Front Matter

Contributors

Foreword

Katherine L. Wisner, M.D., M.S.

Samantha Meltzer-Brody, M.D., M.P.H.

Preface

Introduction: What’s in a Name? Why We Use “Women’s Reproductive Mental Health,” and Toward a Future of Different Names

Lucy A. Hutner, M.D.

Lisa A. Catapano, M.D., Ph.D.

Erika Kelley, Ph.D.

Sheryl A. Kingsberg, Ph.D.

Sarah M. Nagle-Yang, M.D.

Katherine E. Williams, M.D.

Lauren M. Osborne, M.D.

Reproductive Health Across the Lifespan

1 The Reproductive Life Cycle

Alexis Lighten Wesley, M.D.

Mira Zein, M.D.

Melisa Olgun, B.A.

Lisa A. Catapano, M.D., Ph.D.

2 Gynecological Conditions and Mental Health

Brittney Bastow, M.D., M.Sc.

Pooja Lakshmin, M.D.

3 Female Sexual Dysfunctions and Reproductive Psychiatry

Erika Kelley, Ph.D.

Brittney Bastow, M.D., M.Sc.

Pooja Lakshmin, M.D.

Sheryl A. Kingsberg, Ph.D.

4 Contraception: Implications for Mental Health

Lulu Zhao, M.D.

5 Infertility and Perinatal Loss

Neha S. Hudepohl, M.D.

Jessica L. Coker, M.D.

Sharvari P. Shivanekar, M.D.

Madhavi-Latha Nagalla, M.D.

Soudabeh Givrad, M.D.

Lindsay R. Standeven, M.D.

Courtney Erdly, B.A.

Premala Jones, Ph.D.

Katherine E. Williams, M.D.

6 Premenstrual Mood Syndromes

Erin Murphy Barzilay, M.D.

Katherine Unverferth, M.D.

Laura Obler, M.D.

7 Perimenopause

Nicole Leistikow, M.D.

Milena H. Smith, M.D., Ph.D.

Katherine E. Williams, M.D.

C. Neill Epperson, M.D.

Pregnancy and the Postpartum Period

8 A Clinical Approach to Psychiatric Diagnosis and Treatment During Pregnancy

Elizabeth M. Fitelson, M.D.

Lauren M. Osborne, M.D.

Jennifer L. Payne, M.D.

9 A Clinical Approach to Psychiatric Diagnosis and Treatment in the Postpartum Period

Alyson Gorun, M.D.

Mira Zein, M.D.

Melisa Olgun, B.A.

Lisa A. Catapano, M.D., Ph.D.

10 A Treatment Approach to Psychiatric Emergencies in the Perinatal Period

Jovana Martinovic, M.D.

Pooja Lakshmin, M.D.

Mira Zein, M.D.

Melisa Olgun, B.A.

Lucy A. Hutner, M.D.

11 Stress in Pregnancy: Impacts on Mother and Child

Lea Takács, Ph.D.

Vanessa Babineau, Ph.D.

Catherine Monk, Ph.D.

12 Infant Mental Health and the Parent–Infant Relationship: Essentials, Assessment, and Treatment

Soudabeh Givrad, M.D.

Jennifer J. Paul, Ph.D.

Christine Wittmann, M.D.

Mireya Nadal-Vicens, M.D., Ph.D.

Celeste St. John-Larkin, M.D.

13 Depressive Disorders

Lauren M. Osborne, M.D.

Catherine Birndorf, M.D.

14 Integrative Approaches to Perinatal Depression

Madeleine A. Becker, M.D., M.A.

M. Camille Hoffman, M.D., M.Sc.

Nina T. Ballone, M.D.

Ripal Shah, M.D., M.P.H.

15 Bipolar Disorder and Related Disorders

Sarah M. Nagle-Yang, M.D.

Sarah A. DeBrunner, M.D.

Andrea Favini, M.D.

Andrew M. Novick, M.D., Ph.D.

Caitlin Hasser, M.D.

Chandni Prakash, M.D.

Margo Nathan, M.D.

16 Postpartum Psychosis

Caitlin Hasser, M.D.

Jovana Martinovic, M.D.

Pooja Lakshmin, M.D.

Mira Zein, M.D.

Melisa Olgun, B.A.

Lucy A. Hutner, M.D.

Sarah M. Nagle-Yang, M.D.

Lauren M. Osborne, M.D.

17 Schizophrenia and Related Disorders

Sarah M. Nagle-Yang, M.D.

