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Women Say California Insurer Makes It Too Hard To Get Drug For Postpartum Depression

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To get a new drug for postpartum depression, some insurers want women to try other drugs first and even electroconvulsive therapy. It could be a test for California's new mental health parity law.

Speaker 1: 00:00 One out of eight new moms in California experiences, postpartum depression, two years ago, the FDA approved the first and only medication designed to treat postpartum depression. It's called brand X alone, and most women who get it start feeling better within days. But the drug is outrageously expensive, $34,000. And according to a new K Q E D investigation California's largest insurer makes it extremely difficult to get KQ EDIS health correspondent, April Demboski explains

Speaker 2: 00:32 Miriam McDonald was 44. When she told her doctor she wanted to have another baby, the doctor said she had a better chance of winning the lottery. So when she got pregnant, she and her husband were thrilled. But right after having her son, everything turned three days into giving

Speaker 3: 00:48 Birth to him. I was thinking, oh my God, what did I do? I just brought this baby into this world. And I, I can barely take care of myself right now. I feel exhausted. I haven't slept in three days. I haven't really eaten in three days.

Speaker 2: 01:02 As the weeks went by, her depression got worse. She felt sad, but also indifferent.

Speaker 3: 01:07 I didn't want to hold my baby. I didn't want to change him. I didn't have a connection with my child at all.

Speaker 2: 01:15 Mary I'm worried. Her mood might hurt her son. She worried she might not make it at all.

Speaker 3: 01:20 Every day I was crying every day. I felt like I just wanted to die. Every day. I thought about ending my life.

Speaker 2: 01:30 Miriam went to Kaiser Permanente near Sacramento for help. And she says, the doctors there put her on a merry-go-round of medication, trial and error. First one drug.

Speaker 3: 01:40 It was making me more anxious than anything.

Speaker 2: 01:43 Then her doctor up the dose of another drug,

Speaker 3: 01:45 I was having these horrific nightmares.

Speaker 2: 01:48 So he tried another drug that

Speaker 3: 01:50 Night. I started hallucinating. I actually heard a jazz band playing outside of my window of food. Jasmine,

Speaker 2: 01:59 Her doctors will turn to stop taking it, but he said it could take seven weeks before the hallucination stopped. Then he retired. And when Miriam complained to her new doctor at that, she was still depressed for months after giving birth. She suggested some more medications.

Speaker 3: 02:14 I was desperate. I was like, I'm trying to help myself, but things are just getting worse. So what, what am I left with? What do I do?

Speaker 2: 02:26 Merriam did her own research. And she found out about a new drug called Brex and alone. It's the first and only drug designed specifically to treat postpartum depression instead of targeting the serotonin system in the brain, like most antidepressants, for example, it works by replenishing a hormone that becomes depleted after having a baby it's infused into the bloodstream. Over 60 hours, you can go to a hospital

Speaker 3: 02:48 For three days. They give you this drug. It's an infusion. This dis could really get me out of this postpartum

Speaker 2: 02:53 Depression in clinical trials, 75% of women who got Rexann alone started to feel better immediately after the three-day infusion treatment. UNC chapel hill, Dr. Ryan Patterson says for most of the women they've been treating over the last two years, the result is night and day.

Speaker 4: 03:10 People walk out of the hospital, wanting to be with their child, wanting to return home. You can really see that transformation in the hospital room over those 60 years.

Speaker 2: 03:20 But when Miriam asked her doctor at Kaiser for Brex and alone, she said no. And then email her doctor said the existing studies were limited and unimpressive. And she told Miriam that she didn't meet Kaiser's criteria for the drug. She said Miriam would have had to try and fail four medications and electroconvulsive therapy before she could try Brex and alone. And all this had to happen within six months of having her baby for Miriam. It was too late, but she thought, how could anyone qualify?

Speaker 3: 03:49 This is crazy. You know, by the time you even try one drug, that's like four weeks out. Another drug is four weeks out. Another drug is four weeks out. There's just no way.

Speaker 2: 04:02 Kaiser's guidance is an outlier. KQBD analyze the guidelines from a dozen health plans. Three of them require women to fail one medication before trying Roxanne alone. One plan requires two fails, but Kaiser is the only system we found that recommends women first fail for drugs and electroconvulsive therapy. Clinicians who treat postpartum depression say this is ridiculous. That is abusive. That's absurd. That strikes me as insane. It may also be illegal under a new state law health plans must conform to scientific evidence and expert consensus when denying mental health treatments, state Senator Scott Wiener is the author.

Speaker 5: 04:42 If Kaiser is making it effectively impossible to get a particular important mental health treatment, that could definitely be a violation of our parody.

Speaker 2: 04:53 Law. Kaiser says it always follows the law. It also says it's integrated structure. It makes it different from traditional insurers at Kaiser, a patient's doctor determines whether a medication is necessary, not the health plan, but when I ask Kaiser, why it's doctors use criteria that make it so hard for women to get Breck standalone? They said the criteria are just recommendations. Not requirements. Doctors don't have to follow them. The head of psychiatry for Kaiser in Northern California is Dr. Maria Koshy, end of the day, this

Speaker 6: 05:26 Individual clinical decision by both or the provider physician and the patient,

Speaker 2: 05:34 But why issue clinical guidance? If you don't expect doctors to follow it, Senator Wiener says Kaiser providers get questioned or can even face consequences if they don't,

Speaker 5: 05:44 Whether it's couched as a recommendation or requirement is almost irrelevant. It has the same effect.

Speaker 2: 05:51 When Miriam MacDonald's doctor refused to prescribe her Brex and alone, she said she was following Kaiser's that Miriam had not tried for other drugs. When another Kaiser patient, you send you a Munoz requested the drug. She was also told she didn't qualify because she hadn't failed enough medications. You Sandia was devastated by the denial for months after giving birth to her daughter, she still felt suicidal.

Speaker 6: 06:16 I can get out the door sometimes and take the stroller and go walk. And my mind kids, don't see if

Speaker 2: 06:25 It's all going to go away. You said you went to state regulators for help. And the state sided with her ordering Kaiser to pay for Brex and alone. She started feeling better on the first day of treatment,

Speaker 6: 06:41 The nurse came in and she said something funny. And I laughed. It was the first time I had laughed in so long. She

Speaker 2: 06:49 Started looking through photos and videos of her daughter on her phone. She says it was like she was experiencing those moments for the first time.

Speaker 6: 06:57 It was like a switch flipped. He made me happy enough to want to live. It saved my life. Kaiser

Speaker 2: 07:05 Declined to comment on any patient cases for privacy reasons. But Dr. Koshi acknowledged that their Breck standalone recommendations were developed two years ago, based on the safety and efficacy data available at the time she says Kaiser is reviewing them. Now,

Speaker 6: 07:20 Sometimes our practice recommendations are revised and made to know, okay.

Speaker 2: 07:30 In the meantime, women are waiting. It was six months before you send you a Munoz, got Rexann alone and was able to start bonding with her baby Miriam MacDonald suffered for a year and a half. She never got Breck and alone. She eventually got Kaiser to cover a different depression treatment that finally worked for her, but she says she lost so much time with her son. When he took his first steps, she felt like she was barely there.

Speaker 3: 07:56 I felt like I've been robbed really of all those moments of those little milestones, you know, that I'm never going to get back.

Speaker 1: 08:07 That was K Q E D health correspondent, April Demboski reporting.

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Maureen Cavanaugh and Jade Hindmon host KPBS Midday Edition, a daily radio news magazine keeping San Diego in the know on everything from politics to the arts.