“Postpartum and Perinatal Depression”- with Dr. Emily Miller, MD, MPH – PART 2

Dr. Fox: Welcome to today’s episode of “Healthful Women,” a podcast designed to explore topics in women’s health at all stages of life. I’m your host, Dr. Nathan Fox, an OB-GYN and maternal-fetal medicine specialist practicing in New York City. At “Healthful Woman,” I speak with leaders in the field to help you learn more about women’s health, pregnancy, and wellness. Today is part two of my conversation about postpartum and perinatal depression with Dr. Emily Miller. Part one dropped last week and focused mostly on postpartum depression. The conversation picks up today with me asking Emily about potential barriers to women getting their perinatal depression recognized and treated. We’re not going to solve healthcare in the U.S today in this podcast. I suspect we won’t.
Dr. Miller: No.
Dr. Fox: We might but okay. But I’m just curious how much is it because I’ve always felt that one of the barriers to this is…I don’t think it’s that women don’t necessarily have access, so to speak, to mental health care. I think that just it’s so difficult because you know, mental health is one of those fields where if you go into it, it’s very hard, you know, to make a living because all you do is talk to people or prescribe. And so you’re not going to get reimbursed a lot for spending an hour with someone, which is what you need to do.
And so a lot of people come off insurance plans and don’t take Medicare or Medicaid or whatever it is. And then it’s like $400 to see a psychiatrist. And I don’t blame them. They got to make a living. Okay. But because of that, access is difficult. Like, you can see a cardiologist at any point because they’ll all see you. You know, it’s easy in that sense, but you can’t just open a book and find a psychiatrist who can see you tomorrow. It’s just very difficult. And I’m curious how much of that has been your experience that that’s the barrier as opposed to like, you know, stigma or not recognizing, I mean, just, you know, bread and butter logistics, I can’t find a psychiatrist or a mental health provider to see me.
Dr. Miller: Yeah, I think that’s a huge part of it. And I think it’s regionally specific. New York has a very unique kind of community of psychiatrists where insurance just isn’t…I mean, at least that was my experience when I was in New York. It is really unheard of for a psychiatry office to be able to get somebody in, in short term, kind of, wherever. That’s really uncommon
Dr. Fox: And the visits have to be an hour. I mean, you can’t just see someone for five minutes.
Dr. Miller: Totally.
Dr. Fox: It just doesn’t work like that. You need to really talk.
Dr. Miller: Yeah, absolutely. And so I think this is where we have opportunities to skill build because we can get this ball rolling. And I’m not saying that we should be managing intractable bipolar disorder or chronic suicidality that’s been refractory to medications. We need our psychiatrist for these difficult cases that we’re doing the right thing. But 90% of what we’re going to see is, you know, perinatal depression or anxiety. And that’s something that I really do fervently believe is in our wheelhouse.
Dr. Nathan: Yeah. No, I totally agree because that’s where the access…because people have access to their prenatal providers almost always.
Dr. Miller: Yes. And they’re comfortable with us. God willing, like, we’ve done a decent job that they know us, they’ve opened up, I mean, they’ve been quite vulnerable with us for, you know, however many months. And so I think it’s something that they’re used to, they know our teams, they know our office building, it’s less intimidating. And so I think it’s a nice place to be able to improve access.
Dr. Fox: For people listening to this podcast right now, let’s say, you know, they’re pregnant, is there a way they can know if they are more likely to be in that one in seven who’s going to get this many risk factors? And also, is there a way people can lower their risk of this happening?
Dr. Miller: Yeah, absolutely. So there are certainly risk factors. I will say precision in this is, imperfect would be an overstatement, but we know there’s risk factors. Folks that have had a history of mental health condition, you know, a history of depression, teenagers, etc., that’s a predisposition. Folks that have been diagnosed with PMS or PMDD as a risk factor. We also know, you know, social instructional determinants of health are risk factors, some more disadvantaged populations are at an increased risk, but there’s no precision there. This isn’t something that, you know, you’re in a population where it doesn’t affect my group of people. Everybody is at risk and should be attuned. There are the USPTF the United States…ooh, it’s gonna be tricky. PS…Preventive Services Health Task Force.
Dr. Fox: Got it.