Susan Hatters Friedman, M.D.

Caitlin Hasser, M.D.

Ashley Mulvihill, M.D.

Andrew M. Novick, M.D., Ph.D.

Allyce K. Jones, DNP, MSN, PMHNP-BC, APRN

Eric Reed, M.D.

Surya Sabhapathy, M.D., M.P.H.

18 Trauma and Reproductive Health

Priya Gopalan, M.D.

Elizabeth Albertini, M.D.

Priyanka Amin, M.D.

Maureen Curley, Ph.D.

Jody Glance, M.D.

Saira Kalia, M.D.

Neeta Shenai, M.D.

19 Anxiety Disorders and Insomnia in the Perinatal Period

Lucy A. Hutner, M.D.

Joanna V. MacLean, M.D.

Gioia M. Guerrieri, D.O.

Melisa Olgun, B.A.

Julia Frew, M.D.

20 Obsessive-Compulsive Disorder

Neha S. Hudepohl, M.D.

Nicole Leistikow, M.D.

Mimi Levine, M.D.

Lauren M. Osborne, M.D.

21 Substance Use Disorders

Julia Frew, M.D.

Lauren Augello, M.D.

Marley Doyle, M.D.

Constance Guille, M.D.

Susan Karabell, M.D.

Lulu Zhao, M.D.

22 Eating Disorders

Robin Valpey, M.D.

Jyoti Sachdeva, M.D.

Joy E. Moel, Ph.D.

23 Attention-Deficit/Hyperactivity Disorder

Lucy A. Hutner, M.D.

Jaina Amin, M.D.

Jeanne Coulehan, C.N.M., M.P.H.

Madhumathi Rao, M.D.

Melisa Olgun, B.A.

Mimi Levine, M.D.

24 Forensic Issues in Perinatal Psychiatry

Susan Hatters Friedman, M.D.

Aimee Kaempf, M.D.

Jacqueline Landess, M.D., J.D.

Sarah M. Kauffman, M.D.

Pregnancy and Lactation Considerations for Psychotropic Medications

Index

Assistant Professor of Psychiatry, Icahn School of Medicine, New York, New York

Assistant Professor of Clinical Psychiatry, Department of Psychiatry, Case Western Reserve University/University Hospitals of Cleveland, Cleveland, Ohio

Assistant Professor of Psychiatry, University of Pittsburgh Medical Center Western Psychiatric Hospital, Pittsburgh, Pennsylvania

Instructor of Psychiatry/Addiction Psychiatrist, Boston University/Boston Medical Center, Cambridge, Massachusetts

Clinical Psychologist and Postdoctoral Fellow, Columbia University Irving Medical Center, New York, New York

Consultation-Liaison Psychiatry Fellow, Department of Psychiatry, The George Washington University Medical Center/Inova Fairfax Hospital, Falls Church, Virginia

Health Sciences Assistant Professor, Department of Psychiatry and Behavioral Sciences; Co-Director, The Women’s Life Center; and Medical Director, Maternal Mental Health Program, UCLA Semel Institute and Resnick Neuropsychiatric Hospital, The David Geffen School of Medicine at UCLA, Los Angeles, California

Physician, Department of Obstetrics and Gynecology, Colorado Permanente Medical Group, Aurora, Colorado

Professor, Department of Psychiatry and Human Behavior and Department of Integrative Medicine and Nutritional Sciences, Marcus Institute of Integrative Health–Jefferson Health; Director, Graduate Medical Education, Associate Director, Fellowship, Integrative Medicine, Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, Pennsylvania

Chief Executive Officer and Medical Director, The Motherhood Center, New York, New York

Associate Professor of Psychiatry and Behavioral Sciences, Department of Psychiatry, George Washington University, Washington, DC

Assistant Professor, Psychiatric Research Institute, University of Arkansas for Medical Sciences, Little Rock, Arkansas

Midwife/Clinical Practice Manager, Division of Maternal Fetal Medicine, Department of Obstetrics-Gynecology, Columbia University Medical Center, New York, New York

Clinical Assistant Professor of Psychiatry, University of Cleveland Medical Center/Case Western Reserve University, Cleveland, Ohio

Clinical Assistant Professor of Psychiatry, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania

Assistant Professor of Psychiatry, University of Nebraska Medical Center, Omaha, Nebraska

Robert Freedman Endowed Professor and Chair, Department of Psychiatry, School of Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado

