Lisa van Raalte Ph.D. | August 23, 2022

By Cassie Shortsleeve | May 20, 2022

"Ask any new birthing person about the realities of postpartum life or anyone post-menopausal about menopause and they'll usually say something along the lines of, "No one told me it was going to be like this."

There's a lot no one tells you about the way reproductive transitions impact mental health, say reproductive psychiatrists—doctors who specialize in the historically siloed field of mental health throughout the reproductive cycle, from adolescence through menopause.

People have long experienced reproductive transitions and the symptoms and conditions that come with those shifts—like postpartum depression (PPD), for example—but the medical community has not known much about them until recently. While the American Psychiatric Association (APA) has dozens of textbooks on all kinds of psychiatric topics, there has been no comprehensive textbook in reproductive psychiatry—until now.

In December, thanks to a volunteer effort by 80 authors from more than 30 different institutions around the country, the APA put forth a textbook: Textbook of Women's Reproductive Mental Health.

In the authors' words, it's "the first comprehensive text for understanding, diagnosing, and supporting the unique mental health needs of women and others who undergo female reproductive transitions during their entire reproductive life cycle."
Lucy Hutner, M.D., a reproductive psychiatrist in New York and one of the book's co-editors adds: "It's a flag-on-the-moon moment for women's mental health."

After all, when she was training to be a doctor, she was told that the field that she specializes in today didn't exist. As recently as the 1980s, doctors and research studies alike suggested falsehoods such as the idea that mood is protected in pregnancy or that "without exception" psychological changes after having a baby were positive.

It's ironic, Dr. Hutner says, considering that postpartum depression is the most common complication of childbirth. But when you have patients with symptoms of diseases that exist and a field that doesn't, it's more than just ironic; it's detrimental to the overall health and wellbeing of that population. A lack of legitimacy perpetuates shame, misinformation, silence, and stigma.

"This medical textbook is almost symbolically more important than anything else," says Dr. Hutner. "It sort of says, 'Hey, this is as important as any other aspect of medicine.' It validates people's voices. It says, 'We don't need to have this stigma anymore. We're done.'"

The Messy World of Reproductive Mental Health
There's nothing non-existent or niche about reproductive psychiatry. But today, if you find yourself with something like PPD or postpartum anxiety (PPA), one of your first touchpoints with the medical system is likely your six- or eight-week follow-up appointment with your OB-GYN or a few trips to the pediatrician.
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If you're lucky, you might land in the office of someone like Dr. Hutner for specialized treatment. But too often new moms wind up in an OB-GYNs offices crying and reporting their symptoms with little to no guidance.
Just as this setup fails patients, it fails providers trying to care for those patients, too. The American College of Obstetrics and Gynecologists (ACOG), for example, recommends mental health screening at least once in the perinatal period. But as Dr. Hutner puts it, OBs may not always know what to do with positive screens, or may not know how to treat crying patients.
"The training, education, and dialogue around reproductive mental health have been ad hoc. There hasn't really been a standardized way of approaching it," says Dr. Hutner.

In short: Some physicians have training; some don't. Some are great at providing resources or spotting symptoms; some aren't. There are also big issues including systemic racism in medicine, as well as lack of awareness of queer health issues. This leads to a lot of patients who inadvertently wind up feeling invalidated and alone, without treatment.

Looking Ahead at Reproductive Mental Health
Most people recognize the importance of reproductive mental health, and doctors in training are eager to learn more about it. Lauren M. Osborne, M.D., one of the co-editors of the textbook and the director of the Johns Hopkins Center for Women's Reproductive Mental Health, has piloted a new curriculum designed to educate medical trainees in the field. She asked budding psychiatrists to rank six subspecialties of psychiatry—including reproductive psychiatry along with five officially recognized fields. Doctors ranked reproductive psychiatry in the top half, consistently outranking other specialties that are deemed essential knowledge for independent practice and board certification.  
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Yet because reproductive psychiatry isn't yet an official subspecialty of psychiatry, it currently lacks government funding for more post-graduate fellowship programs. And learning about widespread problems such as postpartum depression is elective, not a requirement. This contributes to a lack of faculty to teach reproductive mental health and a lack of providers to treat it."

By Stephanie Collier, MD, MPH, Contributor

"​Pregnancy is an exciting time. You will soon become a parent to an adorable, tiny human. You may expect to experience the rollercoaster of emotions during pregnancy, or emotions may catch you off guard. Some women feel joy at every flutter or kick, marveling at their changing bodies. For other women, pregnancy is hard, giving no reprieve as it brings severe fatigue, mood changes, and constant worries. You may notice that with every passing month, your thoughts are spiraling out of control, affecting your performance at work and your relationships at home. But how do you manage your anxiety, and should you treat it?