Dr. Miller: Oh, thanks. Put out a couple of years ago, it was published in JAMA, their recommendation for prevention of postpartum depression interventions. So this is really exciting work. There’s two psychotherapy-based interventions. One’s called Roses and that’s interpersonal therapy-based modules and then one called Mothers and Babies. And that’s based on cognitive behavioral therapy. And those of those have been proven to reduce the risk of postpartum depression. And I think where the research now is in trying to implement these, you know, they’re not being used on the ground the way that we would hope that they could be. And how do we refine what populations this best works in or how to…kind of anticipating we’re not going to be able to do this for everybody, like who would most benefit?
Dr. Fox: Yeah. When I see women who like you said have a history of anxiety, depression, whatever it is, and they’re pregnant, you know, I sort of tell them, “Listen, there’s bad news and there’s good news.” The bad news is you’re far more likely to have postpartum depression or anxiety, you know, to be exacerbated. So that’s a bummer. That’s not good. But the good news is you’re much less likely to suffer from it because you know exactly what’s happening.” You’re going to wake up and say, “I don’t feel right. It’s my depression. I’m getting treated. I’m calling my doctor.” And so even though it’s more likely to be something you’re working with, you’re less likely to have that, like, three months of just complete misery.
And the people who truly suffer are the ones who don’t know it’s coming. And so, because they have no risk, they’ve never dealt with this before. They know nothing from it. And so they’re just like, “Well, yeah, this is normal that I haven’t gotten out of bed for three weeks and I haven’t eaten for two weeks and I haven’t showered for a week. So yeah, this is what happens to moms.” And then someone’s like, “No, this is like totally not normal. And like, we need to help you.” And it can be a long time until that happens. And I think that’s where just even the education piece that people know that this can happen to anybody. And if you’re having these symptoms that don’t seem right, or you’re not sure if they’re right, just ask. Like, call your OB. It’s like, “Hey, is this normal?” And they’ll be like, “No, come in, let’s see what’s going on.”
Because people just think they have to like, “Oh, you know, being a new mom is, like, awful. And I’m going to be miserable for three months.” Like, no, that’s not the case. It’s not supposed to be the case. You know, if you’re miserable because, again, you have to get up at 2:00 in the morning, that makes me miserable too but that’s normal misery. We’re as, “And now I, therefore, can’t enjoy being with my baby at 2:00 in the afternoon, ever,” that’s not normal. That’s a problem. That’s something that should be addressed.
Dr. Miller: Totally. I think it’s so much better to ask than to wonder. And I think getting that message out to pregnant postpartum people is so important. There’s no symptom that’s too simple. Just check in and express what you’re feeling so we can help navigate it together.
Dr. Fox: Right. And the treatments are for 90%-plus of people, so straightforward. It’s either therapy or a simple medication, or both. We’re talking about, like, basic, basic, basic treatments. I mean, it is nothing crazy that we’re talking about here.
Dr. Miller: Exactly. And things that can…like, they work.
Dr. Fox: Yeah.
Dr. Miller: If we do them right, they do work in most cases. So I think really, it’s just so important to empower women to come to us.
Dr. Fox: Now, switching to the someone coming into pregnancy. So either pre-pregnancy or beginning of pregnancy who does have a history and they come and see you, how do you do that initial intake or consultation, whether she’s your patient or someone else’s patient, but you’re going to be talking about mental health and pregnancy? For someone, again, with diagnoses, on medications, with history, how do you approach that subject for that person?
Dr. Miller: Yeah. So taking a step back even from that, I think it’s important to remember, you know, our field, we’ve talked about postpartum depression for a really long time, and maybe not quite 10 years ago is when this concept of perinatal depression became recognized. And it was, you know, a lot of work but a sentinel article that was published, Kathy Wisner was the lead author in it, it followed 10,000 women, screened them for postpartum depression. And for those who screen positive, they went to their homes, did these diagnostic interviews, really sophisticated, like the best science we have when you have timeline follow back trying to identify when symptoms began.
And of the people who had depression, 40% had postpartum onset depression. So certainly given, you know, the brief time period, that was the highest risk time period for depressive symptoms to occur. But almost a third of women had incident symptoms of depression at some point during their pregnancy. And so this concept of, “Oh no, pregnancy is blissful and wonderful and it protects you from depression,” that’s just not true.
Dr. Fox: God, who says that?
Dr. Miller: Not this girl.
Dr. Fox: Oh, it’s pure bliss. Pregnancy is just wonderful. Yeah. That’s what everyone tells me every day, all day. “Doc, it’s the greatest 40 weeks of my life.”
