Caitlin Whyte (Host): Welcome back to In Their Words. Today, we're joined by Dr. David Silver, a key figure at UPMC Women's Behavioral Health. Dr. Silver's insights offer a deeper look into the critical care provided to women like Ashley Fox, whose story we heard in our previous episode. His passion for women's mental health shines through, as he explains the vital role of their specialized services.

Dr. David Silver (Guest): My name is, David Silver. I am the Director of Women's Behavioral Health here at UPMC in Central Pennsylvania. I've been here since 2018, when my wife and I, developed this service line, which has grown significantly since then.

We expected a lot of challenges and of course there were some, but we were pleasantly surprised with how we were welcomed into the department of OBGYN or the women's service line as psychiatric providers for the OB GYN services and their patients.

And that is really how we introduced ourselves to the system. We approached the system with this idea before we were hired. And the system was very welcoming to this need in the community, took us in and we really started this from scratch. In fact, we started it without even an office space.

And I would go from OBGYN office to OBGYN office into our cancer center practices to see their patients in their offices until we had our office space built out, which was about six to nine months. Our practice was kind of on the road. It was really an interesting way to start. And in fact, I would do it again that way because once we got into our office, we were so well known because we were actually in their offices looking at the providers that were referring to us working with their patients in their office.

They actually felt our presence and when we started our practice in our new office space, the referrals were just flooding in. And so it was a really interesting way to start that I would never have chosen, but in retrospect was very effective. When we got here, I think the OBGYNs had already recognized the need, because of specific patient cases that had happened within a year or two prior to our even introducing ourselves to this system. So we benefited unfortunately from some bad outcomes in the community in getting us here. And the outcomes, unfortunately, in the state as a whole, continue to be alarming.

 I sit on the Maternal Mortality Committee for the state and I have since its inception in 2019. And it is alarming at how many bad outcomes there are from pregnancies related to mental health issues.

 And so this is not a problem that was exclusive to our system, but fortunately for our practice, the system was aware of the problem, I think, before most institutions and welcomed the help. So we really came into Women's Service Line that was ready to have us. We treat women's behavioral health or reproductive psychiatry is a more appropriate term for this, is psychiatry for women who are in specific vulnerable times in their life for psychiatric symptoms. And those time points are related to what we call the reproductive life cycle, which just means times in a woman's life when we would expect normally that there are going to be large, or rapid changes in reproductive hormones.

And there are, generally speaking, three time points. One time point is the premenstrual phase of a menstrual cycle. So, the week or so before menstrual cycles can be really highly symptomatic with mood and anxiety symptoms to the point where women have dysfunction. You can think of it as PMS on steroids, basically.

Host: As Dr. Silver delves into the scope of their practice, we gain a clear understanding of the diverse needs they address. From pregnant and postpartum women, to those battling cancer. UPMC women's behavioral health stands as a beacon of hope for many.

Dr. David Silver (Guest): And that is a group of women that we take care of. That's a small group. The largest group is those people who are pregnant and postpartum. So we'll take care of any woman who is pregnant or lactating, breastfeeding, who is being treated for psychiatric illness. Because many psychiatrists are not comfortable treating women in this time period.

And it is a really important time period to be well treated, because it's a vulnerable time period for worsening symptoms. We will also treat any woman who develops symptoms in that time period. So, everybody is starting to be aware of postpartum, or what we call peripartum depression, which is depression resulting from the physiologic changes of pregnancy and postpartum.

So that is a big part of what we do. So both those with pre existing disease or disease that develops in pregnancy and postpartum are, make up the bulk of our patients. And then the third group of patients that we see, and again, it's a much smaller group, are those women who are not yet in menopause, but are starting to approach it, the perimenopause, which could be two to seven years of time when they are starting to get irregular periods and hot flashes and symptoms that I think people understand pretty well for perimenopause.

But what is not understood is that that time period also is a vulnerable time for about 15 to 20 percent of women to develop mood, anxiety symptoms, and also some cognitive symptoms that we can help them with. So those are the three time periods where we see and treat patients. And that's really what we do from the standpoint of reproductive mental health or reproductive psychiatry.

