Women's Reproductive Mental Health

Dr. Laura Roberts (00:20):

Hi, I'm Dr. Laura Roberts, Editor-in-Chief for the Books portfolio of the American Psychiatric Association, and welcome to the APA Books Podcast.

Dr. Laura Roberts (00:39):

Welcome everyone to Unbound, today we're talking with two editors from this recent amazing textbook of women's reproductive mental health. We'll be speaking with Lucy Hutner and Lauren Osborne. Lucy is an internationally recognized expert in women's mental health, she's one of a small group of psychiatrists in New York City, with really extensive expertise in reproductive psychiatry. This field focuses on mental health needs of women and their loved ones before, during, and after pregnancy. She has particular expertise in perinatal mood and anxiety disorders and in the psychiatric issues of high-risk pregnancies and infertility.

Dr. Laura Roberts (01:18):

Lauren Osborne graduated from Weill Cornell Medical College, received her training at Columbia University New York State Psychiatric Institute. She completed both clinical and research fellowships in women's mental health and is an expert on the diagnosis and treatment of mood and anxiety disorders during pregnancy, postpartum, throughout the menstrual cycle, and perimenopause. Lauren is just a week and a half into a new role, amazingly, as Vice Chair for clinical research in the department of OB-GYN at Weill Cornell.

Dr. Laura Roberts (01:52):

I really am thrilled to meet with both of you, and I know that you have a whole team of amazing people. I think you said that there were 60 authors who contributed to this amazing textbook, which made a big splash right away. We knew with APA Publishing that we really needed something in this area, and felt like the gap in the literature was clearly there. But what was amazing was how you all stepped forward and actually had done so much work in this area and brought it together in such a very, very fine textbook. I just wanted to thank you and tell you how thrilled we were that you all stepped forward. It's always awkward, who's going to speak first, have you guys figured that out, who's going to go first?

Lucy Hutner (02:48):

No. Like with everything else about the work that we've done together, it's all a collaboration, so Lauren can speak first, I can speak first, we're very non-hierarchical in this group.

Dr. Laura Roberts (03:00):

That's great, that's wonderful. Maybe Lauren, I could turn to you, can you tell me why you thought the world needed this book? What was the motivation, the intention behind the book, and the hope for the book?

Lauren Osborne (03:17):

I think a lot of people, when I say that we've recently produced this textbook, they say, it's a new addition, it's an update of an old textbook, because people can't believe that a textbook like this didn't exist, but it really didn't. For me, the initial impetus to get into this work of educating other clinicians and the public about this field, was actually when I finished residency. I went to a program that had a lot of training in women's mental health, and nobody except me was planning to specialize in it. Right after I graduated, within the first couple of months, almost everybody else in my residency class had called me with a question about management in a pregnant woman, because they'd happened to encounter a pregnant woman in the course of whatever else they were doing.

Lauren Osborne (04:03):

That, to me, it really sank home that even though we had had a lot of good women's mental health education, it wasn't enough for these very fine clinicians to feel confident. That said to me, there's a huge gap out there for people who want to specialize in this area, but also for people who don't want to specialize in this area, but find themselves encountering this sort of patient. That was the kind of impetus that started us on our initial work to create, first a curriculum for residents in psychiatry, which was the basis that eventually formed this book.

Dr. Laura Roberts (04:37):

Lucy, I know you were kind of a driving force with the curriculum, or have other ideas that you would like to add to what Lauren said?

Lucy Hutner (04:47):

Yeah, I would love that, I would just echo what Lauren said. When I was the associate director of the women's program at Columbia, I have to say that as soon as we opened our doors, we were flooded with requests for clinical care. Those requests for clinical care have just continued in a really high pace. If you think about the fact that for example, postpartum depression is the most common complication of childbirth, and that's just one tiny facet of women's reproductive mental health. When you compare the clinical need versus the education that was available in the area, we recognized that there was an enormous gap there. That led to, I think Lauren wrote a really wonderful op-ed about the need for education in this area, there was a task force that formed that is now part of the Marce of North America.

Lucy Hutner (05:45):

Along with launching this curriculum, we just basically thought to ourselves, a textbook is really necessary, and the reason why we thought that is because in this digital age, in some ways it's a little bit like, do people actually read textbooks? But it is actually interesting, partly because there's a digital version, which is wonderful, but also because we think of this as a flag on the moon moment. We have been really part of a group of people around the country, and now the world, who are building this field from the ground up. We started from listening to our patients experiences and registering what they said, and then we're building the medical specialty around that.

