[Music] thanks everybody for coming tonight it's uh always fun to talk about one of my favorite topics prenatal mood and anxiety disorders and um so the term perinatal mood and anxiety disorders has really come to be very popular in the last few years people used to talk a lot about postpartum depression which of course is still a thing and we still talk about it but uh the recognition that there's broader uh things going on in the perinatal period than just postpartum depression so that's why i'm using this this broader term tonight um before i get started i'm going to talk about a case um but i also wanted to just remind everybody you know who we are at the women's mood disorder center and why we're here doing this for you um so we're a specialized center that has both clinical work and research that our goal is to kind of improve and influence the care of women's mental health particularly during and after pregnancy but also at other points of the reproductive lifespan and so you can see here what our our missions are are to provide outstanding care we are a teaching clinic so we educate students we try to educate other providers and the public hence hopkins at home on the unique issues surrounding women's mental health we conduct research on these areas and and we hope by doing all of these things to help lead the nation in improving the practice of reproductive psychiatry so what is reproductive psychiatry we talked a little bit about this last week but i always like to define my terms before i get too far into it and and i think it's important to define it because some people use lots of terms interchangeably like the term women's mental health and the term reproductive psychiatry and the term perinatal psychiatry and what we mean by reproductive psychiatry is the study and treatment of psychiatric illness that occurs at times of hormonal fluctuation reproductive hormonal fluctuation so that includes the premenstrual time period you heard from dr hansu last week about hormonal fluctuations in the pre-menstrual it incur it includes the peripartum period which is what i'm going to talk to you about tonight and it includes the perimenopausal period which dr stan devin will talk about next week it's not quite the same as women's mental health so women's mental health is a broader term that refers to anything to do with mental health with women and it can refer to things about gender roles about sex roles about intimate partner violence about things that happen uniquely to women but that aren't necessarily related to these times of reproductive hormonal transition so why should we have such a thing as reproductive psychiatry like why why do women need this special branch of psychiatry well the answer i think is right here in this graph dr hansu mentioned this fact last week but i think it's something that's really important to to see a picture of what it looks like and that is that mood and anxiety disorders are much more prevalent in women than they are in men during the reproductive lifespan and when i say women i mean people who have ovaries anybody who is affected by female reproductive hormone transmissions transitions so that can include trans men it can include anybody who has those ovaries or is capable of producing those hormones and so what you see in this graph is that before puberty rates of this is major depression in boys and girls are exactly the same up until you hit puberty then look what happens to the women skyrocketing above the rate of men all the way through the reproductive years until you have this sharp decline in the post-menopause and actually in the elderly years women have lower rates of major depression than do men so we see something like this and we say well there's something going on during the reproductive years and of course there are things going on in people's lives social things psychological things but there are also biological things going on and that's the study that's the center of what we do at the women's mood disorder center so before i get into a little bit of the treatment and the science surrounding perinatal mood and anxiety disorders i'm going to share with you a case and the reason i choose this particular case is that this is a patient i had in in residency who really set me off on the path of the kind of research i do this was a patient who had been a very fierce competitive athlete in her in her college days and she had grown up to be a fierce competitive adult she was a woman working in a very high-powered male-dominated field and she was very successful in that field and i met her when she was about 20 weeks into her first pregnancy i met her because she was in the hospital being hospitalized for severe pain due to a medical condition that was occurring during the pregnancy and i was a psychiatric consult called in in part to help her with the pain and to part to help her with what her doctors perceived as the significant distress surrounding her pain and what i found was a woman who was severely severely anxious she had never been diagnosed with any kind of mental health condition prior to her pregnancy although she was somebody who had always said that she could get keyed up and tense and had periods of insomnia when she was under stress but she had never defined that as a mental illness of any sort um but when i met her she was incredibly anxious and she had a form of anxiety that we call obsessional anxiety where she had things that she would believe that actually weren't really consistent with reality but she couldn't shake her belief in them and in her case it had to do with certain things at work things that she was convinced she had to get done at work when several people had worked had said no no you don't have to do that you're in the hospital take it easy um and and the result was that her anxiety you know made her uh go and do these things and it was not a good result for her at work and so i was faced with this woman who had been a very competent functional woman who now really was not because of her anxiety and because she was so anxious she refused all of my medication suggestions she was worried that the