Project Manager, National Curriculum in Reproductive Psychiatry, Johns Hopkins School of Medicine, Johns Hopkins Hospital, Baltimore, Maryland

Psychiatrist, Allegheny Health Network, Women’s Behavioral Health, Pittsburgh, Pennsylvania

Associate Professor, Department of Psychiatry, Columbia University Irving Medical Center; Director, The Women’s Program, Columbia University Department of Psychiatry, New York, New York

Assistant Professor of Psychiatry, Obstetrics and Gynecology, and Medical Education, Geisel School of Medicine at Dartmouth/Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire

Assistant Professor of Clinical Psychiatry, Director of Maternal-Infant Psychiatry Program, and Associate Director of Sackler Infant Psychiatry Fellowship, Weill Cornell Medicine, New York, New York

Associate Professor of Psychiatry, University of Pittsburgh Medical Center Western Psychiatric Hospital, Pittsburgh, Pennsylvania

Assistant Professor of Psychiatry, University of Pittsburgh Medical Center Western Psychiatric Hospital, Pittsburgh, Pennsylvania

Assistant Professor of Clinical Psychiatry, Department of Psychiatry, Weill Cornell Medicine; Assistant Attending Psychiatrist, New York Presbyterian Hospital, New York, New York

Founder and Director, Well-Minded, LLC; Special Volunteer, Clinical Research Physician, NIH/NIMH Section of Behavioral Endocrinology, Bethesda, Maryland

Professor of Psychiatry and Behavioral Science and Obstetrics and Gynecology, Medical University of South Carolina, Charleston, South Carolina

Portland VA Health Care System, Portland, Oregon

The Phillip Resnick Professor of Forensic Psychiatry, Professor of Reproductive Biology and Pediatrics, and Adjunct Professor of Law, Case Western Reserve University, Cleveland, Ohio; Honorary Associate Professor of Psychological Medicine, University of Auckland, Auckland, New Zealand

Associate Professor, Maternal Fetal Medicine, Department of Obstetrics and Gynecology and Department of Psychiatry, University of Colorado, Aurora, Colorado

Clinical Assistant Professor, Department of Psychiatry, University of South Carolina School of Medicine–Greenville, Greenville, South Carolina

Co-founder and Chief Medical Officer, Phoebe, New York, New York

Associate Professor, College of Nursing, Rocky Mountain University of Health Professions, Provo, Utah

Mental Health Consultant, Life Perspectives, San Diego, California

Clinical Associate Professor, Department of Psychiatry, University of Arizona College of Medicine Tucson, Tucson, Arizona

Assistant Professor of Psychiatry, University of Arizona College of Medicine, Tucson, Arizona

Assistant Professor of Clinical Psychiatry, Weill Cornell Medical College; Assistant Attending Psychiatrist, New York Presbyterian Hospital, Collaborative Care Center, New York, New York

Reproductive Psychiatrist, The Motherhood Center of New York, New York; Staff Psychiatrist, California Department of Corrections, San Diego; and Physician Director, Maternal Mental Health Program, Hoag Hospital, Newport Beach, California

Clinical Psychologist, Department of Obstetrics and Gynecology, University Hospitals Cleveland Medical Center; Assistant Professor, Department of Reproductive Biology, Case Western Reserve University, Cleveland, Ohio

Chief, Division of Behavioral Medicine, Department of Obstetrics and Gynecology, MacDonald Women’s Hospital/University Hospitals Cleveland Medical Center; Professor, Departments of Reproductive Biology and Psychiatry, Case Western Reserve University School of Medicine, Cleveland, Ohio

Clinical Assistant Professor, Department of Psychiatry and Behavioral Sciences, George Washington University School of Medicine and Health Sciences, Washington, DC

Clinical Assistant Professor, Associate Training Director, Forensic Psychiatry Fellowship, Department of Psychiatry and Behavioral Medicine, Medical College of Wisconsin, Madison, Wisconsin

Assistant Professor, Department of Psychiatry, University of Maryland, Baltimore, Maryland

Clinical Assistant Professor of Psychiatry, Department of Psychiatry, New York University/Langone Medical Center, New York, New York

Attending Psychiatrist, Women’s Behavioral Medicine, Women’s Medicine Collaborative; Assistant Professor, Clinician Educator, Department of Psychiatry and Human Behavior and Department of Medicine, Alpert Medical School of Brown University, Providence, Rhode Island

Lecturer, Department of Psychiatry, Women’s College Hospital, University of Toronto, Toronto, Ontario, Canada

