Brian Lehrer: It's The Brian Lehrer Show on WNYC. Good morning, everyone. Coming up later in the show, something very different that I hope will be both fun and helpful to some of you. We're teaming up for three segments here this month with Jenée Desmond-Harris, the Dear Prudence advice columnist on Slate for some live advice segments. We've been inviting you to write in with your dilemmas that might benefit from some advice. We've picked out two for today and Jenée Desmond-Harris will join us in our second hour. We'll also invite callers, some of you to weigh in on the dilemmas we take on once we lay them out.

Also today, we'll hear from a city council member on the new rules for outdoor dining coming to New York City, but here's how we'll start today. Maybe you've heard in the news that the FDA has approved the first pill to treat postpartum depression. The stats I've seen are that postpartum depression affects hundreds of thousands of new mothers each year in the United States and of course more around the world. The newly approved medication is branded as Zurzuvae or chemically it's zuranolone. We’ll talk about it now in the context of postpartum depression generally with Nicole Cirino, MD, a reproductive psychiatrist. She is a professor at the Baylor College of Medicine in Texas and she's a board member of the support and advocacy group, Postpartum Support International. Dr. Cirino, thanks so much for coming on. Welcome to WNYC.

Oh, we don't have Dr. Cirino's line hooked up yet? All right, then listeners, I will put out the invitation for you. Now I think we have her, but I'll put out the invitation for you anyway. We can take calls with your experiences with postpartum depression, what worked to help alleviate it, if anything, and any questions you have for our guest on the occasion of the FDA approving the first pill to treat the condition. 212-433-WNYC, 212-433-9692. Our guest again is Dr. Nicole Cirino, a reproductive psychiatrist, chief of the Division of Reproductive Psychiatry, and professor at the Baylor College of Medicine and a board member of Postpartum Support International. Dr. Cirino, thanks a lot for coming on. Welcome to WNYC.

Dr. Nicole Cirino: Thank you for having me, Brian. Happy to be here.

Brian Lehrer: Can you begin by just defining postpartum depression?

Dr. Nicole Cirino: Postpartum depression does have several different definitions. Let me use the definition that's being used by the FDA in their approval of this new medicine. It's that it's a depressive episode that can occur during pregnancy or within the first four weeks of the postpartum period. The [inaudible 00:03:19] actually studied women that had depression occur in the third trimester of pregnancy up to the first four weeks postpartum.

Brian Lehrer: One young mom was telling me that she thinks there's a difference between postpartum depression, something labeled as that, and something less serious that people call the baby blues. Is that a distinction you make at Postpartum Support International?

Dr. Nicole Cirino: Yes, we do. We think that most women experience baby blues, which is up to 70% of women. We think it's hormonally mediated. Both conditions are likely hormonally mediated, but baby blues is a milder form of a condition that lasts approximately two weeks and it occurs where you feel not necessarily depressed, but you could feel hyper-emotional. You could feel crying, sadness, elation, happiness. You could feel off in terms of your ability to process emotions or thoughts and it's more mild and it's not persistent. Postpartum depression, technically you have to have five of seven symptoms of depression that last for more days than not over a two-week period of time.

Brian Lehrer: Interesting distinction. What causes postpartum depression and who tends to be vulnerable to it?

Dr. Nicole Cirino: We think one in seven or one in eight women experience postpartum depression and there are many different causes. It's truly a condition that has both biologic causes and then we would say is psychosocial causes as well, the social determinants of health, et cetera. We can look at each of those categories, but let's start first with the biologic categories.

We do know there's a genetic component to postpartum depression. It means that you are more vulnerable to getting postpartum depression if you have a personal episode of depression, if your mother or have an episode of depression in your family, particularly in the postpartum period, or if you're sensitive to hormonal changes. For instance, if you had an onset of depressive symptoms when you were prescribed birth control pills or in the pre-menstrual phase, something called pre-menstrual dysphoric disorder.

From a biologic, I noticed an increased risk at postpartum depression for women who have experienced high-risk pregnancies or have experienced difficult births. There are other obstetric complications that can lead to postpartum depression as well. From a social determinants of health factor, we know that Black women and minority women are more likely to suffer postpartum depression. We know that women who are unpartnered or have a low access to support, et cetera, are more likely to suffer from postpartum depression as well, women with twins. There's some social factors, determinants of health as well can influence the expression of postpartum depression

Brian Lehrer: On the racial disparity, do you think that's largely linked to poverty, relative poverty rates, or other things?