What causes anxiety during pregnancy?
Worries during pregnancy are universal. Hormonal changes of pregnancy, prior heartbreaking miscarriages, and sleep difficulties may all contribute to anxiety for mothers-to-be. You may worry about how a baby will affect your relationships with friends or family members, the health of your future child, the delivery experience, or the financial burden of an additional family member. All of these worries are completely normal. For humans, a certain amount of anxiety is protective; how else could we motivate ourselves to complete our work or run away from a bear?

What are the symptoms of anxiety disorders during pregnancy?
Although it’s normal to be worried about the health of your baby, in some cases this worry becomes debilitating and may require further attention. Thoughts about the health of the baby may become obsessive, even when doctors are reassuring. Worries may also appear as physical symptoms, such as a rapid heartbeat, difficulty breathing, or panic attacks. If this is the first time you experience a high level of anxiety, this may be frightening in itself. When anxiety starts to interfere with your day-to-day functioning, relationships, or job performance, it may be classified as an anxiety disorder — if your doctor picks up on it.

Anxiety can occur at any time during pregnancy, or it may first appear after delivery (perinatal anxiety is the term used for anxiety during pregnancy and after delivery). The rates of generalized anxiety disorder appear to be highest in the first trimester, likely due to hormonal changes. The most common symptoms of anxiety include constant worrying, restlessness, muscle tension, irritability, feeling dread, an inability to concentrate, and difficulties falling asleep due to worries. Some women also experience symptoms as a result of other anxiety disorders, including panic disorder, obsessive-compulsive disorder, or post-traumatic stress disorder.

Unfortunately, two of the most common mental health screening tools in pregnancy (the Edinburgh Postnatal Depression Screen and Generalized Anxiety Disorder 7-item Scale) are not great at detecting anxiety in pregnancy. Although underdiagnosed, anxiety disorders during pregnancy and in the postpartum period are common, and may affect up to one in five women. Many women suffer in silence.

What are the effects of untreated anxiety on the fetus?
When thinking about management of anxiety, it is important to consider both the risks of treatment as well as the harms of untreated anxiety. Although less studied than depression, research suggests that anxiety may negatively affect both the mother and the fetus. Anxiety increases the risk for preterm birth, low birthweight, earlier gestational age, and a smaller head circumference (which is related to brain size).

What are some treatments for anxiety during pregnancy?
Fortunately, there are many treatments that can reduce anxiety during pregnancy and help you feel better. For many women, anti-anxiety medication is not an option during pregnancy, as there is little information on the safety of such medication on the fetus. Some women who had previously taken medications for anxiety may wish to discontinue medications during pregnancy for personal reasons.

Therapies such as cognitive behavior therapy (CBT) demonstrate promise in the peripartum period (the period shortly before, during, and after giving birth). CBT focuses on challenging maladaptive thoughts, emotions, and actions, and it uses anxiety management strategies such as diaphragmatic breathing (adapted to pregnancy).

If your anxiety is severe, medications may be an option for you. Selective serotonin reuptake inhibitors (SSRIs) are commonly prescribed for depression and anxiety during pregnancy and after delivery. It does not appear that SSRIs are associated with an increased risk of major congenital malformations. However, SSRIs may be associated with transient neonatal symptoms such as jitteriness, tremor, crying, and trouble feeding, which resolve on their own in a few days.

The use of benzodiazepines such as lorazepam (Ativan) and alprazolam (Xanax) during pregnancy has long been a controversial topic. Although older studies showed an association between their use and an increased risk for cleft lip and palate, a more recent study looking at benzodiazepine use during pregnancy did not show this link when these medications were used alone (although there may be an increased risk when combined with antidepressants)."

By Melissa Willets | Updated August 22, 2021

By ​Loren Kleinman | May 12, 2021

"The day Lily was born, my husband, Joe, took pictures, murmured soft words, and held her every moment he could. "I want to stay home with her for her first year," he said. "I read it's important for their development."

Luckily, he was able to as he was honorably discharged from the Navy. But despite my three-month maternity leave, I wanted to go back to work.

But when we returned home from the hospital, I unraveled. No time to shower, eat, or pay a bill. Our lives revolved around Lily. Everything I imagined about motherhood exploded. Dreams of gardening with my daughter in a Snugli on my chest were replaced with her unrelenting cries and endless diaper changes.

Yet to Joe, she was just a baby. "What did you think having a baby would be like?" he asked.