Lucy Hutner (06:27):

For us, it really felt like this wonderful moment of saying, this field exists, this is a knowledge base, this is a fund of knowledge that we can use. Along with the flag on the moon moment, which we were so humble to be able to achieve, we think of it also as a stepping stone. For example, Lauren and I are both involved in a project now where we are trying to build mental health education for OB-GYN providers. There's a lot of ways in which we see this as some of the very first steps in building out education in a lot of different arenas.

Dr. Laura Roberts (07:04):

It's intrinsically interdisciplinary and will really have influence across multiple areas, I imagine. Maybe people know, but I did consultation-liaison psychiatry for many, many years, and this is kind of where my heart was. I remember, it wasn't really all that long ago, where we at University of New Mexico, covered all the patients. Outpatient, inpatient, people who hadn't gotten preventive care, high-risk, complex patients, everybody. I think for us on our C-L team, when we got a call from the women's health area, a woman who's just given birth, or a woman who is presenting in distress, maybe even not even aware that they're pregnant. Oh my gosh, the complex issues, and the resources were so limited, maybe a subsection in a chapter in a consult-liaison textbook or something.

Dr. Laura Roberts (08:09):

It wasn't that long ago, so I look to your textbook with a particular sense of the importance, the potential for fatalities, the potential for mortality, poor outcomes for mothers, for families, for babies, is profound, and then you look across the life cycle. Anyways, it wasn't that long ago that there really wasn't much of a coalesced literature, and I just want to say how deeply I appreciate this particular book, because it's very immediate and very real for me in my own clinical experience.

Lucy Hutner (08:49):

It's interesting you say that, Laura, I started out and I still consider myself a C-L psychiatrist. As part of my work in the women's program at Columbia, I started the first dedicated obstetric C-L service there and really focused both on obstetric inpatients as well as high-risk MFM patients in the outpatient setting. I can't tell you how much I relate to what you just said, and I think in terms of our textbook, I'd love to hear what Lauren thinks about this as well, we were trying to really bridge another gap.

Lucy Hutner (09:22):

Which was, we were trying to make it as academically rigorous as possible and as evidence based as possible, but also make it clinically relevant. So that any general psychiatrist who opens up the textbook won't feel like they're being bombarded with too much basic science or basic neuroscience. We were trying not to make it a quick guide, but we were trying to make it clinically relevant, but at the same time highly evidence based and really based on the science. I'd love to hear what Lauren thinks about that, but we really did try to bridge that gap, so I'm excited to have your feedback about that.

Lauren Osborne (09:59):

I actually have a great anecdote that I think illustrates that we succeeded in that goal, which is that I remember when I took the Boards, it was a question on the Boards about lithium in pregnancy. I knew what the answer was that they wanted me to give, and it was actually an incorrect answer that was not consistent with the literature. I found that very frustrating, I didn't give the answer they wanted, I said if I fail the Boards for this reason, so be it. One of the activities I do is that I'm one of the editors of the PRITE, and the reason I've stuck with being an editor of the PRITE for so long is that I want to fix that problem, I want to make it that we're not asking incorrect questions on the Board.

Lauren Osborne (10:38):

I'm really pleased to say that on the PRITE we've had a lot of interest in reproductive psychiatry, the outline of the test has just been revised to include a whole extra section on reproductive psychiatry. This year, as we were preparing to write our questions, and actually at the PRITE meeting right now in Chicago, as we're preparing to write the questions, several of the other editorial board members emailed the college staff and said, could we get access to this new textbook, because this is the resource we need to back up those questions. When we write PRITE questions, we usually do use textbooks because we don't want journal articles, we want a really sound, evidence based source. To me, that says, we've bridged that gap, it is clinically relevant, but it is going to enter the canon as something that people can really rely on and feel comfortable it's giving them the evidence based answers that they need to handle this. I hope that helps to illustrate.

Dr. Laura Roberts (11:37):

I love that, and I have to tell you, the reason I wrote the professionalism Q and A ethics book, was because I was so irritated with every exam I took where they would do a few forensic questions. They were legitimate questions, but that was the ethics portion of the psychiatric accreditation exam. Anyways, it's interesting, I wonder how many books have been motivated by our own frustration, by basically the standards of the field lagging, or the formal questions... It's a really interesting point, but anyway, I'm right there with you, Lauren, that's great. How in the world did you get so many people to come together, I imagine it was wonderful and fun and hard, but how did that process go for you all?