Dr. Nicole Cirino: We think that it could be related to poverty rates, access to care, bias in communities, or discrimination against either women seeking care or screening women for postpartum depression in women who do not have access to healthcare. There's probably several factors involved there.

Brian Lehrer: We'll get to the newly approved pill, which is obviously the news hook for this conversation, but I see that there was another postpartum depression drug approved in 2019 described at that time as the first medication approved by the FDA for this called Zulresso, but I see that has to be administered intravenously. Is that right? Can you talk about that medication and how you or anyone else in practice has had experience with that over the four years that it's been approved?

Dr. Nicole Cirino: Yes, that was the first FDA-approved medicine for postpartum depression. It is an infusion that requires 72 hours typically in a hospital setting or an overnight infusion setting. It's typically runs for just the medication, $34,000 for this infusion. The uptick actual use of this medication has been limited. I saw a recent New York Times article that Sage had said that there's I believe about a thousand participants thus far since the FDA approval.

The cost has been significantly prohibitive of our use in the widespread throughout the US. Many of us have seen very little use of this medication. Now it is the same mechanism of action as the current medicine, the oral pill. That is what is exciting, is also is that this medication now has a similar mechanism of action, which is different than other mechanisms of actions for antidepressants and is in oral form.

Brian Lehrer: How before 2019, before there was any medication, was postpartum depression treated? You're a psychiatrist, so I imagine there have been best practices and there would still be that are interpersonal, not just drug treatments.

Dr. Nicole Cirino: Interestingly enough, we absolutely do have behavioral interventions that are personal interventions, but we actually frequently use medications that are approved for a major depressive disorder like for instance, sertraline block, the class of SSRIs to treat postpartum depression. It is not that we have a medication that we're using for the first time with these two FDA approvals, it's just that these are medicines that are generic, have been studied, are effective and have not been FDA-approved partly because of -- Part of how our system works is the FDA approval process often requires a good deal of financial support, et cetera. The older generic medicines are often not going to go for that indication.

Brian Lehrer: All right. Tell us about the new medication. What is it?

Dr. Nicole Cirino: Zuranolone is in the category of what we call a neuroactive steroid. It is a synthetic version of a metabolite of progesterone. Progesterone is one of the hormones of pregnancy that obviously significantly increases during pregnancy with a rapid drop in the postpartum period. It's believed to be these drops in hormones that produce neuroactive steroids or changes in the brain that can increase the onset- -of perinatal mood and anxiety disorders.

This is a synthetic oral version of something called allopregnanolone or allo. It works on one of the neurotransmitter systems in our brain, which is the GABAergic system. This is a medication that one would take at night for 14 days. It's considered to be in the new category of some antidepressants or a more rapid-acting antidepressants. You’ve heard of medicines like esketamine, other medications that work quickly, more traditionally quicker than the SSRIs or the traditional antidepressants that can take up to four to six weeks to take effect.

This one had seen benefit over placebo, three days, and then at 14 days, and then it's been followed up to 45 days. Women would take it for 14 days, stop it. That is the mechanism of action is that it should be a shorter-acting, not a long-term medication.

Brian Lehrer: If you're just joining us, we're talking about the first postpartum depression pill approved by the FDA. Listeners, we can take your stories of dealing with postpartum depression, or your experiences with what helped alleviate it, if anything, and any questions you have for our guest on the occasion of the FDA approving the first pill to help treat the condition.

Our guest is Dr. Nicole Cirino, a reproductive psychiatrist, chief of the division of reproductive psychiatry at the Baylor College of Medicine, and a board member of the support and advocacy group Postpartum Support International. 212-433-WNYC is our phone number, 212-433-9692. You can also text your question or comment to that number. You can always tweet us as well @BrianLehrer, but the number for your calls and texts, 212-433-WNYC. Christina in Maurice Plains has a question that I imagine a lot of people have a version of. Christina, you're on WNYC. Thank you for calling in.

Christina: Hi, good morning. I think you kind of answered it, but if you could go into a little bit more detail. I was prescribed Zoloft with my first daughter for my postpartum depression. What's the specific difference between Zoloft and this new pill?