Assad Meymandi Distinguished Professor and Chair, Department of Psychiatry, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina

Clinical Assistant Professor, Department of Psychiatry, University of Iowa Hospitals and Clinics; Women’s Wellness and Counseling Service, Iowa City, Iowa

Professor of Medical Psychology, Departments of Obstetrics and Gynecology, and Psychiatry Director, Women’s Mental Health @Ob/Gyn, Columbia University Irving Medical Center; Research Scientist VI, New York State Psychiatric Institute, New York

Assistant Professor of Clinical Psychiatry, University of Illinois at Chicago, Chicago, Illinois

Chief, Department of Behavioral Health, Harvard University Health Services, Cambridge, Massachusetts

Assistant Professor, Department of Psychiatry, Michigan State University/Pine Rest Christian Mental Health Services, Grand Rapids, Michigan

Associate Professor of Psychiatry, University of Colorado–Anschutz Medical Campus, Aurora, Colorado

Clinical Assistant Professor, Department of Psychiatry, University of North Carolina School of Medicine, Chapel Hill, North Carolina

Assistant Professor, Department of Psychiatry, University of Colorado—Anschutz Medical Campus, Aurora, Colorado

Resident, Department of Psychiatry, UCLA Semel Institute, Los Angeles, California

J.D. Candidate, Yale Law School, New Haven, Connecticut

Associate Professor of Psychiatry and Behavioral Sciences and of Gynecology and Obstetrics; Director, The Johns Hopkins Center for Women’s Reproductive Mental Health; and Fellowship Director, Advanced Specialty Training Program in Reproductive Psychiatry, Johns Hopkins University School of Medicine, Baltimore, Maryland

Assistant Professor of Psychiatry; Clinical Director, Healthy Expectations Perinatal Mental Health Program; and Associate Director of Clinical Services, Connections Program for High-Risk Infants and Families, University of Colorado School of Medicine, Anschutz Medical Campus, Aurora, Colorado

Associate Professor, Departments of Psychiatry and Behavioral Sciences and Gynecology and Obstetrics, and Director, The Johns Hopkins Women’s Mood Disorders Center, Johns Hopkins University School of Medicine, Baltimore, Maryland

Consultant Psychiatrist, Auckland District Health Board, Epsom, Auckland, New Zealand

Attending Psychiatrist, MedStar Georgetown University Hospital, Washington, DC

Senior Clinical Instructor, University Hospitals, Case Western Reserve University College of Medicine, Cleveland, Ohio

Assistant Professor of Clinical Psychiatry, and Director, Gender and Sexuality Clinic in Psychiatry, University of Illinois at Chicago, Chicago, Illinois

Associate Professor of Clinical Psychiatry, Department of Psychiatry and Behavioral Neuroscience, and Associate Professor of Clinical Obstetrics and Gynecology–Secondary Appointment, University of Cincinnati, Cincinnati, Ohio

Clinical Assistant Professor, Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine; Attending Physician, Women’s Wellness Clinic; Director of Integrative Mental Health, Stanford Center for Integrative Medicine, Stanford, California

Assistant Professor of Psychiatry, University of Pittsburgh Medical Center Western Psychiatric Hospital, Pittsburgh, Pennsylvania

Clinical Assistant Professor, Department of Psychiatry, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania

Instructor, Department of Psychiatry and Behavioral Sciences, The Johns Hopkins University School of Medicine, Baltimore, Maryland

Assistant Professor of Psychiatry and Behavioral Sciences, and Assistant Director, Women’s Mood Disorders Center, Johns Hopkins University School of Medicine, Baltimore, Maryland

Anschutz Chair in Perinatal Mental Health and Assistant Professor, Department of Psychiatry, University of Colorado School of Medicine; Medical Director, Healthy Expectations Program, Children’s Hospital Colorado, Aurora, Colorado

Postdoctoral Research Scientist, Columbia University Irving Medical Center, New York, New York; Faculty of Arts, Department of Psychology, Charles University, Prague, Czech Republic

Clinical Instructor, Department of Psychiatry, UCLA Resnick Neuropsychiatric Institute, The David Geffen School of Medicine at UCLA, Los Angeles, California

Assistant Professor of Clinical Psychiatry, Department of Psychiatry, University of Pittsburgh Medical Center, Pittsburgh Pennsylvania

Child and Adolescent Psychiatry Fellow, Division of Psychiatry, Children’s National Medical Center, Washington, DC

