Development Of A Reproductive Psychiatry Track For Psychiatry Residents: Challenges And Solutions

In 1985, the United States Public Health Service Task Force recognized the overwhelming dearth of knowledge in the field of women’s health [1]. Since then, a strong body of research has documented the influence of reproductive stages and transitions on psychiatric illness in women. Studies have particularly identified the increased risk of mood disorders and depression among women as compared to men [2]. More than 50% of individuals seeking mental health services are women and more than 80% of these women will undergo childbirth. Together, these statistics highlight a critical need to educate psychiatry residents in women’s mental health and improve competency in addressing the mental health needs of their female patients [3]. Furthermore, in 2015, the American College of Obstetricians and Gynecology recommended that all pregnant women should be screened for depression and anxiety [4]. The following year, the United States Preventive Services Task Force provided further clarification, stating that perinatal anxiety and depression screening should only occur when there are adequate resources allowing for diagnosis, treatment, and follow-up [5]. The recognition of clinical need, combined with this newly-highlighted heightened public health need, lead to a call to develop reproductive psychiatry, a field dedicated to understanding and treating women’s health needs during the reproductive period [6].

Despite this increased awareness about the importance of reproductive psychiatry, psychiatrist competency in the field has not developed adequately to address the public health and patient needs. Many general psychiatrists are unwilling or unable to provide antenatal, perinatal, or postpartum psychiatric care [6]. A survey conducted in 2015 revealed that only 59% of residency programs require training in reproductive psychiatry, and the required training is often minimal [6]. Specifically, 72% of programs that provided any training required only five or fewer hours of didactics and 23% of programs offered no didactics at all [2]. Addressing this lack of training in reproductive psychiatry among psychiatry residents could potentially address the scarcity of mental health professionals competent in reproductive psychiatry. Indeed, the National Task Force on Women’s Reproductive Mental Health, founded in 2013 to address the lack of education in this area, concluded that residency programs need to better equip their residents with knowledge and skills in reproductive psychiatry [6].

In this commentary, we discuss our efforts to develop a reproductive psychiatry track for psychiatry residents, the challenges and barriers we faced, and the methods we used to navigate these barriers.

SUNY Upstate Medical University (SUNY UMU) is an academic medical center located in Syracuse, New York. SUNY UMU serves as a referral center for the surrounding region, which includes the neighboring five counties. SUNY UMU’s Psychiatry residency program currently enrolls twelve residents each year. Recognizing the deficit in reproductive psychiatry, the residency program launched an effort to develop an elective rotation to fill the void.

The process was guided by four overarching principles and needs– collaboration, leadership buy-in, sustainability and flexibility—underpinned by the Bolman and Deal’s four frames (Figure I) [7]. In line with the human resource and political frame, we carried out multiple collaborative meetings with the various site supervisors, facility and program leaders and included residents and medical students in the planning process. This was done to minimize resident and programmatic burden and help structure the current curriculum within the bounds of the existing residency curriculum. These meetings also helped ensure flexibility and sustainability, so it could be adapted to future changes in collaborations and to standardize the curriculum to the proposed new national curriculum [5]. Finally, we used the symbolic frame to highlight the need for this curriculum from clinical, public health and educational perspectives.

We encountered two interconnected challenges. Our first challenge was developing and incorporating a clinical and didactic curriculum into the existing residency curriculum. This challenge was particularly critical considering the need to meet ACGME requirements. Our second challenge related to the establishment of clinical sites for the elective. This challenge was both a geographic and structural one. SUNY UMU’s primary teaching site does not have inpatient obstetric and gynecology (OB/GYN) services, which compounded the problem of services being split between various health centers in suburban Syracuse.

The development of the curriculum began with the identification of an existing reproductive psychiatry curriculum. We chose Brown Alpert Medical School’s curriculum for this purpose [8]. This curriculum formed a template for both identifying the required didactics and discerning clinical site requirements. Based on this, we carried out an environmental scan to identify clinical sites that could provide the required clinical experience in perinatal mental health and substance abuse services. As expected, our environmental scan identified multiple clinical sites offering the required clinical experience; however, the exposures were varied and the locations were geographically distant, particularly from the main location of the majority of the residency’s clinical experiences.