Dr. Nicole Cirino: Yes, so that's a good question. Zoloft is most commonly prescribed medicine to postpartum depression and has a good amount of data showing both safety and efficacy for postpartum depression as well as safety in lactation. Pediatricians, the American Head of Pediatrics support women to continue breastfeeding on Zoloft.

This medicine works in a different way. Zoloft has several cousins of medicines like Prozac and Lexapro, and several cousins. This is a unique medicine that works in a different way, more of a neuroactive steroid, a metabolite of progesterone. It’s given for a 14 days total, that’s the treatment total. It does begin to work sooner, according to the two randomized control trials, which is day 3 and day 14 is when you start to see effect and sometimes you do not see effect that quickly with something like Zoloft. It is not yet studied in breastfeeding this medication. The women who are taking this new medicine would have to pump and dump or stop breastfeeding until we have more data about its safety in breastfeeding.

Brian Lehrer: What about the effects-- Well, let me follow up on Christina's specific question by asking, what about this newly approved medication that's been approved for postpartum depression, that's why it's in the news, for other kinds of depression? It sounds like from what you're describing that it has some advantages like how fast acting it is over many other antidepressants that are on the market. Does it have other applications as well?

Dr. Nicole Cirino: Well, interestingly enough when Sage and Biogen went for FDA approval, they went for FDA approval of both postpartum depression and major depression, which is the depression that does not occur in the perinatal period. The FDA did a fast-track approval of this medication for postpartum depression but described that they were not ready to give approval for major depressive disorder, which is for men and women not in the postpartum period. They want more data. We do not yet know that this is a medicine that's going to be treating major depressive disorder in men and women.

Brian Lehrer: Jocelyn in Rockland County, you're on WNYC. Hi, Jocelyn.

Jocelyn: Hello. Good morning to everyone and thank you, doctor, for being here to answer questions. You did answer one of my questions, which was about breastfeeding and how that have to be stopped during the use of this new drug. I was also wondering if it bioaccumulates. As you said, it hasn't fully been studied yet so there would be a cautionary principle involved there.

I wanted to tell a little bit about my story. About a month before I had my child, this was 34 years ago, I got very, very depressed. I was thinking, "Oh, my God, what have I done? I'm bringing a child into this world full of strife and world in war, and my own marriage isn't steady or kind. What have I done?" I had this child. I went to the hospital, had my daughter, and my ex-husband, who is now deceased, he refused to allow my parents entry into the hospital to visit their granddaughter. It was only his parents who were not very comforting people.

There was my sister who was able to-- She lived right nearby, so she was able to spend time with me and helped me with the things I needed. There was the grace and comfort of the larger community that I grew up in, which was really supportive with bringing me foods and stories and tidbits from the neighborhood. But the actual family life, it was so depressing. I truly wish there had been something around when this happened to me 34 years ago because the depression seeped into everything. It was very difficult to live the first few months. I was delighted with my daughter. I was overjoyed, but I was also very anxious and worried for what kind of world she was in and what kind of marriage I was in. That's my story.

Brian Lehrer: How did you get out of it? Oh, Dr. Cirino, go ahead. I'd rather hear you than me.

Dr. Nicole Cirino: No, no, I want to-- That's a good question. I just wanted to say that this is before Postpartum Support International was developed when you had the baby. Can you imagine now-- What is your name caller, I'm sorry?

Jocelyn: Jocelyn.

Dr. Nicole Cirino: Jocelyn. Postpartum Support International now has 24-hour maternal mental health hotlines, peer support, free support groups, information. You can call there and you get a peer counselor. What really Postpartum Support International has done is actually take women that are isolated and do not have that support and connect them because we are not meant to be alone and unsupported after we're home with a baby. That is not how society is meant to be. [crosstalk]

Jocelyn: No. It takes a village to raise a child. It really does, especially if you're in a cruddy marriage that's not giving you the support, and care, and kindness you deserve as a person, and especially that an infant deserves as a little being. Yes, without my sister, and my brother, and calls with my parents, I don't know what I would have done. I was really in a bad spot. I'm so grateful there are now new drugs that are out there that can target this kind of depression, and as you said, also be used for other types of depressions perhaps. I'm so glad that things are moving forward for women and there's much more respect and dignity given to women and their issues during pregnancy and after.