medications would do something to the baby and one of the things that i got really interested in in her is that she had severe insomnia and she also had some things in her blood work that led me to realize that she had elevated levels of inflammation and we've all heard the word inflammation but nobody really knows exactly what it means or a lot of people don't know what it means and it really means the elevation of certain parts of your immune system that are responses to infection and in her case she had some elevated markers of inflammation and no real obvious reason why that was happening and so i was curious about that what could be going on in this woman's body i continued to treat her through the pregnancy without any medications with psychotherapy and then in the postpartum she finally agreed to take medications she got extremely better when she took medications in the postpartum and then about eight weeks after she had given birth she had a severe relapse and it was almost like a curtain came down over over her she went out of my office one week looking great she came back the next week looking terrible and i said what happened and she told me that she had been started on a particular type of birth control pill called the mini pill which is only progesterone and not estrogen and so that was the other thing that that tickled my research fancy and said huh i wonder what the progesterone is there's something about progesterone in particular that has something to do with mood and anxiety disorders so i just want you to hold those two thoughts in mind inflammation and progesterone because you're going to see a little bit later in the presentation that that comes back into the type of research that we're doing now at the women's mood disorder center and it was all inspired by this patient so what are mood nate perry made alone anxiety disorders and what causes them i'm going to talk to you about our research in the biology of these disorders but of course biology isn't the only thing going on right there are stressful things that happen in life there are genetics that don't have to do with current biology but have to do with what did your parents have what did your grandparents have your aunts your uncles your well not so much your uncles in the case of perinatal but your aunts to your sisters um there is biologically there's hormonal flux that which changes things that in neurotransmitters there's inflammation as i mentioned there are changes in sleep and circadian rhythm changes that occur during pregnancy changes in physical activity if you're somebody who has um benefited from exercise and the sort of mood buoying properties of exercise and you suddenly find yourself in a pregnancy with bed rest that's going to have a huge difference and make a huge difference in your mood and there's also a lot going on with social world transitions and social rhythm changes right if you are used to being a single person or perhaps part of a couple but not a parent to suddenly shift into parenthood is a very different uh different way of life so all of those things can go into perinatal mood and anxiety disorders one of the things that we focus a lot on in this period is hormones um with good reason right hormonal change is vast across the perinatal period and what this graph is showing it will concentrate on the red and the blue lines so the red line is estrogen and the blue line is progesterone those are the two major reproductive hormones and down here on the bottom we have the months since the start of the last menstrual period with the delivery of the child this big purple flag over here and so what you can see is that the the levels of estrogen and progesterone go up dramatically across pregnancy and then it's like a cliff within about 48 hours you're back down to the way you were before and that hormonal cliff is something that every woman goes through after giving birth and for some women some women are very vulnerable to that fluctuation and will develop symptoms of postpartum depression now the cliff happens for everybody but not everybody develops symptoms so what we know is it's not the actual hormones themselves that are causing problems at least not these two hormones but rather the change and individual women's vulnerability to that change that vulnerability may come about because of genetics it may come about because of other life experiences that a woman has had for example early life adversity it may come about because of some other reason that we haven't figured out yet but some women are extremely sensitive to this shift and in fact all women are a little bit sensitive to this shift the baby blues which is um mood volatility that occurs just in the first couple of weeks after birth occurs to 85 to 90 of women so everybody has some kind of vulnerability to these shifts so i want to talk before we get into the the research that we're doing about perinatal mood and anxiety disorders i want to talk a little bit about treatment um because i think when people know anything about postpartum depression or perinatal mood and anxiety disorders what they know is the way these disorders have been portrayed in the media in particular the way the treatment of them has been portrayed and so i want to bust a few myths here and talk about what the facts are before we get into the science that we're doing so the first myth we want to talk about is that pregnancy protects women from mood and anxiety disorders now this is a myth of long-standing um it was something and i was just working this morning with somebody who's writing a piece about something that happened in an asylum in the 19th century when we thought that there was such a thing as therapeutic pregnancy so they actually felt that in order for women to recover from mood and anxiety disorders it might benefit them to get pregnant and they would prescribe pregnancy the reality is pregnancy is not protective from movement anxiety disorders it's risk neutral right you're not at any increased risk during pregnancy but you're also not protected and the postpartum is different we're going to talk about that in a little bit and this