Now, a slight, difference in our women's behavioral health practice compared to other women's behavioral health practices in the country. And I say in the country because there really aren't many women's behavioral health practices. But in this region, we serve a large part of the population.

But in addition to the reproductive psychiatry that we do, I also will see patients, women with cancer diagnoses who are having distress, because as you, may remember, I am a Board Certified Gynecologic Oncologist who was in practice for 15 years treating surgically and with chemotherapy, patients with gynecologic cancers.

And that population is still a population I feel very connected to and I'm happy to continue to help out with, but from the mental health standpoint at this point in my career. We see everybody, to answer simply, but what, what I think should be recognized, if it's not by people listening, is that the, those people who are in low economic situations or in underserved populations; those are the populations that need this service most.

We accept all insurances, all from medical assistance to private coverage and even some self paying patients. So I, our door is open to those people who are in need of this service. But clearly, the underserved populations or underrepresented populations are those populations that are struggling the most with these problems.

 Honestly, we rely, and I do think the UPMC system does a good job with outreach and awareness making communities aware of what's available.

I can't say that our practice, in particular, has had awareness or outreach efforts without guidance of the system as a whole. But from how do we get our patients, I think that is wrapped into your question and I would say that our patients are largely referred into us by other doctors, and that's why joining the Women's Service Line was an important thing to me when we were looking around to see where we wanted to end up.

And so being part of the Women's Service Line makes us perceptually more available to these referring doctors. Our patients are largely referred into us by OBGYNs, also by the primary care physicians in the region. But our cancer folks are almost exclusively referred in by the oncology services in the area.

That extends beyond our system. But the oncologists in the region are aware that we're here for women with cancer and we get referred all sorts of women of all levels of the community to see us. And I will also say our community extends pretty far out. I mean, we see patients all the way out to Pittsburgh and all the way out to Philadelphia and all the way down to the state lines of Maryland and up to the state line of New York. We really have a large catchment area for our patients.

Host: The conversation shifts to the challenges of awareness and outreach. Dr. Silver's words, echo the importance of visibility and ensuring that those in need can find the help they deserve.

Dr. David Silver (Guest): So I can say I remember the case well and I can say that we are fortunate that in this niche of psychiatry when we treat patients, we usually see really good outcomes. And it's not meant to be a self fulfilling comment. It's just the way this is. If patients are treated appropriately, they will have good outcomes. And I say that as a hopeful message to anybody who's listening. There is a good reason to get treatment. It works, right? And so, if you get it, there's a high chance that you're going to get a good outcome. So, despite the fact that it happens so frequently, every time we see it, it is heartening for us.

It reaffirms to us why we're doing what we're doing and how important it is to people. So I can't over, overestimate how it does feel because I don't think it's possible to overestimate it. And all I can say is that we're really fortunate to have patients that recognize the importance in their own mental health care and allow us to help them get to this place where they can move on beyond pregnancy and continue to lead a more productive life and a more satisfying life than they would have.

And as important, maybe more important, because I have a doctor's view on this, a healthy life, because people are starting to recognize the fact, not the opinion, but the fact that these are medical illnesses. And when you have symptoms, you are unhealthy. And so not having symptoms makes these people healthier, let alone more productive and more comfortable and happier, all of which are as important.

They are healthier. They will live longer. They are less likely to develop physical ailments down the road. It is why we're here. And so, when we hear these things, it's as much accomplishment as I could possibly feel about something. That is the pinnacle of what we want to accomplish.

So, these are the things that keep us going because, days are long and these problems are heavy. And so, having results that support the work that we do, collectively, I will say. And when I say collectively, I do mean not only amongst the therapists and prescribing providers, but also the patients included in this work. When these things are accomplished collectively, there is nothing better that we can get out of what we're doing. This is why we're here.

Host: As we explore the impact of financial support, Dr. Silver highlights the ongoing need for resources in mental health care. The UPMC Pinnacle Foundation support of the Women's Behavioral Health Fund emerges as a crucial element in their mission to help those who might otherwise go without care.

