psychiatric Services in 2015.

A whopping 78% of those who screen positive don’t end up getting mental health treatment per a 2015 research review published in the journal Obstetrics & Gynecology.  Why have women in these states with mandatory screening not been getting treatment?  Well, for starters:

  1. Some obstetricians and pediatricians are afraid to screen for PPD because they are not equipped to refer.  But why is that?   Why is it hard for them to all rely on the resources available via Postpartum Support International?  Its website lists resources in every state.  And many states have already formed, or are in the process of forming, chapters to focus on state-specific efforts at advocacy, training, and other improvements.
  2. The resources to whom doctors (obstetricians, pediatricians, general practitioners, etc.) can refer mothers are limited, especially in more rural areas.  And in more rural areas, it’s harder to find mental health practitioners trained in prescribing meds to pregnant/breastfeeding women, let alone trained in treating moms with PPD.
  3. All too many mental health practitioners don’t take the woman’s insurance or there are significant limitations from an insurance coverage perspective.
  4. There’s a very long wait (several months) to see most mental health practitioners, especially for the first time….a woman in the throes of PPD can’t afford to–both literally (from a cost perspective) and figuratively (from a life & death perspective).
  5. There’s little incentive financially, thanks to insurance companies’ lack of adequate coverage for doctors who do such screening…..in my opinion, screening should be done at the standard 6-week postpartum checkup and therefore covered as part of that checkup.

Attention, American policymakers….our mothers are worth it.  I mean, we make such a big stink about fetuses and unborn babies in this country, let’s start thinking bigger picture, shall we?  Without mothers, there would be no babies to conceive and bring into this world.  Let’s start treating mothers less like second-class citizens and more like human beings who deserve to be able to give birth to and care for their babies without getting sick with PPD and possibly dying in the process!

 

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I Can Understand How the Despair from PPD Can Cause a Mother to Want to End Her Life

As a preface to this post, I’d like to share an excerpt from my book that reflects how the pain from postpartum depression (PPD) can fill a mother with so much despair and hopelessness–especially when she doesn’t know what is happening and why, and that there is a cure for whatever it was that is causing her to feel/behave/think the way she is feeling/behaving/thinking–that she would want to end her life.

One too many times, I gave Ed a miserable look and told him how scared I was that I didn’t know what was going on with me and I was afraid that I’d never get better. There would be tears in my eyes but I couldn’t cry. Most of the time, he didn’t know what to say. It was way after I had fully recovered from PPD that Ed finally admitted that he had feared I would never get well, never return to my old self, and never appreciate watching [our daughter] grow up.

Each day, I’d stand by a window, staring out at the snow and pleading for God to help me get through all this. I’d say over and over again, “Please, God, please help me get through this. My baby and husband need me … help me to be strong!” It was difficult for me to focus on any tasks. Often I’d sit there in the kitchen by myself or stand in the middle of a room, unsure of what to do next or not wanting to do anything at all. I felt like staying in bed all day long or in a tight ball hiding in a corner, rocking myself for comfort, but I couldn’t because I had to take care of [my baby]. During that time, I tried my best to interact with [my baby], to play with her, and talk to her.

…….. I thought I was never going to get better, I wasn’t going to be able to go back to work, and I wasn’t going to ever be well enough to take care of the baby. I just wanted to shrivel up into a tiny ball and disappear. I couldn’t bear the thought I was going to be like this for the rest of my life.

Although I never thought about actually ending my life, I constantly thought about disappearing because I just wanted all the misery to end.  And I most certainly couldn’t imagine staying in my PPD state for the rest of my life.  So it’s a good thing my PPD was cured when it was, as I’m not sure how much longer I would have lasted.  I have heard many other mothers who suffered from PPD that thought about disappearing as well.  I have also heard a few instances of mothers thinking about taking their own lives and/or actually attempting suicide.  Each time I hear these stories, it makes me feel more committed than ever to continue blogging and trying to reach people who are struggling with PPD.

I’ve been wanting to share a couple of important articles about suicide as the second leading cause of death for women in the postpartum period….one article is from last June and the other is from 3 months ago.