Clinical Professor of Psychiatry, and Director, Women’s Wellness Clinic, Stanford University School of Medicine, Stanford, California

Norman and Helen Asher Professor of Psychiatry and Behavioral Sciences and Obstetrics and Gynecology; Director, Asher Center for the Study and Treatment of Depressive Disorders, Northwestern University Feinberg School of Medicine, Chicago, Illinois

Assistant Professor of Psychiatry, Harvard Medical School; Associate Program Director, BIDMC Harvard Psychiatry Residency Training Program, Beth Israel Deaconess Medical Center, Boston, Massachusetts

Clinical Assistant Professor, Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford, California

Assistant Professor, Department of Obstetrics and Gynecology; Clinical Assistant Professor, Department of Psychiatry, University Hospitals/Case Western Reserve University, School of Medicine, Cleveland, Ohio

The following contributors have indicated financial interest in or other affiliation with a commercial supporter, manufacturer of commercial products, provider of commercial services, nongovernmental organization, and/or government agency, as listed.

Owner, CEO, and Medical Director: Glenbervie Healthcare (d/b/a The Motherhood Center).

Brain and Behavior Research Foundation; National Institute on Drug Abuse; Janssen Pharmaceuticals; Arkansas Children's Research Institute.

Consultant, Research, Speaker: Sage Therapeutics. Advisory Boards: Asarina Pharma, Sage Therapeutics.

Consultant: Sage Therapeutics.

Co-Founder: Phoebe, Inc.

Consultant/Investigator/Scientific Advisory Board: AMAG, Astellas, Daré, Duchesney, Ovoca, Lupin, Materna Medica, Mitsubishi Tanaba NA, Palatin Technologies, Pfizer, Sprout, Strategic Science Technologies. Stock Options: Materna Medica and Viveve. Physician Education Group Board: Ms. Medicine.

Speaker: Psychopharmacology Institute, March 2020.

Patent: “DNA Methylation Biomarkers of Postpartum Depression Risk” (No. 13851897.2-1403 PCT/US2013068241).

Grants: Fulbright Commission (Czech Republic); European Regional Development Fund-Project “Creativity and Adaptability as Conditions of the Success of Europe in an Interrelated World” (No. CZ.02.1.01/0.0/0.0/16_019/0000734).

Katherine L. Wisner, M.D., M.S.

Samantha Meltzer-Brody, M.D., M.P.H.

This book is a timely and much-needed contribution to the literature. Our most sincere thanks are due to these industrious and talented editors—Drs. Lauren Osborne, Lucy Hutner, Lisa Catapano, Sarah Nagle-Yang, and Katherine Williams—who have constructed this long-awaited and urgently needed Textbook of Women’s Reproductive Mental Health. The commitment and passion of this group is inspiring! For far too long, this area of medical practice has fallen between the specialties of psychiatry, obstetrics and gynecology, and pediatrics. The result? Today, more than 20 years after the establishment of postresidency training in reproductive psychiatry, a comprehensive textbook of the field has yet to be published. This work was inspired by the National Curriculum on Reproductive Psychiatry (NCRP), a comprehensive educational resource that is free of charge and funded by the American Board of Psychiatry and Neurology (www.ncrptraining.org).

Why is this book important? Women develop mental health problems at significantly higher rates than men. The prevalence of any mental illness is higher among women (22.3%) than men (15.1%) (National Institute of Mental Health 2020). Young adults ages 18–25 years have the highest prevalence (25.8%) compared with adults ages 26–49 (22.2%) and 50+ years (13.8%). More women (47.6%) receive mental health services compared with men (34.8%). Women are twice as likely as men to develop major depressive disorder. Furthermore, 10%–15% of women experience depression during the perinatal period, which makes depression one of the most common complications of childbirth (Gaynes et al. 2005). These statistics illustrate that psychiatric disorders in women are common during the reproductive years and that the hormonal fluctuations associated with the reproductive life cycle contribute to the etiology of mental illness in women. Medical practitioners in all fields will encounter female patients with mental illness across the lifespan, particularly major depressive and anxiety disorders. Consequently, there is a great imperative for high-quality educational materials that increase the competency of providers.