Dr. Miller: Totally. And then roughly a third had symptoms before pregnancy began. And so I think this is where, you know, in my mind, we absolutely need to be screening in pregnancy and talking about this in pregnancy. And the way I do this way, the way I recommend everybody do this is we screen using a validated screening at the first prenatal visit because then we’re going to get a sense of where are they now? And then we’ll talk about history in a moment, getting back to your question.
And then again, you know, late second, early third trimester, has incident, has new depressive symptoms evolved, and then postpartum? And I think those are nice touchpoints to make sure that we’re not leaving…I mean, gosh, if we just screened postpartum, we would have 60% of people vulnerable. You know, we would call it postpartum depression but they’ve been suffering this entire time because we haven’t asked the right questions. You know, we have validated screens. They take less than five minutes. They’re freely available. They’re in multiple languages. There’s really no excuse not to ask the questions. We just have to find ways to implement it in our offices.
Dr. Fox: For the record, Emily, in my convoluted timeline, I was going to get to that. In my brain, I started postpartum then I was going to go to beginning of pregnancy, then I was going to go to the middle of pregnancy and talk for everybody. We have the same circle. I just started a different point on that.
Dr. Miller: I love it. I love it. Well, good. Well, sorry to divert your questions.
Dr. Fox: Well, I know because I know you’re thinking, you’re like, “Dude, why is Fox skipping this?” Like, we have to screen in pregnancy. What’s wrong with this guy? How does he have a podcast? How does this idiot have a podcast?” And I’m like, “No, no, no. I knew about that. So it’s all good.” Now, we started screening during pregnancy as well for the exact same reason. You know, we screen postpartum and that was like, everyone’s doing that. Like, that’s the new thing. You know, that was a craze, so we’re doing that.
And then we’re like, you know, yeah, but the screen and pregnancy, and as you said, you pick it up, you pick it up at the first visit. If you ask people, they’ll tell you. It’s like, people may not tell you they smoke unless you ask them, “Do you smoke?” It’s the same thing. People may not tell you that they have anxiety, depression, OCD, unless you say, “Do you have anxiety?” You know, like, if you’d ask them, “Tell me about this.” That’s just how humans are. They’re not always going to just tell you everything about…either because they’re a little embarrassed or because they don’t even think about it as something they should be talking about with their OB-GYN potentially, or they forgot the two years. I mean, that happens all the time. Like, “Oh yeah. Two years ago, I was like a whole thing, I was on medication for six months and I was in therapy.”
It doesn’t always come to mind when people are thinking about their pregnancy, you have to ask. And when you ask, they’ll tell you. People tell the truth to their doctors. Everyone thinks that everyone lies to their doctors, they don’t. We hear everything. I mean, we know everything. It’s really amazing. And you just have to ask. So with that said, what do you do for someone who does have a history and is coming into pregnancy? Like, “I’m going to see Dr. Miller because she is the bomb on this topic and she’s going to, like, totally get this.” Or the doctor sends you that patient, how do you approach that situation?
Dr. Miller: So I think understanding their history. Now, we are not psychiatrists. So the psychiatrists I work with, they do a way more sophisticated thing than what I’m going to be able to include in my initial visit. And so I think we need to recognize that we’re not psychiatrists and we’re not expected to be psychiatrists, and that’s okay. But there are parts of this history that we can elicit that are gonna really help us move forward. So just the basics. When was this diagnosed? How were you treated? Was that treatment effective? That’s going to give you like 90% of what you need to know.
If they’ve been on a pharmacologic agent before and it worked, hey, that’s going to be a good one to start with almost no matter what it was. Because what we don’t want to do if we’re starting pressing you about medications in pregnancy, we’ll say, “Yeah, okay. That worked for you before but I’m going to try something different and let’s just keep our fingers crossed and hope it works.” Because goodness, now you’re going to expose them to this one medicine, have to down titrate, restart what they otherwise knew was going to be effective from the get-go. So really trying to get a sense of what’s worked in the past, and can we just go ride on that success?
What hasn’t worked in the past? That’s also really important. I think, again, sometimes we go to sertraline, it’s the most studied medication in all of pregnancy. We have a lot of fluency and comfort with it. And so, you know, we want to know, have they tried that before and it didn’t work or they had intolerable side effects? We need to know that information. How many major depressive episodes have they had? Is this something that, hey, it happened once and, you know, they’ve been [inaudible 00:14:38] since they haven’t had any depressed mood since then? Or has this been episodic where we think, “Oh gosh, this is a real risk of recurrence?”