The one from 3 months ago (5/2/2018) was written by Catherine Pearson on Huffington Post titled “Suicide is a leading cause of suicide for new moms but awareness is low.”  The article focuses on the story of Kari who died by suicide back June 2010.  Kari’s sister, Karla, shared the story to try to educate other mothers on how deadly PPD can be. Like some of the other stories I’ve shared on this blog, Kari’s family was unaware of how bad her PPD was until it was too late.  Her family was getting her ready to move in with them to help her out until she felt better, but never had a chance to do so.   Within 4 weeks of giving birth, she died by suicide.  Her condition had quickly gone from giving birth to not being able to sleep (what happened to me) to feeling super anxious to wanting to harm herself.  The day before she was going to see a doctor about her condition, she died by suicide.

The one from last June (6/5/2017) was written by Gina Louis for Medium titled “The Night Postpartum Depression Almost Killed Me.” This is the story of a new mother who, after struggling with feelings of inadequacy and feeling a failure of a mother and wife that her children and husband would be better off without, she planned to take her own life one night.  She was going to let the dark hole of despair swallow her up.  But she thankfully didn’t carry it out that night.  She got help.  She is now, like me, a survivor speaking up and trying to help others realize that PPD can be overcome with the right help.  As my experience has made me feel stronger and more confident than before, her experience has made her feel stronger and more confident than before.

What Kari’s sister and Gina Louis are trying to do by sharing these stories is to educate folks on how deadly PPD can be and how quickly things can become deadly.  PPD is a serious condition that can lead to tragic consequences quickly.  If you or someone you know is suffering from PPD, please seek/get them to seek treatment asap.

For a country that is so advanced in medicine and technology, we must ask ourselves why American mothers don’t have enough access to, or education about, maternal mental health treatment and why American policy makers can’t do more to address the stubbornly high rates of pregnancy-related death and pregnancy-related suicides, which account for one in five postpartum deaths.

If you or someone you know needs help, call 1-800-273-8255 for the National Suicide Prevention Lifeline.
You can also text HOME to 741-741 for free, 
24-hour support from the Crisis Text Line.
Outside of the U.S., please 
visit the International Association for Suicide Prevention for a database of resources.

Please Throw Me a Postpartum Party Instead of a Baby Shower, Thanks

and

A truly useful baby shower gift after the baby’s arrival is having relatives, friends, neighbors, etc. chip in funds for hired help [like a postpartum doula] for the first one to two months.

Additionally, as this article suggests, the shower that is thrown should entail a list of family/friends who will help (with watching the baby so the new mom can get some much-needed alone time/rest/shower, picking up groceries, cooking, dishes, laundry, cleaning, etc.) during the first 6 weeks postpartum.  This could include a meal plan via http://www.mealtrain.com deliveries or doing take-out and dropping the food off.

Perhaps if we focused more on ensuring new mothers have the support they need after the new baby arrives, there would be fewer instances of postpartum mood disorders!

 

A Must for All New Jersey Medical/Mental Maternal Healthcare Practitioners, Doulas, Midwives, etc.

After a two-month dry spell in posting on my blog due to lots going on at home and at work, here I am briefly to help spread the word for the Postpartum Support International 2-day training on November 15-16, 2018 in Fort Lee, New Jersey:  Perinatal Mood Disorders: Components of Care. 

Led by PSI’s very own Birdie Gunyon Meyer, RN, MA (whom I’ve known since I became a member in 2006), Lisa Tremayne, RN, CPPD, CBC, and Joanna Cole, PHD, it is a critical training intended not just for mental health care practitioners but anyone and everyone who would ever need to care for an expectant or new mother.  That includes obstetricians/gynecologists, general practitioners, pediatricians, doulas, midwives, nurses, ER doctors and their staff, etc.

You can visit the site that goes over the training objectives, location, and cost via the above link, but the training will cover the basics in identifying/treating perinatal mood and anxiety disorders (PMADs)–which include antepartum depression, postpartum depression, postpartum anxiety, postpartum panic disorder, postpartum OCD, postpartum PTSD, and postpartum psychosis–as well as understanding risk factors, treatment options, breastfeeding, consequences of untreated conditions, impact on loved ones, importance of social support, cultural differences, spirituality, etc.