is a good example i think of how you're not protected during pregnancy so this graph shows you something from a study that was done a number of years ago on pregnant women with bipolar disorder and the purple line here is is women who stayed on their medication treatment during pregnancy the orange line is the women who discontinued treatment and down the bottom we have the time following conception and what you can see without even looking at the numbers you can see that women who stayed on their medication did a lot better than the women who stopped their medication and what we have here the time scale is is the time to relapse the time that had they had recurrence of moods so for the purple line even by the end of pregnancy a lot of the women were remaining well but the orange line very few of the women women remain well and what that comes out to in terms of our rate of relapse is that about 85 percent of the women who stopped their medications for pregnancy relaxed during the pregnancy now the the people who did well didn't get away scot-free right a number of those relapsed about 37 percent of women who stayed on their medication relapse and that may have to do with inadequacies in the way we're treating women and pregnancy i think a lot of people are scared of using medications so these women remained on medications but we don't know that they remained on optimal treatment the next bit myth that we're going to bust next myth is pregnant women should tolerate depression or anxiety for the sake of the baby i can't tell you how many patients have come into my office and said well yeah i feel terrible but i want to do what's right for my baby so i'm just going to deal with it and i'm not going to have any treatment because that's what's better for the baby but the reality is that women will relapse as we saw on the last slide and depression and anxiety lead to poorer outcomes for the baby and for the mother so these poorer outcomes have uh take the many different routes there are indirect effects of mood and anxiety disorders during pregnancy pregnant women who are depressed or anxious have higher rates of substance use they're more likely to have poor nutrition they're less likely to get good prenatal care they're more likely to be smokers so all of those are things that are i call them indirect effects because they're not something that the depression or anxiety is directly causing onto the fetus or onto the mother's body but they're things that people who are depressed or anxious are more likely to engage in and those things themselves can have effects on the mother and on the fetus in addition to these kind of indirect effects we have direct effects of depression and anxiety and those direct effects take many forms they are effects on the newborn they can be effects on the subsequent child and their effects on the mother so the effects on the newborn from women who are depressed or anxious in pregnancy those babies are born with higher cortisol cortisol is the stress hormone so it's the hormone that goes racing through your body when you're in a stressful situation and if you are stressed anxious depressed during pregnancy your baby will be born with higher cortisol what does that mean practically well that means that that baby is more reactive so the baby may be more likely to have increased fussing and crying the baby may be more likely to react in ways that are going to uh great on the mother and in and increase the likelihood that she will then have mood and anxiety disorders right if you have a baby who's fussier and cries more it's going to affect your mood those babies are also born with higher plasma norepinephrine which is that's adrenaline so we think of adrenaline as another you know neurotransmitter that courses through your body in stressful situations so again leading to increased reactivity for those babies we also know that babies born to moms who are depressed or anxious have decreased motor tone poor reflexes there are higher rates of preterm birth and babies are more likely to be born with low birth weight and these are this is we're talking untreated depression and anxiety we're not talking something that's the effect of medications that women use but the direct effects of the illness the illness itself in addition to those effects on the newborn there are effects on the child so when the newborn is born remember i said those are those increased rates of cortisol when a baby is born making that baby more reactive that and other things may lead to the baby having increased rates of psychological disorders himself or herself later in life so i've pictured here a child with adhd which is increased in women in children born to women with perinatal mood and anxiety disorders but also depression and anxiety themselves are also increased in those children and those studies have been done that separate that out from the effects of having a mother who is depressed or anxious so we know that the effects of depression or anxiety and pregnancy even separated out from the effects in the postnatal environment so the effects when you are a baby um we know that there are these increased rates so that's a direct effect during the pregnancy there are also effects on the woman and i really like to make sure that people understand that because a lot of the time when we talk about whether or not we should treat perinatal mood and anxiety disorders the emphasis is on the child and of course we care about the children and of course we want uh to not have any negative effects on the children but the woman is not just a vessel to produce the child the woman is as a person as well and we have to think as well of the effects on her so women who are depressed or anxious in pregnancy will have increased pregnancy symptoms like nausea or vomiting as i mentioned before they're more likely to use alcohol and tobacco once the baby's born they're more likely to have more frequent pediatrician visits and by that i don't mean in the good way right the good way is you attend all your well-child visits i need excess pediatrician visits because they're anxious about what's happening with