And then getting a sense of what their mood is now. And that’s not just your feeling all right. Right? You know, I’m being silly but it’s a validated screen. Most people use an EPDs or a PHQ-9 something where we can get objective data that we can anchor to. I can’t tell you how many times someone says, “Yeah, I feel fine. I feel good.” And then they fill out the screen and they…we use the PHQ-9 here…screen positive. I mean, loosely speaking is 10 or more and their PHQ-9 will be a 17. Like, “Well, let’s back up. You say you’re fine.”
Dr. Fox: Other than the fact that I feel horrible, I’m fine.
Dr. Miller: Yeah. So I think using that just creates a space for a dialogue. But I also think when we give the screen, we need to give context to it because I also get a lot of screens back that are a screen score of a zero. And I would argue that that is physiologically impossible if you’re first trimester. So I worry about those zeros that they’re not really answering honestly. And so I think it’s important that we don’t just slap a screen in front of somebody, but say, “We ask everybody this. It is so important that we understand how you’re feeling. I want you to be honest, this is going to help me better care for you. and give some context about, you know, tracking this throughout pregnancy.”
Dr. Fox: Because obviously, I’m sure you see a lot of women who come to you specifically either themselves or from their doctors. Do you find a lot of pushback either from the pregnant people themselves or maybe their psychiatrist, psychologist, internal medicine doctors, whatever it is, you’re like, “Yes, I think you should stay on this medication or start this medication?” Again, early in pregnancy and they’re like, “No, that’s not happening. I’m not willing to do that.” Or, “I’m not willing to prescribe it.” Because again, what we were talking about before that they’re concerned about the risk of the medication. Is that something that you’re still having a lot of conversations about or do you think that that maybe has changed over the years, or both?
Dr. Miller: Yeah, maybe both. I mean, it certainly still happens and it happens a lot. I will tell you, and I’m sure you’ve experienced this too, it’s a bit of an uphill battle when somebody has planted the seed of, “Ooh, you need to come off of this medication.” Then trying to get them back on is hard. I also think if they’re being managed by [inaudible 00:17:01] doctor or psychiatrist or whoever that’s prescribing SSRIs, a little bit, seems to be the most common. When that person says, “Ooh, I’m not comfortable in pregnancy,” it sends a signal. And I wish that communication is, “Yeah, maybe I’m not comfortable in pregnancy…” I mean, I get it. “I’m also not comfortable with untreated depression in pregnancy. And so let’s keep you on this until we can link you to the right person to help with this decision they took.”
Dr. Fox: I guess it’s not so much a struggle now compared to before. I think that maybe that’s where I practice, a lot of the psychiatrists are very comfortable with pregnancy and pregnant women. And maybe some of the struggles that I have is more with the pregnant folks themselves potentially just that they don’t recognize. I tend to spend a lot of time with people, even again, no history, nothing, just routine pregnancies, just like I would talk about anything. We talk about mental health just like, “Remember, like, this is important for you. It’s important for your baby. It’s not like you versus the baby here. Like, you know, if you’re not well, the baby’s not well. If you’re well, the baby is…”
Like, try to get people to think just in that sphere, particularly for people with a history saying like, “Listen, yeah, I mean, would it be great if none of us ever needed any medication ever?” Sure. But we don’t live in fantasy land. It just doesn’t work like that. Like, if you’re going to have crippling anxiety in your first trimester, not only are you just suffering, which I don’t want you to do, and potentially just the concept of suffering and the stress might not be good, but even aside from that, maybe you won’t take your vitamins. Maybe you won’t have good nutrition. Maybe you won’t be able to exercise. Maybe you’ll miss visits. Maybe you’ll do something drastic. We won’t see any more. I mean, all these things could potentially happen. I’m like, that’s so much worse than whatever risk the medication is. I mean, it’s like 10 times worse.
Dr. Miller: Totally.
Dr. Fox: When you start putting that in context for people, occasionally someone will say, “I don’t really have anxiety. Like, I’m fine. I started this in college and I don’t really need it and we can go off it and see what happens.” All right. That happens but the majority of people know, “If I stop this medication, I’m not well. I can’t go to work. I can’t leave my house.” It’s clear as day that they should not be stopping their medication. And it’s important that we tell them that, that we value their mental health, not just because, like, it’s nice because it’s important. Like, they need it.