Brian Lehrer: Jocelyn, thank you very much for your call. Dr. Cirino, how much is this a political as well as a medical issue? For you, the FDA is a government agency after all, and many women's health issues are on various levels political related to women's place in society in many ways, how medical science prioritizes women's health issues or not, and other factors. How much is this a political question for you beyond the question of the FDA, or including the question of the FDA approving the new medication?

Dr. Nicole Cirino: Yes, interesting question. The politics of FDA approval, health care for profit, I think a lot of us are frustrated with the lack of research money spent towards maternal mental health and why we have not moved the needle forward as far as we should in terms of maternal mental health. Luckily, we do have a lot of research looking at postpartum depression, postpartum anxiety, but things like postpartum psychosis and some of the tragedies that continue to hit the United States in terms of women's suffering to postpartum psychosis and some of the more severe conditions, we just have not seen very many drug treatments, or new treatments or even research in those areas. I feel we keep working on it but we are disheartened.

Brian Lehrer: Related to this, a text and a tweet that have come in. Listener writes, “So fitting that a drug could help women would be so costly.” Now that relates to the previous drug we were talking about, the one administered intravenously, which you said has not actually been used that much in its four years since FDA approval, partly because of its cost. The listener was reacting to that. “So fitting that a drug that could help women would be so costly, not a surprise.” Then a listener tweets, “Help for new mothers as well as quality universal childcare should also be approved.” Can you respond to either of those two listeners?

Dr. Nicole Cirino: Yes. Regarding cost, it is true that new medicines, when they come out, are typically cost-prohibitive. I was reading one financial analysis of this, that was concerned about the pricing of this new medicine because it did not get the FDA approved for major depressive disorder. Meaning that now we are such a smaller population this medicine to be used for. I'm not into the profit margin, et cetera, but is that going to actually increase the cost of this medicine and make it cost-prohibitive?

The good news is that SSRIs like Sertraline and Zoloft are very inexpensive. They've been around for so long. There are still effective low-cost medicines that we can use to treat postpartum depression, but we just don't know where the price point's going to come out on this medicine. [crosstalk]

Brian Lehrer: Oh, you don't know yet where the-- So now we're not talking about the old medicine that you already said was expensive.

Dr. Nicole Cirino: The new one.

Brian Lehrer: Now we're talking about the newly approved one, which I gather is not actually going to be available to patients until October. You don't know what the price point is going to be?

Dr. Nicole Cirino: They have not released the price point according to what my research over the last two days. They are waiting to release that information. They also are waiting to see what category, the classification in terms of controlled substances it's going to come out on. There are a few more questions to be asked before we're going to actually see it on the shelves for sure.

Brian Lehrer: What about insurance coverage? Do you have a sense yet of whether it's going to be generally covered by most private insurance policies?

Dr. Nicole Cirino: This is the million-dollar question, right? I don't know if they're going to make you work through one to two tiers first, fail other agents. There's a lot that we don't know, and this is why our complicated healthcare system can sometimes be a barrier for access to care. I would not be thinking that that's going to be a simple process to get it into our doctor's hands and for me to start using for our patients in our perinatal mood disorder clinics. I think there's going to be some barriers and I'm waiting to see what's going to happen. Just want to remind the audience that that does not mean wait for treatment. We still have treatment available. We're doing it every day, multiple times a day that is effective.

Brian Lehrer: That insurance question--

Dr. Nicole Cirino: That's the older medicines.

Brian Lehrer: That being the million-dollar unknown, that's a story, that's a political story. Do you think members of Congress or anyone else should take this up and say try to pass legislation to guarantee its approval as some other things are required to be covered by insurance?

Dr. Nicole Cirino: There are a lot of people attempting from all angles to make this accessible and affordable. We have a political wing of Postpartum Support International but I'm not involved in what they're doing, like currently on being able to access sertraline alone, but we are all aware that new medicines that come out can be expensive. We want to get them into the hands of the women that are suffering. If anyone has ideas, I'm happy to pass it on to the political wing of our organization for sure.

Brian Lehrer: Oh, our listeners have ideas about political activism. Listeners, text and tweet them, text at 212-433-WNYC, or tweet @BrianLehrer, and we'll make sure that Dr. Cirino sees them to pass on to the political wing of her group that works on these issues. Let's take another phone call. Elizabeth in Morristown, you're on WNYC. Hi, Elizabeth.