the child there's more likely to be poor maternal attachment between the mother and the baby and being depressed or anxious during pregnancy is a major risk factor for postpartum depression now i said before that pregnancy was a risk neutral time it's not a time of increased risk of mood and anxiety disorders but the postpartum period is a time of elevated risk we know that women are more likely to develop mood and anxiety symptoms in the postpartum than at other times in their lives so we want to do anything we can to prevent that because we there are major risks of having a depressed mother for children and for women so if we can treat mood and anxiety disorders in pregnancy and thereby prevent that postpartum depression and prevent that kind of double whammy of the effects of depression and anxiety and pregnancy plus the effects of depression and anxiety after pregnancy we're going to have a better outcome for the family another myth psychiatric medications in pregnancy harm babies this is probably the biggest myth i spend a lot of time dispelling um i would say almost every patient who comes in to see me says well i've had depression in the past and i used medication x but i know i can't take that because i'm pregnant and the reality is for almost all medications that simply isn't true most psychiatric medications can be taken safely in pregnancy now that's not to say there are no risks some medications are associated with some risk in pregnancy but remember that the illness itself is associated with risk so what we're weighing is the risk of the illness and its effects on the mother and child versus the risks of medication and those effects on the mother and child we're not weighing a risk against a benefit and i think one really good way to understand this is to look at an actual piece in the media that reported on some scientific literature and to see the kinds of things that people are listening to and then come to their doctors with questions about so this is a i'm actually going to get out of my slideshow to show you a little bit of a video and this was from an article that was done a couple of years ago on whether or not ssris are linked with autism in pregnancy um with autism for the children whose moms used ssris in pregnancy um and this article purported to find that there was an increased rate of autism in the kids born to moms who used ssris in pregnancy and i just want you i'm just going to show you a little snippet of this and i want you to listen to the reporter's tone and to look at the graphics of the video a troubling connection between mothers who take widely prescribed antidepressants at a higher risk of their children developing autism nbc's ann thompson has a deeper look in what is a time of great expectation and anxiety for women today a set of scary headlines a new study finds the most commonly prescribed antidepressants if taken during the second and third trimesters are associated with an 87 increased risk of autism but experts say we're gonna stop the video there still a very small um because i think that that that's the part that you need to see um and and i hope that what people took away from that i'm just gonna get back into my slideshow here i hope what people took away from that was the the sort of dramatic language that was used so a troubling connection um troubling connection a set of scary headlines and then they kind of roll the headlines forward so that you can see those those scary headlines and then they use graphics like uh 87 kind of flying up at you out of the screen and so if somebody watches that then she's going to go away with the notion that ssris are scary drugs that they cause autism in children that that risk is hugely increased 87 percent increased um and a little bit farther into the story i didn't get to this part you'll hear them saying uh saying something that implies that the women are that are causing the autism in their children by taking these drugs so anybody who sees that is going to be terrified to to take medication in pregnancy and going to think that they're better off not doing so but i think it's really important to focus in on the details and to really understand what these studies are saying so they talked about 87 percent increased risk well what that meant was moving the risk in that case was actually almost doubled it was 1.87 uh in the group that had autism and one in the other group those are just average numbers right but that doesn't tell you what is the absolute risk in the population so a good way of understanding this is to step back for a moment from our discussion of ssris and autism and think about something simple like what's your chance of having a heart attack if you drink coffee and there was a study that said it came out that showed if you drink coffee three cups of coffee a day you're going to double your chance of a heart attack you're going to have a hundred percent increase in your chance of a heart attack but when you look at the actual numbers you have no caffeine it's a one percent risk of a heart attack three cups of coffee is a two percent risk so that is a doubling one to two percent right but it's still a very very small risk of a heart attack and so you might think maybe there are other reasons you want to have cups of coffee well the same thing is true with the treatment of perinatal mood and anxiety disorders if there's a compelling reason to treat even if there's something that does cause a risk you need to think about what is that absolute risk rather than is it a doubling or does it increase it by a certain percentage so finally the the next myth i want to talk about is that postpartum depression is rare and affects only the mother not the baby um this is one of the easiest myths to bust postpartum depression is actually the most common complication of childbirth and it causes substantial harm to babies and families i mentioned before problems with bonding in women who are depressed or anxious in pregnancy and of course that's more true if they're depressed or anxious in the postpartum and we know that there's substantial uh trauma done to families where a mother is