Dr. Miller: Yeah. We tend to do this a lot in obstetrics is counsel without, kind of, risk-risk decision-making. And I think it’s so important to emphasize…I mean, not to be catastrophic about it. Most people with untreated depression, they’re going to get through a pregnancy and things will be okay. So not to catastrophize but just to emphasize that untreated depression carries risks. And I also sometimes talk about even depending on someone’s comfort level talking about pathophysiologies.
We know depression is an inflammatory condition. We know that there are changes in your body that are happening. There’s biology that is changing and that biology can impact your fetus, can impact your placental development. And so we could let that go unchecked and have that exposure, or we could try to curtail that risk and get you feeling better. And sometimes just really articulating what that untreated or undertreated depression cascade could look like and the sematic risks of that helps people understand that the decision isn’t just, you know, snap your fingers, just not have a major depressive episode. I wish it was because I’d just be snapping all day but it hasn’t been effective when I’ve tried it before.
Dr. Fox: Yeah. That’s how I tell people about COVID. I’d be like, “Yeah, it’d be great if there were no COVID, but it’s here.”
Dr. Miller: Totally.
Dr. Fox: So it’s like, would you rather get the vaccine or get the virus? Because if you don’t get the vaccine, you’ll get the virus, like that’s what’s going to happen. And even if you get the vaccine, you still might get the virus but it would be less. If we could transport to a world without COVID, that’d be great, but it’s not happening. So it’s the same. I 100% agree. I wanted to pivot here because it’s important that we talk about this. People are saying, like, you are not just treating pregnant women, pregnant people for depression, you are also doing research into this, like actual clinical research, basic science research. Like, what are the things that you’re trying to answer in your own research?
And you could also talk about things that you feel you have answered or have touched upon just so we get a sense of like, what would research even look like in this field? You mentioned the idea of maybe preventative strategies for people who are at higher risk, but what else are you looking at? Because I know you’ve done some really cool stuff and I’ve heard you present on it. And I wanted to give you a chance to talk, you know, to really nerd out here.
Dr. Miller: Yeah. Oh, good. This is where I really shine. You know, this is my favorite thing to talk about. So interrupt me if I go on too much. But I think there’s so much to do and it’s really exciting because I feel like there’s palpable change that’s happening. So the research I do spans from translational neurobiology, which I’ll circle back to, to kind of how we optimize our health systems to best deliver care, and kind of everything in between.
So the neurobiology is really looking at biomarkers. And some of the work that I and my team have done are focusing on looking at changes in the brain, and specifically changes in the cerebrospinal fluid, the fluid that feeds the brain in pregnant people that have depression compared to pregnant people that don’t have depression and seeing these increased inflammatory cytokines, or these markers where there’s extra inflammation around the brain in people that are experiencing depression. And then trying to understand how those markers of inflammation got there and understanding the mechanisms of disease.
Dr. Fox: Meaning do they cause the depression, or are they an effect of depression, those types of things.
Dr. Miller: Yeah. Totally. And I think this is important because it gives us opportunities to identify biomarkers. It’s so hard to distinguish early pregnancy or late pregnancy from major depressive disorder in some cases. Where like, yeah, you are moving slower and your eating habits have changed, and you are feeling more fatigued. And so I think we can use our clinical judgment and our clinical assessments, but I think it’d be really nice to have some augmented, you know, biologic markers to help support that just because it can be difficult. The other piece is it allows us to then target new therapeutics. Brexanolone, you know, has been FDA approved for postpartum depression and that’s exciting. That’s the first new medication we’ve had in decades.
Dr. Fox: Talk about that a little so our listeners know what you’re talking about.
Dr. Miller: Brexanolone is a newer, it’s been around for a couple of years, FDA-approved treatment that is specific to postpartum depression. So it’s the first FDA-approved medication that is targeting depression in the postpartum period. And it’s an IV infusion. It’s 60 hours. You have to be admitted to a hospital so you can undergo some pretty intensive monitoring when it’s happened. But when they compare it and there’s been three randomized trials, kind of the best quality evidence we have, that have compared people who got placebo, who got kind of an IV infusion that was just the water basically to those who got this Brexanolone, and they found that those who got Brexanolone had a pretty drastic and pretty quick reduction in their depressive symptoms and that persisted for 30 days.