Elizabeth: Hi. I'm so grateful to hear all this treatment and support for people, for women. I had a doctor that told me to, “Stop crying, you just had a baby.” Anyway, my question is, I did get treatment. I finally found a female--

Brian Lehrer: I'm taking a wild guess that that doctor was a man.

Elizabeth: Oh, yes and it was horrific. I had horrible postpartum depression, and I finally found a female doctor that helped me and I went on antidepressants. My question is I was great. I was present as a mother. It really helped me but then fast forward, I had my kids over 25 years ago, when I hit menopause, I fell into the dark abyss again. Are women that have postpartum, are they predisposed for menopausal waves of depression as well, and does this medicine help?

Dr. Nicole Cirino: Thanks for bringing that up. I wasn't-- yes, absolutely. We also run a menopause program here at Baylor. We know for sure that that is a risk factor for perimenopausal mood instability or perimenopausal major depressive disorder is having postpartum depression. We think women who are sensitive to the hormonal fluctuation are going to be sensitive throughout their lifetime. I usually will see a patient back after her second baby, after her third baby. Sometimes it's just to monitor them and to make sure that they don’t get depressed again, but then often, we will see them back during the perimenopausal period as well.

It's a similar mechanism of action. You have estrogen and progesterone withdrawal during the perimenopausal period. You have a withdrawal of, for instance, this allopregnanolone, the medicine that we're now finding that is helpful for postpartum depression, that there may be some version of it that we could also use in perimenopausal depression, but that's a couple of years from now I think.

Brian Lehrer: Elizabeth, thank you for your call.

Dr. Nicole Cirino: That’s also--

Brian Lehrer: Go ahead Dr. Cirino. You want to finish a thought?

Dr. Nicole Cirino: I was just going to say that it's just fun to think about that's also why we do use hormone therapy to help with mood in the perimenopausal period, because we're talking about the same thing, neuroactive steroids, which are hormones. Yes.

Brian Lehrer: To Elizabeth's anecdote at the beginning of her call that her doctor at the time said, “Stop crying, you just had a baby.” Here is a text that came in that says, “In 2007, at the birth of my first son, I had postpartum depression. I told no one at the time because I thought it was shameful to feel depressed after having a baby, which society says should have been the best time of my life.” This listener writes, “I hope doctors are screening new mothers today and teaching new moms symptoms so they can self-identify and better advocate for themselves.” Do you think that's happening between the time that Elizabeth of Morristown had her horror story doctor and the question that this other listener is texting?

Dr. Nicole Cirino: The universities I've been at have been generally committed to maternal mental health, progressive, we all screen every patient that comes through. For instance, Texas Children's now at Oregon Health Science University, we are advocates at Postpartum Support International for universal screening. We provide education at like birthing classes. We screen everybody for depression. That is not happening everywhere, but it's certainly, anyone in my field, that is going to be what they're going to do, is teach the OBs about perinatal mood anxiety disorders, teach the obstetric providers screen, all the patients, educate them.

Even this interview and what we do is part of educating women that it is treatable, that we're here to help you, that there are treatments available now at low cost, so yes, there's been a big change, I would say.

Brian Lehrer: If any doctor today--

Dr. Nicole Cirino: We have a long way to go.

Brian Lehrer: If any doctor today were to tell a new mother, “Stop crying, you just had a baby,” is the right response, “You’re fired, I'm finding another doctor now?”

Dr. Nicole Cirino: [laughs] I would say that someone that has not probably been paying attention to their updated training in the obstetric and gynecologic world, which includes perinatal mental health training, they need to get back on some courses and I'd be happy to train them at PSI as well.

Brian Lehrer: At Postpartum Support International where my good Dr. Nicole Cirino is a board member as well as being chief of the reproductive psychiatry department at Baylor. Do you have an opinion more broadly on the same track about routine follow-up that new mothers get? Is it not until a six-week checkup as one young mom said to me recently, and maybe it should be much sooner after birth, and to assess the mom's mental health as well as physical health and health of the baby, like after a week or something like that?

Dr. Nicole Cirino: Yes. That's why we've gotten pediatricians on board as well. We recommend, and so does the American Academy of Pediatrics, that the pediatricians screen the moms at their two-week visit or their one-week visit. We also screen the moms in the hospital before they go- -home for depression. Absolutely missing-- I mean, the most severe psychiatric condition, which is postpartum psychosis, actually, 90% of it occurs in the first four weeks, so we do want to screen women earlier and we're finding creative ways to do that.