Over the past decade, increasing advocacy, research, and health policy changes have underscored the need for clinicians with expertise in women’s reproductive health. The shortage of psychiatrists in general and specifically those with expertise in reproductive mental health is a major public health concern. For example, most women with perinatal depression do not receive adequate screening nor treatment (Cox et al. 2016). Few residency programs require any training in reproductive psychiatry. No consensus set of competencies or formal certification process exists. Given these significant gaps, The National Task Force on Women’s Reproductive Mental Health was formed and subsequently urged residency training program directors to ensure that all psychiatrists acquire basic knowledge and skills in reproductive psychiatry (Osborne et al. 2015). This book is the resulting compendium of excellent up-to-date information to address that goal.

Reproductive events in women’s lives are powerful experiences that change the course of health in both biological and psychosocial domains. As health care professionals, we must view these events as opportunities for engagement to improve short- and long-term health. They also compose a “natural longitudinal laboratory of women’s reproductive health” (Wisner 2007) for hypothesis generation and research. The physiological noise that menstrual cycling, pregnancy, lactation, and menopause create in the interpretation of research data has been reconceptualized as an opportunity for elucidating the impact of reproductive function on brain health.

This outstanding work is divided into two parts. Part I provides a comprehensive overview of the reproductive life cycle and covers mental health concerns across the lifespan, including the relationship between gynecological and sexual health and mental health as well as infertility, the premenstrual period, and perimenopause. Part II is devoted to the perinatal period and offers a conceptual framework for a clinical approach to the pregnant and postpartum patient, followed by evidence-based reviews of the management of psychiatric disorders (by diagnostic category), as well as covering stress in pregnancy, infant mental health, and legal/forensic issues. The individual chapters are structured logically for continuity and consistency in information presentation. Critical summaries of the epidemiology, risk factors, screening methods, and clinical features are presented. Expert views of the impact of reproductive events on the clinical presentation are particularly salient.

This book must be required reading for all faculty and trainees who will care for women. This information must be part of the education of all mental health professionals. We strongly endorse this outstanding textbook. It is an overdue and very welcome tool to use in our training programs.

This is a textbook of women’s reproductive mental health. It is not meant to be a comprehensive look at all aspects of women’s mental health but, rather, a look at the somewhat narrower field of reproductive psychiatry—the branch of medicine that encompasses the science and practice of treating mental, emotional, and behavioral disturbances related to female reproductive stages. It is the product of a remarkable volunteer effort representing the work of 83 specialists, including reproductive psychiatrists, obstetrician-gynecologists, and other specialists in women’s health. Together, these authors represent more than 30 institutions across the United States and Canada.

This textbook is the first specifically in reproductive psychiatry, although it follows in the footsteps of the foundational text in women’s mental health edited by Susan Kornstein and Anita Clayton nearly 20 years ago (Kornstein and Clayton 2004). This book appears at a moment when women’s reproductive mental health is coming into its own as a discipline, with (at current count) 17 postresidency training programs and an extraordinary blossoming of interest among current psychiatry trainees. However, this textbook could not have come about without the changes in the research and clinical landscape that have occurred over the past 30+ years, changes that have removed women’s health from the fringes of our profession. These changes can be charted back to 1985, when the Public Health Service called for the expansion of medical and behavioral research into conditions that were more prevalent in, or unique to, women (Kirschstein and Merritt 1985). The National Institutes of Health (1987) responded with a policy—later upgraded to a mandate in 1993—to include women in clinical research. These early landmark policies and the refinements that have occurred to them since (including a 2001 requirement that data be reported by sex and a 2014 requirement that preclinical research include animals of both sexes) (Arnegard et al. 2020; National Institutes of Health 2011) have resulted in a dramatic expansion of our knowledge base about how reproductive cycle transitions affect women’s mental health.

Alongside this expansion of research, our field has seen the founding and growth of professional societies devoted to women’s mental health or reproductive psychiatry. These include the International Society of Psychosomatic Obstetrics and Gynecology (founded in 1962), the International Marcé Society (founded in 1980), and the International Association for Women’s Mental Health (founded in 2001), along with numerous national branches of these societies and independent local and regional groups. This time has also seen a number of key public policy initiatives in the United States, including statewide projects to combat perinatal depression (Schade et al. 2011) and requirements that all pregnant and postpartum women be screened for depression (Rhodes and Segre 2013). Clinical programs devoted to the field have burgeoned as well, with specialized inpatient units, mother–baby day hospitals, and numerous specialty outpatient practices in both academic centers and the community.

This growth in research, policy, and clinical programs has been gratifying, but it has been dismaying to realize that most psychiatrists receive no education, either during their training or afterward, in reproductive mental health. More than 50% of psychiatric patients are women, and more than 80% of women will experience at least one pregnancy (and nearly all will have menstrual cycles and go through menopause), yet most psychiatrists lack the knowledge of how these transitions affect mental health.