Dr. David Silver (Guest): So, as I think many people are aware, while there is greater recognition of the importance, I think, of mental health, and mental health care, it is still frequently lagging behind in things like support and funding.

So, having the support of the Foundation and a fund where money can be collected to help us move things forward, is not only critical for us to move forward, but really is appreciated by us and anybody who's involved, I think, in mental health care. So, yeah, I, think, unfortunately, it is not done enough, and fortunately for us, we are at a place where it is being done, and it's, very much appreciated.

Where we are right now is, I believe we are the place to come to in central Pennsylvania for this sort of service. And we are looking to move to the next level, which would include not only the services provided now, which are fairly exhaustive, but some added services like TMS, which is not a medication but a non medication intervention for depression and anxiety.

Like having a partial program or intensive outpatient program connected to our practice so that we can see outpatients like we typically do and at the same time, be available for those outpatients that need a higher level of care. Patients that might benefit from stopping by for care every day of the week, Monday through Friday.

This is not something that is a typical outpatient psychiatry practice we can provide right now, and there is no maternal IOP available in Central Pennsylvania. The closest ones are hours away, not one, but three, four, five hours away to get to the closest. So, it's not something that's possible for a pregnant woman to go to on a daily basis.

So, we would envision our practice growing in a way that we would be able to to provide that additional level of care as part of our practice and connected to our practice. People who are pregnant or postpartum with little babies, not only have the stigma of mental health that every other individual has, but they also have the stigma of thinking that people think they are not good parents because of their mental health issues.

These patients should not, in my opinion, be mixed in with the general psychiatry services because they won't show up to those services. However, if we have those services like TMS, like an intensive outpatient service where it's exclusively for moms, pregnant or postpartum, they will show up and we will do extra things like have maybe a daycare service attached to that so that they don't have to worry if they don't have people who can take care of their kids.

They just come, we'll watch their kids while they are getting their care. Things like that, that will go, you know, the extra yard to take care of patients. That's where I envision us moving clinically. And in addition, we will move forward in training OBGYNs to have a better understanding of how to treat patients with these problems.

Because they're the first line. They're the people that identify these people. We want to train OBGYNs to be comfortable with these treatments or at least to initiate the right treatments and then maybe refer out. But if we can get enough OBGYNs trained to put a trained OBGYN into every one of our system's, Outpatient OBGYN offices, that will go a long way to taking care of our community because there won't be this boundary of identifying somebody who needs care in the OBGYN office and then waiting until they get to the psychiatrist's office, our office.

Some of those patients never show up. If they do show up, they may not show up right away. So there's a lag time. So that would be another part of where we want growth. And then the third part of growth would be with continued research in these patient populations and disease states, which we are starting to do at a low level and hope to grow into.

So we really want to have a whole institute of reproductive psychiatry here in central Pennsylvania.

Host: Dr. Silver's vision for the future of women's mental health care, is both inspiring and ambitious. His words, paint a picture of a comprehensive institute, dedicated to reproductive psychiatry in central Pennsylvania.

Dr. David Silver (Guest): I appreciate that we have time on your podcast, and I appreciate the continued interest the Foundation gives us. I can only say this, and this is certainly a biased statement, I think that the Foundation's interest in this set of problems for our community is not only welcomed, but can never be enough, honestly. These problems are huge problems that are only just being recognized. And they are problems that are treatable.

So there is such a if you look at the cost benefit on this, it's really in so much in the favor of doing it, right? Because if you do it, they get better. It's not the kind of disease state that if you do it, they're not going to get better, most of the time. They are going to get better. And so, so if the more we can get patients treated, the more good outcome we're going to see.

And I think there must be a way to say it clearer than I just did, but I hope the message is clear. We welcome all support. We feel very fortunate to have you all behind us. So I just want to say thanks.

Host: As our conversation with Dr. Silver draws to a close, his gratitude for support and his unwavering commitment to his patients, shine through. His final thoughts serve as a powerful reminder of the transformative impact of accessible mental health care for women. Please, don't forget to rate, review and share this podcast.

Thanks for listening to stories from UPMC in central PA and the UPMC Pinnacle Foundation. Until next time. Take care.