Brian Lehrer: Listener texts, "What about the effect of a hospital stay on postpartum women? I've seen a spike in postpartum depression that coincides with a rush to close nurseries and maternity wards so that mom can come home with baby, but most women who have just dealt with a major procedure and surgery have no chance to recuperate. Once they leave the hospital, there's often no realistic chance to rest. The only time it's in the recovery room, but we are forcing their baby to be near them 24/7 so they can never rest up enough to gain equilibrium in their life." That's the text. Do you agree that's an issue?

Dr. Nicole Cirino: Yes, I have a rant piece on baby-friendly policies, which is-- of baby-friendly policies. Essentially, part of what they do is remove a nursery from the hospital so that mothers can room in with their babies immediately for 24 hours after the delivery. I'm not sure when they're looking at the baby-friendly side of that, that they're looking at the maternal mental health side. I agree that sleep and recovery and healing after a major birth or surgery is very important. I would agree with that caller.

Brian Lehrer: On the new drug that's been approved for postpartum depression, the first pill to be so approved by the FDA, which is the news hook for this conversation. Harris in Manhattan has a question. Harris, you're on WNYC. Hello.

Harris: Hi. This drug is truly revolutionary. The question I have is what are the side effects? Can it be used for other forms of depression? Is there any contraindications for breastfeeding?

Dr. Nicole Cirino: Oh, good. Okay, yes. I touched on a couple of those. The side effects are going to be just somnolence, dizziness, sedation, this GABAergics, the type of medicine this is make people tired. That’s kind of on purpose. That's why it helps with anxiety. That's mainly the side effects you're going to see. The black box warning says, "Do not drive within 12 hours of taking it," so we're taking it at night.

In actual principle, whenever I give a woman a sedating medicine who's postpartum, we are cautious to remind them not to co-sleep. We're cautious to have a partner available should the medicine be more sedating than we think it is going to be for them, so really to have that being monitored. The other question was, is it effective in major depressive disorder? I touched on that briefly, but the pharmaceutical company did put it forward to try to get it FDA-approved for major depressive disorder, but the FDA wants more data. We do not know but I suspect it probably will be used for major depressive disorder that's outside the perinatal period at some point.

Brian Lehrer: As we run out of time--

Dr. Nicole Cirino: Did I answer that?

Brian Lehrer: Yes, I think you answered that pretty thoroughly. Harris, thank you for your call. Dr. Cirino, as we run out of time, this is something I guess that people aren't generally prepared for. It's not like you get an early warning sign that you have heart disease or cancer, and then you can gear up for your treatment over time, or other diseases and conditions that you may be able to do that for. It's like, boom, you have a baby, and boom, this hits you and you didn't know it was coming.

What advice can you give to new mothers, or people who are pregnant right now, not even new mothers, or maybe in the future, as this drug is going to come on the market in October, and people don't know yet if it's going to be affordable? You said they haven't set the price for it yet, we don't know yet if insurance is going to cover it. What's your advice for individuals who are going to give birth not knowing what their treatment options are going to be?

Dr. Nicole Cirino: Right. I would say a couple of things, especially if you're someone that might be vulnerable to depression, that means that you have a history of postpartum depression or a difficult delivery, labor, high-risk pregnancy, then I would talk to your partner, your physician early on and discuss that they are concerned about the risk factors. Could you be watched more closely, make sure that there’s screening that occurs, and let's not wait for this treatment to come out.

Like I said, there's already treatments in place, but you want to do a combination of psychosocial support and decreased isolation, a chance to heal, so if somebody's helping you with the baby, basic self-care, and then possibly, if you consider seeing a mental health professional that specializes in perinatal mood disorders. You can also find that at Postpartum Support International postpartum.net, finding an expert in the area. It is actually a very treatable condition, perinatal mood and anxiety disorder. It's often missed, undertreated and misunderstood, but if you actually get treatment, you do get well. That's what I recommend.

Brian Lehrer: Dr. Nicole Cirino, chief of the division of reproductive psychiatry at the Baylor College of Medicine, and a board member of Postpartum Support International. Thank you so much for joining us. Judging from our calls and texts and tweets, you've been very helpful to a lot of people today. I really appreciate it.

Dr. Nicole Cirino: Thank you so much.

 

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