This textbook offers one tool for improving that knowledge base, and the textbook would not exist if not for the efforts of another extraordinary volunteer effort, the National Curriculum in Reproductive Psychiatry (www.ncrptraining.org), or NCRP. The NCRP was conceived at the Biennial Perinatal Mental Health meeting in 2013, when a group of academic psychiatrists came together to present a symposium on the current state of education in reproductive psychiatry. In the wake of that symposium, the presenters formed the National Task Force on Women’s Reproductive Mental Health, with an agenda to research the current state of education in reproductive psychiatry and to move toward national standards. Informed by surveys of residency and fellowship directors, the task force identified six core knowledge areas for specialists in the field of reproductive psychiatry:

As we explored whether these topics were being covered in current residency training, it became apparent that most were not—and that the major barriers to teaching included lack of qualified faculty and lack of time (because reproductive psychiatry is not a specialty required by the Accreditation Council for Graduate Medical Education [ACGME]). It also became clear that residency programs would be unlikely to pay for the curriculum for a non-ACGME specialty and that other groups of learners (advanced-practice nurses, psychiatrists in general practice, obstetrician-gynecologists, and residents in other fields such as pediatrics and family medicine) would also benefit from this training. We therefore set out to create an interactive Web-based national curriculum, based on our competency guide, that could serve three purposes:

In 2017, the task force merged its curriculum efforts with those of Marcé of North America (formerly the Perinatal Mental Health Society, sponsor of the original conference where this idea was hatched), which had simultaneously been working on a fellowship-level curriculum. Together, we have created a curriculum that can be used in a modular fashion for residency education and in its entirety as a fellowship curriculum. The NCRP has won numerous educational awards, including the Educational Innovator Award from the Johns Hopkins Institute for Excellence in Education (2018) and the Scholarship in Teaching Award from Case Western Reserve University (2019), and has been funded by a Faculty Innovation in Education Award from the American Board of Psychiatry and Neurology.

Lucy A. Hutner, M.D.

Lisa A. Catapano, M.D., Ph.D.

Erika Kelley, Ph.D.

Sheryl A. Kingsberg, Ph.D.

Sarah M. Nagle-Yang, M.D.

Katherine E. Williams, M.D.

Lauren M. Osborne, M.D.

When we first proposed this textbook to the American Psychiatric Association, we editors (all of whom call ourselves reproductive psychiatrists or perinatal psychiatrists) were adamant that the title be reflective of the subject—mental illness that arises at moments of female reproductive transitions. This is not the same as women’s mental health—women’s mental health is a broader definition that includes our subject, the intersection of mental illness with female reproductive cycles—but also includes other categories, such as female sex (e.g., brain sexual dimorphism, female-specific comorbidities, pharmacokinetic sex differences) and female gender (e.g., gender roles, gender-linked trauma). “Reproductive psychiatry” or “reproductive mental health” alone would not do because this book does not address mental illness related to reproduction in men. “Women’s reproductive mental health” seemed the most accurate term, but we are conscious of the fact that it may not long remain so. Definitions of “woman” are evolving rapidly in our society, and we recognize that many people assigned female sex at birth do not identify as women, that many people assigned male sex at birth DO identify as women, and that many people of both biological sexes identify as neither (Stroumsa and Wu 2018). The view that gender and sex can be categorized into two genetically fixed, nonoverlapping constructs has been swept away, and increasingly, our reliance on two culturally constructed categories is misleading and outdated (Hyde et al. 2019). As of the writing of this book, the data concerning mental illness at times of reproductive transition in people who are not cisgender women are extremely limited. We know little about either the biological or psychological effects on mental health of hormonal transitions for transgender men who choose to become pregnant, for example, or whether premenstrual mood symptoms present or are interpreted differently in nonbinary individuals than in cisgender women.

Although we are thus conscious that the resulting book is therefore focused primarily on the reproductive mental health of cisgender women, we are also confident that this will not always be the case. We hope and expect that subsequent editions will be able to incorporate more about people with gender-diverse identities and that one day there will be enough data for an additional book. Physicians have been writing about mental health associated with female reproductive transitions since the time of Hippocrates, and in the United States, it has been just over 20 years since the establishment of the first postdoctoral fellowship position in women’s mental health, yet this is the first comprehensive textbook on the subject. It may be another 20 years before enough data accumulate for a whole textbook on reproductive mental health in people with gender-diverse identities, but we do not think it will be another 2,500 years.