depressed when the child is in is in early childhood one thing that's not talked about and offered talked about rarely is a complication from postpartum depression and i'd say talked about rarely in the lay press not among scientists is suicide so suicide is actually a major cause of maternal death in pregnancy and it accounts for up to 20 of all postpartum deaths in countries that track suicide as a maternal death it is actually the leading cause of maternal death in the first year postpartum it outstrips things like hemorrhage and other things that people tend to think of as more related to to maternal deaths we don't track suicide that way here in the united states although the cdc is moving to a system that will that will be able to do that and those data are starting starting to come out now but even without tracking it here we do know that it's a major contributor to postpartum deaths and if we don't prevent postpartum depression we're not going to be able to prevent suicide so we the other myth i like to bust and i mentioned this at the beginning was that depression is the only mental illness that affects perimeter women if anybody's heard of any perinatal mood and anxiety disorder as i mentioned it's postpartum depression but in fact any mental illness can occur during pregnancy or postpartum just as they can at other times in a woman's life and anxiety disorders are actually substantially more common than depression and i think that that's a really important thing to point out because i think anxiety disorders get less noticed or people think that they're less serious when in fact they affect more women and in my clinical experience i find that women who are anxious are less likely to be willing to take treatment than women who are depressed because they're anxious right so so we really need to consider that group of women so i hope i've given you a little taste of what kinds of clinical factors go on with perinatal mood and anxiety disorders now let's turn and look at some of the biological factors that are associated with perinatal mood and anxiety disorders i want to be very careful not to say the biological factors that cause these disorders because in fact we don't the research isn't at a point where we can say that we have a cause we can only say that we've identified some things that seem to be associated with perinatal mood and anxiety disorders and a lot more research is needed before we get to the point where there's a cause in fact i'm not even sure we're going to get there anytime soon with perinatal mood and anxiety disorders because you remember that graph i showed at the beginning that big circle with so many different things that go into this even if we isolate what the biological causes may be we're not going to be able to change the fact that there are social role transitions sleep disruption is going to remain a part of being a new parent and so we can never even if we isolate the biological factors we can never get to the point of saying we've figured out what causes it if we can just fix that it will be over but we can get a lot farther than we have so far so i'm going to talk today just about two little tidbits of research that that were involved in the women's mood disorder center that i hope will help us to advance the science one is inflammation i mentioned before changes in the immune system and inflammation and this research is trying to answer the question does inflammation make pregnant women anxious or is information associated with anxiety and pregnancy and then in other research we're looking at postpartum depression and asking the question well what if we had a hormonal test that could help us to predict postpartum depression so let's talk first about inflammation and the immune system this is a complicated picture and you do not have to understand any of these um letters that are involved in it all you have to understand is the fact that we have some things in green that are going up and some things in red that are going down and what this is trying to illustrate is the complicated changes that occur in the immune system during a normal pregnancy so the immune system is what keeps pathogens out of our body and helps to keep us well in the light of pathogens so during pregnancy it has to change right because the fetus is a pathogen in some senses it's an outside body that resides within the body of the mother and if the immune system just went on its merry way it would quickly kill the fetus and we would not be able to reproduce so people used to think that what this meant was that the immune system was just dampened down in pregnancy so inflammation and other things that get get the immune system going are all lower in pregnancy we now realize it's much much more complicated than that and it changes several times across pregnancy with different kinds of the immune system going up and down but it all acts together to to essentially show us that the things that part of the immune system that are the barriers to things from the outside getting in are strengthened during pregnancy and that makes sense right this is already inside there are other things out there viruses bacteria other things that you don't want to get in so the parts of the immune system that keep those things out are strengthened whereas the parts of the immune system over here that kill things that are already inside those parts are weakened and again that makes sense the fetus is already inside you don't want to kill it so this is what happens in normal healthy pregnancy we keep pathogens out but we don't kill pathogens that are already in and the easiest way to understand this is to think about the flu a lot of people know that pregnant women don't do very well with the flu but it's not because they get the flu more often it's because if they get the flu they're actually less likely to get the flu because remember these immune barriers have strengthened but if they get it they're more likely to diet because this part of the immune system is weakened so what does this have to do with anxiety well we've done some research that has looked at rates of anxiety and markers