Broadly, we used a collaborative, interest-based strategy to address the two aforementioned challenges. At the outset, we ensured a diverse representation on our team which consisted of a member from every important aspect of the educational system, including faculty, residents and medical students. A senior resident assumed the leadership role of coordinating the various team members. The team settled on two different sites for outpatient services (one each for substance use disorders and perinatal mental health) and two different sites for inpatient services (for inpatient consultation-liaison). We were fortunate that each of the collaborating institutions recognized the crucial nature of the elective from both an educational and a clinical perspective. Despite this recognition, however, the allocation of time and personnel to resident supervision at these sites proved to be a critical barrier. To address this, we collected information regarding the specific interests of the collaborating institutions and faculty and discussed the new limitations and resultant advantages of the proposed rotation. We worked with residents, residency and institutional administrators, and faculty within the psychiatry and OB/GYN departments to explore ways to attain the shared goals. We ensured that the new curriculum addressed some of the current needs and built on the strengths of the residency as identified by both program administration and residents.

The result of our efforts was a phased three-year curriculum that was incorporated into the existing residency curriculum. Our final curriculum incorporated introductory didactics in Postgraduate Year (PGY)-2, advanced didactics and outpatient perinatal experience in PGY-3, and research and/or inpatient consultation liaison experience in PGY-4. The clinical experience includes experience of working with peripartum women with serious mental illnesses, new onset mental illness, and substance use disorders. The experience also includes exposure to attachment and mindfulness-based therapies, and bereavement support groups in addition to traditional group and individual therapies, such as Dialectical Behavior Therapy, Cognitive Behavior Therapy, Interpersonal Therapy, and psychopharmacology during pregnancy and lactation. The didactics involve education on topics including premenstrual dysphoric disorder, perimenopause, infertility, the use of psychiatric medications in pregnancy, as well as perinatal depression, anxiety, substance use and psychosis. Further, we included a section on feminine psychology, and are in the process of developing an outpatient consultation program with the on-site OB/GYN services. In collaboration with the various site faculty, we also built in a feedback and evaluation system to create a flexible and evolving track. We anticipate that the collaborative development and built-in dynamicity will help us adapt the curriculum to evolving needs.

In conclusion, implementing an elective reproductive psychiatry track in residency programs undeniably raises unique challenges that have to be addressed in an individualized and collaborative manner. This is particularly critical in programs that are limited in terms of access to appropriate clinical sites. We borrowed a number of strategies from leadership literature, including the systematic use of Bolman and Deal’s framework, and interest-based negotiation strategies and techniques. We also recognized the need for “champions” and advocates at every level of the clinical and administrative team. Finally, we understood the importance of residency programs including residents in the collaborative process to foster a sense of empowerment and to minimize their clinical burden.

The need to provide education in reproductive psychiatry during residency training is substantial and has remained unaddressed for far too long. We hope our efforts can serve as a springboard for other programs to develop similar training in reproductive psychiatry.

References:

1. Nagle-Yang S, Miller L, Osborne LM. Reproductive Psychiatry Fellowship Training: Identification and Characterization of Current Programs. Academic Psychiatry. 2017;42(2):202-206. doi:10.1007/s40596-017-0690-8.
2. Wharton, W., E Gleason, C., Sandra, O., M Carlsson, C., & Asthana, S. (2012). Neurobiological underpinnings of the estrogen-mood relationship. Current psychiatry reviews, 8(3), 247-256.
3. Osborne LM, Maclean JV, Barzilay EM, Meltzer-Brody S, Miller L, Yang SN. Reproductive Psychiatry Residency Training: A Survey of Psychiatric Residency Program Directors. Academic Psychiatry. 2017;42(2):197-201. doi:10.1007/s40596-017-0672-x.
4. Committee on Obstetric Practice (2015) Screening for perinatal depression. The American College of Obstetricians and Gynecologists Committee Opinion No. 630. Obstet Gynecol 125(5):1268–1271
5. U.S. Preventive Services Task Force (2016) Final recommendation statement: depression in adults: screening. https://www.uspreventiveservicestaskforce.org/Page/Document/RecommendationStatementFinal/depression-in-adults-screening1. Accessed 2 Feb 2019.
6. Osborne LM, Hermann A, Burt V, et al. Reproductive Psychiatry: The Gap Between Clinical Need and Education. American Journal of Psychiatry. 2015;172(10):946-948. doi:10.1176/appi.ajp.2015.15060837.
7. Bolman LG and Deal TE (2008). Reframing organizations: Artistry, choice and leadership (4th Ed.). San Fransisco: Jossey-Bass.
8. https://www.brown.edu/academics/medical/about/departments/psychiatry-and-human-behavior/overview-training-dphb/womens-mental-health-fellowship-overview/womens-mental-health-fellowship-curr