That said, we have tried whenever possible to incorporate available data in the appropriate chapters and to use inclusive language and case examples. In addition, we would like to outline here some special considerations for those living with gender-diverse identities and for sexual minorities who face challenges not shared by other groups, as well as some basic definitions that may not be familiar to all readers and may be useful in understanding the subsequent chapters.

Research indicates that LGBTQ+ individuals may experience increased barriers to health care, including discrimination, stigmatization, and lack of provider knowledge about the health care needs for this population (Baptiste-Roberts et al. 2017; Chapman et al. 2012; Institute of Medicine 2011). Psychiatry providers should be familiar with guidelines for the health care of LGBTQ+ patients, such as those published by the Gay and Lesbian Medical Association (2005), The Joint Commission (2014), and the American Academy of Child and Adolescent Psychiatry (Adelson and American Academy of Child and Adolescent Psychiatry Committee on Quality Issues 2012).

The term gender roles refers to society’s expectations regarding behaviors, traits, and attitudes according to one’s sex assigned at birth. A patient’s (or their partner’s) expectations and attitudes toward gender roles may affect their sexual functioning (e.g., traditional gender norms reflect expectations that women should be sexually subservient to men). Gender identity reflects how one identifies one’s own gender, such as male, female, transgender, or nonbinary. It is influenced by socially defined constructs, and it is increasingly apparent that there may be a heritable biological component as well (Polderman et al. 2018). Sexual orientation refers to one’s pattern of emotional and physical arousal and the gender(s) of persons to whom one is sexually or physically attracted. Sexual identity refers to individuals’ assessment of their own sexual orientation (e.g., lesbian, gay, bisexual, questioning or queer) (Levine and Committee on Adolescence 2013). Sexual orientation and sexual identity are unrelated to gender identity.

Providers working with transgender individuals should be familiar with the World Professional Association for Transgender Health (2012) standards of care. Transgender individuals seeking gender-affirming therapy (e.g., feminizing or masculinizing hormone therapy, surgery) require referrals from mental health providers, which is described further in the standards of care document. Psychotherapy is not an absolute requirement for hormone therapy and surgery, although it is highly recommended. Mental health professionals working with individuals seeking or undergoing gender-affirming therapy (e.g., hormone therapy, surgery) should be aware of the benefits and risks of these therapies on mental health and sexual function.

Part of the criteria for recommendation for gender-affirming therapy is persistent, well-documented gender dysphoria (World Professional Association for Transgender Health 2012). Gender dysphoria in adolescents and adults is typically defined as a distressing, marked incongruence or discrepancy between one’s gender identity and one’s sex assigned at birth and the gender role, primary sex characteristics, or secondary sex characteristics associated with that sex (American Psychiatric Association 2013; Knudson et al. 2010). DSM-5 (American Psychiatric Association 2013) includes specific criteria for the diagnosis of gender dysphoria. Despite some controversy regarding gender dysphoria as a diagnosis (e.g., potential stigmatizing or overpathologizing effect) (Davies and Davies 2020), the diagnostic label was changed from gender identity disorder to reduce the potential stigmatizing effect, and the diagnosis was retained in part to acknowledge the full impact of dysphoria and to increase access to gender-affirming services (e.g., billing requirements) (Byne et al. 2018).

Sexual identity can be fluid and dynamic across time (Diamond 2008). Thus, clinicians should be careful not to make assumptions about patients’ sexual behavior or about their family planning or reproductive health care needs based on their described gender or sexual identity. For example, many women who have sex with women also report having had sex with men (Diamond 2008). Discussion of issues such as contraception, risk for pregnancy and sexually transmitted infections, and accessing services for third-party involvement in reproduction (e.g., gestational carrier) or adoption is still relevant to women who have sex with women, as well as for trans men (who may continue to have vaginal intercourse with men) and for trans women, who have disproportionately high rates of HIV (Baral et al. 2013). Research regarding rates and phenomenology of sexual dysfunction among LGBTQ+ persons is scarce, although it remains important to assess sexual functioning in this population with consideration of the biopsychosocial model. Notably, LGBTQ+ individuals experience greater rates of victimization and mental health concerns (e.g., depression, anxiety) (Institute of Medicine 2011), which can negatively affect sexual function. Additional sexuality considerations across female reproductive milestones are outlined in the following discussion.