"Not like this," I snapped, taking off my spit-up covered shirt and replacing it with a clean one.

It wasn't just the dirty shirt. I had thoughts of hurting myself and my baby, an alarming desire to drive us both off the road. I hated myself for these thoughts, but I hated her more. I hated that she never slept, and resented that I couldn't, either. I hated breastfeeding, which was not magical as I'd pictured, but painful and lonely.

I missed our date nights, coming and going as I pleased, and clean clothes.

Darkness settled over me, unlike any depression I'd experienced. I began experimenting with cutting myself just to feel something other than exhaustion, spending long minutes in the bathroom, my only escape. With each cut came relief from the burden of this new, agonizing life.

"You were in there a long time," Joe teased me.

Low spirited, I replied, "I wish I never had to come out."

He reached out to console me and saw the cuts on my arm. I didn't hide them. I didn't care. But Joe called his therapist, who told him about a clinic for women with postpartum depression.

"He doesn't even know me," I argued.

"You're going," a frazzled Joe said. "Today."

My First Dose of Postpartum Depression Treatment
We arrived to find a room filled with infants, dads, and moms, many of the latter red-faced and crying, while their husbands stood by, holding babies. I was amazed to see so many men like my husband, cradling their little ones, in solidarity with their wives, as the women went one by one to meet with a psychiatrist.

When it was my turn, I looked back at Joe and Lily. A concerned smile dusted his face. "We'll be right here when you're done."

During my intake, I asked flatly, "Will I ever love her?"

"This is a classic postpartum depression question. You will love her," the psychiatrist assured me. "But I have to ask, do you have any plans to kill yourself?"

Without hesitation, I said, "I want to drive off the road." Then I wept.

I wasn't allowed to drive until further notice, and if I didn't abide, the psychiatrist warned, "We'd have to consider hospitalization."

Joe ferried me to and from the clinic every day, no matter how many times he'd been up with Lily the night before. On weekends, Joe tended to me and to Lily, making sure we both ate and slept, as his parents flew out from Washington State to lend a hand, a relief to both of us.

For the first time, I felt some hope.

Every week, I attended weekly dialectical behavior therapy sessions (DBT), learning skills for coping with my anxiety and insomnia like radical acceptance and positive self-talk.

Things Only Got Worse
Then, one night, after Joe put Lily to bed, we sat on our back porch, me with my usual glass of wine, him with his Coke and ice.

"Are you OK?" he asked, as I stared, glassy-eyed, into the trees.

Before coming outside, I'd already washed down a handful of Tylenols, along with sedatives and a few glasses of wine.

"I can't live like this anymore." I paused. "Lily deserves a mom, not me."

Joe sighed and said, "I'm calling the clinic's emergency line."

The therapist on duty advised Joe to bring me to the hospital immediately, even though I protested. But I had no choice. I confessed my desire to kill myself, so I could go voluntarily or in an ambulance.

Joe stayed with me for nine hours in the emergency room, until there was a bed ready in the psychiatric unit. His parents watched Lily at home.

"Please don't let them take me away," I called out to Joe, as a nurse led me to the unit.

"I'll see you in the morning," Joe answered back. "You will be OK."

When he arrived the next day, I pleaded with him to get me out.

"Someone tried to kill themselves last night," I cried. "I don't belong here."

"Can you give it a chance?" he begged.

I sat back in my chair and folded my arms. I resented Joe for bringing me here. At the beginning of our relationship, I'd been the strong one, helping him through his own hardships. But Lily changed everything.

"I have to get back," he said. "Focus on getting better, not getting out."

When Joe leaned in to give me a kiss goodbye, I stopped him. "I want a divorce when this is over," I whispered.

He teared up and said, "You've said some of the meanest things anyone has ever said to me."

I felt no remorse. Before the baby, we never went to bed angry. Now, I loathed him for keeping me here. I was determined to punish him, and I did, lashing out constantly, but he kept visiting and taking my phone calls. He never stopped trying.

I was discharged after five days. Joe and I argued for the entire ride home. When we arrived at the house, I imploded: "I can't take this anymore!"

I threw chairs and baby toys, wailing, and punching the wall. Joe couldn't calm me, so he took Lily and his parents to the farthest part of the house.

The next morning, Joe gave me a choice: "You either go to your parents' house and take a break, or you go back to the hospital."

I chose the first option.

A few days later, Joe called me. "I told my therapist what happened. He called Child Protective Services," he said matter-of-factly.

"They're going to take Lily away?" I asked.
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Shocked, I suddenly realized how much I wanted her."

By Paige Glidden | May 07, 2021