I don’t think it’s a panacea. We actually don’t even use it here at Northwestern right now. It’s expensive. There’s pretty significant side effects. We don’t have longitudinal data. And I mean, the truth is other treatment options also work. So I’m not quite sold but they’re starting to investigate. The same company, Sage Therapeutics are starting to investigate oral medications. And I think that becomes a little bit more accessible and acceptable to patients. It’s interesting in their data, if you track the depressive symptom response for those even in the placebo group, there’s a pretty dramatic reduction in depressive symptoms by being in the hospital…
Dr. Fox: By being in the hospital.
Dr. Miller: …and having supportive care for 60 hours. So they see that in psychiatry trials a lot. There is a pretty significant placebo response. And I think, I don’t know if it’s placebo per se or, you know, kind of this Hawthorne effect, this knowing that you’re cared for, knowing that you’re supported, knowing that people are watching you that just is impactful. So I think it’s an important movement for our field. I don’t think it’s a panacea but I think it’s something to kind of keep on everybody’s radar.
Dr. Fox: And then in terms of the research we were talking about in systems. So talk about that a little bit.
Dr. Miller: So the work that I do is an intervention that’s called collaborative care and collaborative care is a very specifically ascribed health services intervention that kind of introduces a few new concepts into the care of mental health within primary care spheres. So specifically there’s a care manager, typically a licensed clinical social worker who is the cornerstone of the system who is kind of the interface between the patient, the primary care clinician, and then a supervising psychiatrist. There’s a patient registry. Everybody that’s enrolled in the system gets data inserted into this registry and we track symptoms. And then there’s a supervising psychiatrist.
So instead of the psychiatrist seeing every single person, the psychiatrist along with the care manager, they meet every week and describe everyone in the registry and how they’re doing on their treatment. And if they’re doing well, great, keep going on that treatment. If they’re not responding, then the psychiatrist can give some high-level, “Hey, let’s increase the dose of this medication.” Or, “Let’s change the modality of the therapy.” Or, “Let’s add therapy or add medications.” And so they can, in that way, kind of oversee the care of hundreds of people instead of just a couple dozen people, if they were seeing every single person for, you know, 60 minutes.
And so it’s a way to really allow primary care clinicians to optimize, practice kind of at the top of their license with respect to mental health care. And it’s been shown in 83 randomized trials, which is remarkable, who paid for that 83rd trial is…Like, “We just need this one extra then I’ll know it works.” But it’s been shown to improve depressive symptoms, improve, you know, patient-reported outcomes, and then actually improve some somatic health outcomes. Like, arthritis symptoms have been examined. Diabetes control has been examined. But we’re not primary care doctors. And then we kind of are but we’re not, but we kind of are. Our research is evaluating this in the perinatal context and trying to adapt some of the periphery and leveraging some implementation science to better understand how we can expand access to mental health care by integrating collaborative care into our obstetric offices.
Dr. Fox: I know that you’re also an advocate. You’re involved in advocacy, certainly for women’s health in general. I know you’re in the COVID space. But just in terms of mental health, what are you doing there? You’re starting groups, you’re running committees, you’re doing a lot of stuff, you’re everywhere.
Dr. Miller: Yeah. I mean, there’s just so much passion in this space. And I think one of the things I’ve really learned from is having patient experience or client experience to be able to reflect that back. So, you know, working on the Marce of North America is…Marce in general is an international perinatal mental health organization that’s involved in research and advocacy. Just trying to get patient education. Some of the research supported generates funding to support the work that, you know, folks are doing, working with different stakeholders on the insurance fear to cover some of the important stuff that’s done. You know, kind of anything and everything we can do to get this information out because it’s so important.
Dr. Fox: Emily, you know, that I think you’re awesome. And I just love what you’re doing and I love where your career is going and all the good that you’re doing. Clinically, research-wise, advocacy, education, you’re just the real deal and it’s awesome. And thank you so much for coming on the podcast, and for being my friend. And I look forward to obviously seeing you, and I’m just really appreciative because my listeners, I’m certain, are just gonna fall in love with you and everything that you’re doing.
Dr. Miller: Well, thank you. And it’s certainly the mutual admiration society here. You clearly have more fluency in this space than most, and your patients are lucky to have you, and I am lucky to call you a friend.
Dr. Fox: Thank you for listening to the “Healthful Woman” podcast. To learn more about our podcast, please visit our website at www.healthfulwoman.com. That’s healthfulwoman.com. If you have any questions about this podcast or any other topic you would like us to address, please feel free to email us at hw@healthfulwoman.com. Have a great day.
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