There's Now a Medical Textbook for Reproductive Mental Health—Here's What That Means

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.

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.

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.

Things are changing. While there used to be just a few fellowship programs in reproductive psychiatry, there are now 16 across the U.S. and one in Canada, says Dr. Osborne. The growth in such programs over the last 10 years means the field is just a few programs shy of the level at which leaders can start to think about lobbying for reproductive psychiatry to become an official subspecialty of psychiatry. Once it's official, psychiatrists in training will be required to learn about it in their studies, and the field becomes eligible for government support of education.

The hope is that one day, other health care providers, such as OB-GYNs, family medicine doctors, and even midwives, will be able to assess, triage, and treat garden variety reproductive mental health issues while referring more serious cases to specialized reproductive psychiatrists, Dr. Osborne says.

In the meantime, the book's authors are also creating a mental health education toolkit to go along with the textbook specifically for obstetric providers. Its progress in a medical system can sometimes seem set-in-stone, says Dr. Hutner. But medicine can and should change. "We're allowed to shift the lens in medicine—and we should shift it—based on the experiences of our patients."

This textbook is a prime example of that, especially in light of important aspects of medicine such as social context. "A lot of times, social context in medicine is considered a sort of sidebar; we understand that it matters, but it's not fully embedded within the education of doctors," says Dr. Hutner. This textbook takes issues such as systemic racism, a lack of paid family leave, and family structures, and fully embeds them into health outcomes, she says. The book also acknowledges the work to be done—especially in terms of what has yet to be researched in reproductive mental health, including the experience of non-pregnant partners, LGBTQ+ parents, and more. (The book is noted as the "1st edition," allowing room for future revisions and additions.)

There's a very real, very steep upward battle to get women's work—whether it's in the field of reproductive psychiatry or something else—recognized, says Dr. Osborne. The book, after all, was a volunteer effort. And the biggest change it could lead to is perhaps the greatest: "No birthing parent should have to go through what so many people have gone through in years past," says Dr. Hutner. "So much of the suffering is unnecessary."