Lauren Osborne (12:34):

Maybe I'll jump in and start with that question because it really is a process that started with our work on the curriculum. We started that work with six people who all wanted to do something for psychiatry residents, and the six of us were people who all knew each other professionally. We worked together pretty seamlessly, and we created a module about perinatal depression together. When we got to the end of that, we said, this is great, but it took us a year to do this, and we need to ramp this up, how can we expand? We took those six people and put each one of them in charge of another group, and then we sought volunteers from within the reproductive psychiatry community. We had one experienced leader on each group leading another group of volunteers.

Lauren Osborne (13:19):

We were open to all comers, there were people that we asked to be on it because we knew their work, but we also welcomed trainees and other people to be part of it. That structure of working was in place throughout the time that we worked on the curriculum, and we really shifted that over into the textbook. The five editors of the textbook are people who've been involved from day one with the curriculum, who led modules in the curriculum, and who had that experience of leading a group of people to create this material. We then went and made each of those editors responsible for a certain number of chapters in the book. Sometimes they were the author of the chapter, sometimes they were corralling people who had worked on the curriculum module and saying, could you be the lead author? We kind of had that structure in place, and since the five of us knew each other really well, we could fan that out into the larger group. Lucy, do you want to add to that?

Lucy Hutner (14:13):

I would just add to that too, I think that one of the things that has just been so wonderful is the collaborative spirit among all of us. I think we have tried to make it as easy and efficient for everyone as possible to contribute, partially because every single person who has contributed to both the curriculum and the textbook is a volunteer, they're graciously donating their time, nobody has protected time for this. We wanted to make it as easy as possible, so for example, with the textbook, the group of editors, we actually drew up an author's guide for every single author, especially the lead author of each chapter.

Lucy Hutner (15:48):

Each group was able to obviously generate their own content and generate what they wanted to talk about, but we provided a very standardized structure for them that was consistent across the textbook and consistent with what the APA Publishing group wished to have so it would make the ultimate editing process as seamless as possible. We, to be honest, worked backwards, where we started with what we wanted to be with the end product in terms of the structure, and then basically gave that structure to each author in a very rigorous way. So that each author and each author group was basically able to fill in the gaps with their content, but we didn't want to have a lot of editing and back and forth at the end, we wanted it to be as seamless as possible. I think that really helped, especially with as many authors that we had.

Lauren Osborne (15:48):

I also think that a key thing that helped us was that I had a grant from the ABPN Faculty Innovation and Education Award that helped put together the end of the curriculum. Part of that grant money I spent on supporting the time of one of my research assistants to be a project manager, for both the curriculum and the textbook. Her name is Courtney Erdly, she's fantastic, she's now a graduate student in psychology, but she was uber organized and that was essential. She kept an organized Dropbox of everything, she chased authors who hadn't sent their things in, we absolutely could not have done it without her.

Dr. Laura Roberts (16:29):

I want to make sure, because there was a little bit of a smudge in the audio on it, so her name is Courtney Erdly?

Lauren Osborne (16:36):

Courtney Erdly.

Dr. Laura Roberts (16:37):

Courtney Erdly, a big shout out to Courtney.

Lauren Osborne (16:39):

Yes, absolutely.

Dr. Laura Roberts (16:42):

And all the wonderful colleagues who end up supporting these fantastic books that we publish and don't really get as much recognition, so Courtney plus, we want to shout out.

Lauren Osborne (16:56):

Absolutely.

Dr. Laura Roberts (16:57):

Were you guys surprised by the public grabbing hold of this and some pretty famous people grabbing hold of this, were you surprised?

Lucy Hutner (17:12):

I'll take that and, Lauren, if you want to add to this too, I was really surprised. Basically, at least my contribution to this question, was that I was being asked by a journalist in Parents magazine about a totally different topic. She was asking me about how pregnancy changes the brain, and when I was talking to her about some of the literature around that, I said, a lot of the literature is still really being developed because one of the seminal papers on this just came out in 2016. This is a field that's really rapidly evolving, and by the way, we're in the middle of doing this first textbook, it's about to come out in 2021. The journalist said, wait, are you joking, how is that possible that you haven't had a textbook? We said, yeah, the APA did an amazing job, and they allowed us to be working on the very first comprehensive textbook for women's mental health, it's coming out this year. She said, okay, I'm going to ask my editor if she's interested in this story for Parents magazine on this.