of inflammation across pregnancy and this slide that i'm showing you is actually data from a study that was in not very anxious people it was in healthy women and what you can see again you don't need to understand the specifics you just need to see that the red and the blue lines look different so the blue line is women who were more anxious during pregnancy the red line is women who were not at all anxious in pregnancy and these three things tr1 tr2 tr3 those are visits during pregnancy and pp1 and pp2 are at six weeks and six months postpartum and what you can see is that in early pregnancy these lines are not very far apart but starting in the late pregnancy and moving on into the postpartum period these lines diverge and the more anxious women are higher so this what we're measuring on this graph is a marker of inflammation and so this is showing us that as anxiety increases for these women who are more anxious their inflammation is always increasing now which way is it going right is it the anxiety causing the inflammation the inflammation causing the anxiety or a third thing that's related to both of them that we don't know what we just do know that there's this association so when we noticed that we thought well is does this have something to do also with the hormonal shifts that are happening and we have this hypothesis that decreased levels of some hormones that are related to progesterone remember my patient at the beginning who had that progesterone only pill that that may be leading to increased inflammation and anxiety and those things in turn may predict postpartum depression so maybe there's this three-way thing going on with hormones and inflammation and we've done some other research showing that in fact there may be a way to predict the development of postpartum depression by looking at your hormones in pregnancy so we've done a lot of research on a hormone called aloe pregnant alone those of you who were here last week heard dr hansu talk about aloe pregnant alone and its role in premenstrual mood disorders well it also plays a role in peripartum mood disorders and the research we have done shows that your level of alloprogenolone early in pregnancy may predict who's going to go on to develop postpartum depression and maybe it's tied into that inflammation we're seeing in the anxious people but in this study what we found here we have on the bottom the aloe pregnant alone level and here we have on the on the y-axis the odds of developing clinical depression and you can see that as your alloy pregnant level gets higher your odds of developing clinical depression gets lower so we found that each time you increase the amount of valor pregnant alone you decrease the odds of developing postpartum depression but it's complicated so i showed you before this very simple neat elegant story of inflammation just going up as anxiety went up across pregnancy but remember i said that was in a group of healthy women who were not very anxious we did the same study in a group of women who were very anxious and we found a totally different pattern in this study we had again we're doing inflammation across pregnancy second trimester third trimester and this is a composite spore of inflammation from a bunch of different markers and what we found is that the healthy women showed a slight rise in inflammation as they went across pregnancy but the women who had chronic anxiety were lower than the healthy women and actually dipped down but it was the women who were healthy at the beginning and became anxious who had this increase across pregnancy that burst that we saw with the other anxious women so what that means is it's incredibly complicated and we have to think about not only are women anxious but what type of anxiety they have and is the anxiety something that pre-existed that makes them different in some way from healthy women or is it anxiety that starts in the pregnancy and that's maybe a whole different story so those are just a few tidbits of the kind of research we're doing and i always like to bring it back to why are we doing this and what's the possible clinical application well inflammation is something that we have both drugs and other natural products to treat so if we could find that inflammation was really playing a role in perinatal mood and anxiety disorders we might have things other than ssris to try for treatment i've pictured here omega-3 fatty acids some non-steroidal anti-inflammatory drugs which at the moment you can't use that safely in pregnancy but maybe someday um and other anti-inflammatory foods we've also developed treatments based on the hormonal theory so if aloe pregnant alone has something to do with postpartum depression and low alloy pregnenolone predicting who's going to develop postpartum depression let's make a drug based on allopregnantalone so last year or two years ago now march 2019 the fda for the very first time approved a drug for postpartum depression there's never been a drug that's had an indication specifically for postpartum depression this drug brexit alone is a synthetic version of aloe pregnant alone now it's not something that's um that's in common use at this point because it's a iv drug that can only be administered inpatient it's very expensive but it's a drug that's based on a theoretical model of how postpartum depression might work and the data are very compelling and so it's a start getting us toward a more specific kind of treatment for women with these perinatal mood and anxiety disorders so what's the future the future is how can we prevent these we we have we're getting getting to the point where we know how to treat them but let's try to prevent them from happening and so that's the kind of research that we'll be trying to do over the coming years i want to give a shout out to all the people who work with us at the women's mood disorder center um dr jennifer payne our director who who's not with us tonight but who inspires us and all the work we do and all of the wonderful fellows research assistants and faculty who are associated with our center and also just to acknowledge the funding for our research you