Please attend and/or help spread the word about this training.  It is so, so critical that we ensure as many people as possible are trained so that fewer mothers suffer unnecessarily (like I did) and even worse, fall through the cracks and become another tragic outcome of a perinatal mood disorder.

 

Join Elly Taylor of Becoming Us on her U.S. tour of training sessions for parents and professionals!

My friend, Elly Taylor, is an Australian relationship counselor, author of the book Becoming Us, and founder of an organization of the same name, which she created to teach professionals and support mothers and their partners.  Both the book and organization’s mission is to help the mother and partner navigate the peaks and valleys of the parenting journey via 8 essential steps that Becoming Us as “map, compass and travel guide all in one.”

Elly is here in the states for her “Seed Planting” workshop tour in Chicago, Beverly (MA), Providence (RI), New York City, Houston and Los Angeles.  For the complete schedule and how to register, click here.

At Darling Harbour, Sydney (2014)

Elly and I have a bunch of things in common.  We are both postpartum depression (PPD) survivors and book authors (though hers is award winning).  We were both blindsided by PPD and the challenges of parenting.  We are both members of Postpartum Support International.  Elly loves NYC (where I’ve spent the last 29 years working) as much as if not more than I love Sydney (where she lives).  She is fortunate enough to be out here in NYC each year for the past 3 years on Becoming Us-related reasons; whereas, I’ve been back to Sydney 3x in the past 21 years (I so wish I could return more often!).  I look forward to seeing Elly during her stay in NYC!

Professionals:

Sign up for Elly’s 2-hour interactive workshop that will teach you key tools to prepare/support expectant/new parent couples to anticipate/cope with the changes–and stay connected through the challenges that come with–early parenthood. You’ll come away with ways for parents to nurture themselves and their partners so the whole family can thrive.  This workshop is designed for couple and family therapists, birth professionals, infant or child mental health professionals, and any others who work with expecting, new or not so new parents.

The transition to parenthood is a major one that consists of numerous transitions.  The training will teach you what the transitions are and how they can negatively impact mothers and their families. You’ll learn how to plant Becoming Us “seeds” that reduce risk for the most common parenthood problems including perinatal mental health issues and relationship distress. Finally, you’ll discover the groundbreaking Becoming Us approach to parenthood and how you can apply the model to your work with parents at any stage of their family life cycle.

Parents:

Sign up for Elly’s 1-hour interactive workshop that will teach you about the transitions that parents normally go through in their first years of family, the steps to navigate each of these transitions and staying connected through the challenges that come with early parenthood. You’ll come away knowing how to nurture yourselves while growing a family that thrives.

 

 

The Robin Study is Looking for New Mothers to Participate in a Research Study

The Robin Study is a research study evaluating an investigational oral medication in women with postpartum depression (PPD).  An investigational medication is a study drug that will be tested during a study to see if it is safe and effective for a specific condition and/or group of people.

To be eligible for the study, you must:
  • Be 18 to 45 years of age
  • Have given birth within the last 6 months
  • Feel any of these symptoms associated with PPD for 2 weeks or longer:  insomnia, crying/sadness, lack of appetite, sudden weight loss, hopelessness, lack of interest in baby, loss of interest in things you used to enjoy, intrusive/disturbing thoughts
  • Have symptoms that began no earlier than the third trimester and no later than the first four weeks following delivery (I know that many mothers don’t develop PPD until 6 weeks or later, but this is a specific requirement for this particular research study)

If you qualify and decide to participate:

  • Your PPD symptoms will be continually monitored by qualified study staff (nurses and clinicians), under the guidance of the study doctor.
  • You will receive study-related medical care and the assigned study drug at no cost.
  • You will be required to take the assigned study drug at home every night for 14 days. You’ll have nightly phone calls with the study coordinator and will come into the study site three times while on the medication and two times as follow-up. Your total participation will last about 76 days.
  • Transportation may be provided for those who require assistance.

To learn more about the study, review frequently asked questions, and see if/how you may qualify, please visit www.TheRobinStudy.com, call (844) 901-0101 to speak with a study representative, or fill out the contact form and a study representative will follow up with you.