Lucy Hutner (18:24):

She then circled back to me several weeks later and said, can you please do a story, can you please talk to me? She did an entire story on this basically saying, yes, now there's a textbook of women's mental health, and this is why it matters. Really talking about how this again, is a field that we really have built from the ground up about listening to our patients' experiences, listening to the voices of women and other birthing parents, and recognizing the need. Then in concert with that, then building the book from the ground up. I think people are really struck by the newness of it all, the fact that we're building this, we're doing all this heavy lifting. Some people also comment about, wow, I can't believe that there's been such a huge clinical need and there hasn't been these resources. I think it hit something in people, Lauren, what do you think?

Lauren Osborne (19:20):

Yeah, I totally agree, and I was initially surprised, but thinking back on it, I think I shouldn't have been surprised. One of the reasons I shouldn't have been surprised is one of the reasons that we work in this field, which is that this is a very motivated patient population. These are people who really want to get better and who really want to have the knowledge to do what's right for themselves and what's right for their babies. I find that patients are really hungry to have information, and I will frequently give journal articles to my patients, because they want to know what the literature is. In retrospect, it doesn't actually surprise me that there's this broader interest out there, because I just think it's a population that is desperate for the information and that's really motivated to work on their own mental health, which isn't always the case.

Lucy Hutner (20:10):

I'll just add one quick thing to that too, the other thing that I hear a lot from my patients is that they are actually, strangely enough, swimming in information in some ways, because they look on social media, they go to their friends, they go to different websites. If anything, nowadays there's not necessarily a dearth of content, it's just that people don't know what to trust, and they don't know what is high quality evidence based information. I think that was another facet of the textbook is really saying, we don't just have to rely on opinion or what other people think. Having peer to peer conversations are wonderful, but this is another way of thinking about it, that we're allowed to really develop evidence based scientific fund of knowledge from the ground up.

Dr. Laura Roberts (21:09):

Another thing I really love about the book is that you address issues across the age spectrum. I don't know if you want to comment a little bit about some of the life cycle dimensions or developmental dimensions of the book.

Lauren Osborne (21:24):

We've been talking a lot about the pregnant patient population, and that does tend to get a lot of the limelight in women's mental health, but of course, pregnancy isn't in a vacuum, it's just a moment in women's lives. What we believe, and most reproductive psychiatric clinicians believe, and there's biological evidence to support this, that women who are vulnerable to psychiatric illness during pregnancy and postpartum, it's part of a vulnerability to sensitivity to hormonal transitions more generally. The women who are vulnerable to illness and pregnancy and postpartum are also vulnerable to illness at menarche in the premenstrual period and at perimenopause.

Lauren Osborne (22:04)

While a big chunk of the book is focused on pregnancy and postpartum, we also address those other areas of women's lives. Including things like infertility, so related but tangentially to women's lives, to women's pregnancies. I think that's really important, because we know that the rate of depression, for example, in women, or I should say in people with ovaries, is double the rate of men during the reproductive years and then comes back down in the postmenopausal period. That whole reproductive lifespan, from menarche through the perimenopause, is a time when women are much more vulnerable than men, and we can't look at pregnancy in a vacuum. That was a really important goal of ours, to set it all in that context. Lucy, do you want to add anything to that?

Lucy Hutner (22:50):

I would just add to that, we felt pretty strongly about the idea of making it comprehensive throughout the reproductive lifespan. Partially because in addition to what Lauren said, I feel like some of these other issues... there's still so much to explore and still so much to understand about certain areas. For example, perimenopause is, I think, an area that the door is just starting to become open in terms of our scientific understanding, but also the clinical relevance of what that means for patients. That is just one example, and we just felt very strongly about including the entire reproductive lifespan. Interestingly, some of the offshoot projects, so for example, the mental health education toolkit that we're doing for OB-GYN, we're starting very much in the perinatal period. Because this is where there's a clear intersection between psychiatry and OB, and it's such a high need time, but we never want to lose sight of the entire reproductive lifespan.