Go See Tully, and Let’s Talk

Just a quick post tonight with a movie review of “Tully” written by a friend of mine, Mrs. W.

Initially, Mrs. W was annoyed like I was about the movie’s apparent failures based on a couple of negative movie reviews she and I both read this past weekend.  Like me, she did not want to see the movie.  That is, until I sent her the review from a postpartum psychosis survivor, Melissa Bangs, who happens to be the star of her own one-woman show “Playing Monopoly with God” that’s been on tour for the past couple of years and is headed to New York City next week!  Reading this positive review of someone who is a PPP survivor peaked Mrs. W’s interest, and so she went to see “Tully” yesterday.  Please take a moment to read Melissa’s personal thoughts from the perspective of an actual PPP survivor!

Without further ado, here’s Mrs. W’s movie review:

“Ok. So I saw it tonight………….

  1. There are a couple triggering scenes.  One of them was in the first half of the movie, which almost caused me to leave because my whole body got amped up like I was going to have an anxiety attack.  But I calmed myself down and was able to sit through the last half of the movie, which was less emotionally jarring.
  2. I don’t want to spoil the movie, but I will say that the main character definitely has postpartum psychosis but no one ever says it outright.  There are a few things said (like when her husband told the doc she was depressed with their second child) that might mislead people to think she has postpartum depression (PPD), but I think the movie left out the actual diagnosis on purpose because it wants the audience to figure it out on their own.  However, I do think the movie shines a light on postpartum mental health and how a struggling mother could slip through the cracks …to the point that even a husband who doesn’t pay close attention would fail to notice his wife’s condition.
  3. It is a shame that the doctor in the movie doesn’t say it outright that she has PPP.  It was definitely a missed opportunity to shed light on the subject no one talks about.
  4. Also, Charlize Theron played the heck out of that role.”

Hmmmm, it’s interesting that Mrs. W thinks the film makers deliberately left out the diagnosis of PPP to cause the audience to want to figure it out on their own.  I, on the other hand, don’t have such an optimistic perspective and in this case would not give the film makers such credit for the reasons stated in my blog post about Tully.  What the movie and the subsequent posts on social media has done, at least in the maternal mental health circle, is promote discussion about maternal mental health.  But that’s within the already existing circles of advocates, mental healthcare practitioners, and survivors.  I haven’t really heard much about discussions going on among the general public, which is why first and foremost we must capture the proper message about maternal mental health conditions (and bust stigmas associated with them) to educate people, share widely and DISCUSS!  THIS is why I am still annoyed about the lost opportunity to educate the public.  The film makers could have easily inserted a diagnosis into the screenplay.  But they didn’t.

Anyway, the whole point of this post is to weigh different perspectives and not let a couple of negative movie reviews completely shut off all interest in seeing a movie.  Just as Mrs. W had done, she started out with an opinion that was formed based on a couple of negative reviews of people (not really clear if they themselves were PPD or PPP survivors) who did see the movie.  Because of these negative reviews, she was annoyed and had zero interest in seeing the movie.  After I showed her Melissa’s review, she went to see it and was able to form her own opinion after seeing it.  Then she shared with me her thoughts about the movie.

Mrs. W did confirm that the movie:

  1. Puts a light on maternal mental health in terms of mothers’ struggles being real and women like Tully falling through the cracks due to lack of awareness and lack of support from significant others and loved ones.  Motherhood is not easy.  A mother who is struggling will fall through the cracks if she doesn’t get the help she needs.  New mothers need practical/emotional help during the first couple of months.  Forget about the whole supermom thing.
  2. Falls short in raising awareness that postpartum mood disorders are experienced by 1 out of 7 mothers and definitely not anything to be ashamed of.  They are very real, serious, painful to experience, and life-changing.

And yes, Charlize Theron plays the heck out of ANY role she plays.  But for me, even if Charlize earns an Oscar nom, I still can’t set aside my annoyance (that I blogged about previously) to see it.  As a person of principle, I would not want to pay even $1 to watch a movie that fails an opportunity to educate the population properly by sending unclear signals on the condition Tully really suffered from.  To each his/her own, as they say…..