Dr. Laura Roberts (23:59):

Here we are, this is such a lovely, positive conversation about affirming women while also acknowledging that women haven't really been seen and their clinical needs really tended to. I would say, I'm sorry it took us so long to put together this textbook, and I'm thrilled that we did it at least when we did and we got just the right people to help us. But obviously with the overturning of Roe v. Wade, the issue of women's needs, women's clinical needs, education around reproductive health issues, I think will be more salient and top of mind. Trying to put this in an apolitical way, I think it will be more relevant for people in their thinking, no matter where one sits on a political spectrum. I don't know if you have any reflections there, clearly education is changing in many states across the United States. The OB-GYN training for example, is going to be challenged, many states are not going to be meeting the standards for curriculum in OB-GYN, for example, Lauren, with your new role. Anyhow, I don't know if you have any observations that you'd like to make in this very early days after Roe v. Wade being overturned, but things are going to change a lot, and have already changed dramatically.

Lauren Osborne (25:27):

I think things are going to change a lot, and they're going to change for all psychiatrists, because we're going to go back to the days where we have to consider in many states, abortion will only be allowed if it affects the health or life of the mother. Psychiatrists in the '60s we're put in the role of determining whether somebody's mental health would be so adversely affected that she should be allowed to have an abortion, so all psychiatrists are going to be put back in that position, not just people with a specialty in reproductive psychiatry.

Lauren Osborne (25:59):

Then I think there's going to be a huge impact on women's mental health. One of the things that's the most clear risk factors for the development of postpartum depression is unwanted pregnancy. We're going to be facing a world where we have a lot more unwanted pregnancy, and that's going to have huge repercussions for women's mental health. I think that it's going to be half the country that's going to be in that position, so it's early days, but I just think it's a huge revolution in the way we have to think about this and in the way we think about women's health rights. About healthcare for women as being a right that every woman should have access to, so it's different.

Dr. Laura Roberts (26:48):

I'm being a little sneaky, maybe you can tell, because I want another book. I do, because I think again, across age spectrum, across socioeconomic classes, across politics, across personal background, just in every dimension, I think we're going to have to take a fresh look at this. Anyway, so please take this back to your team and see if you can help us, because I agree that psychiatrists are going to be squarely in the middle of a lot of this. Either in helping to develop clinical guidance, either as consultants in the care of individual patients. Or in perhaps influencing policy on state and national levels around, what is health, what defines health and wellbeing in relation to these issues? Lucy, did you have a...

Lucy Hutner (27:48):

Just to add to that too, one of the things that we wrote about in the preface was this idea that we think of this as a living document. For the topics that we were able to include in there, probably for every one that was included, there were two or three that we couldn't include or didn't, either because there wasn't a known expert in the field or because a lot of the field is still being developed. We really think of this as just step one, there were a number of issues that we started to touch upon that we think are incredibly important, including health disparities, care for Black and other minoritized communities. Also reproductive mental health care across the sex and gender spectrum, and not just limited to women's mental health.

Lucy Hutner (28:41):

Those are just a few topics that we really feel like there's an opportunity to really broaden this out. Another topic that we've gotten a lot more dedicated to focusing on is trauma informed care in a lot of different varieties in its full spectrum. More to come, but again, it was one of those things where at a certain point, we have to measure twice, and cut once, and decide that this was going to be the first edition of the book. But yes, it felt to us like it was opening Pandora's box in a good way, where there was just all of these potential collaborations and ideas spilling out.

Dr. Laura Roberts (29:20):

I hope we'll have a continued conversation. It's been just a joy to talk with both of you, I want to thank you for this really groundbreaking, fantastic book. For the listeners of our podcast, I really encourage you to take a look at it. It has really broad relevance, and as you have emphasized, deep evidence where it exists. Several places in the book makes comments about how much more we need to know, so I thought there was the right degree of humility and confidence that were communicated at the same time, which is challenging as editors and authors. Thank you so much for joining us today on Unbound.

Lucy Hutner (30:00):

Thank you, and thank you for your leadership in really allowing us to have this book come to fruition, we're so grateful to the APA Publishing group and to you.

Lauren Osborne (30:09):

Absolutely.

Dr. Laura Roberts (30:10):

Thanks so much.

Producer (30:20):

Psychiatry Unbound is hosted by Dr. Laura Roberts and produced by Iain Martin. Our original music is by Willow Roberts, and our executive producer is Tim Marney. The podcast is made possible by the generous support of Stanford University. We are a production of American Psychiatric Association Publishing. Be sure to visit psychiatryonline.org/podcast to join the conversation, access show notes and a transcript, and discover new content. Or subscribe to us on your favorite podcast platform, thank you for listening.

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