Melanie Cole, MS: Today we're sharing this special episode of On the Mind, the official podcast from the Weill Cornell Medicine Department of Psychiatry. This conversation features Drs. Lauren Osborne and Alison Hermann. We discussed Reproductive Psychiatry and how to best support Women's Mental Health Across the Reproductive Life Cycle.

Dr. Daniel Knoepflmacher (Host): Welcome to On The Mind, the official podcast of the WoW Cornell Medicine Department of Psychiatry. I'm your host, Dr. Daniel Knoepflmacher. In each episode, I speak with experts in various aspects of psychiatry, psychotherapy, neuroscientific research, and other important topics on the mind.

Today, our focus will be on reproductive psychiatry, a crucial subspecialty that focuses on the relationship between psychiatric conditions and transitions in the reproductive cycle, like menstruation, pregnancy, or menopause.

The field of reproductive psychiatry emerged over the past 30 years, ushering in a greater scientific understanding of how shifts in sexual hormones affect the mental and physical health of women. On this episode, we'll provide an introduction to the field of reproductive psychiatry. We'll identify common conditions that emerge over the lifespan, explore the complex connections between reproductive hormones and psychiatric illnesses, and learn about advances in treatment that have revolutionized the management of postpartum depression and other disorders. 

Dr. Daniel Knoepflmacher (Host): We're lucky to be joined by not one, but two prominent reproductive psychiatrists on the podcast today. It's a pleasure to be able to welcome Dr. Lauren Osborne, an Associate Professor of Psychiatry and Obstetrics and Gynecology here at Weill Cornell, who is the Vice Chair for Clinical Research in the Department of Obstetrics and Gynecology. I'm also happy to introduce Dr. Alison Hermann, who is an Associate Professor in Psychiatry and the Clinical Director of the Weill Cornell Medicine Women's Mental Health Program.

As a colleague, I've personally learned a lot about Reproductive Psychiatry from both of you, so I'm really excited for this opportunity for our listeners to benefit from your great expertise. So, I'm going to jump right in. I want to begin by asking both of you to share your own stories. Lauren, how did you end up becoming a reproductive psychiatrist?

Dr. Lauren Osborne: Well, I definitely have had an unusual path. Medicine is a second career for me. I started out working in book publishing after college, and it was actually the experience of having my first child that got me re-exposed to the medical system and thinking about the possibility of going to medical school. I went to medical school because of an interest in reproductive science and was very much planning to be an OB-GYN and discovered though when I got into my clinical rotations that I did not like surgery, which is a major part of what OB-GYNs do. And I began casting around for other specialties where I could maintain that focus on the science of reproduction. And I ended up, after doing an elective rotation in women's mental health, deciding that psychiatry with a focus on reproduction was my path.

Host: And I think that there might be a crossing paths here, but I want to hear from you, Alison. What was your path?

Dr. Alison Hermann: Yeah. Thanks and thanks for having me. So, you know, I've always been interested in neuroscience and the human stress response and how hormones may interact with that. Actually, before I decided to go to medical school, I thought about doing a PhD in that area and decided that a clinical route was a better route for me ultimately.

So, I started residency actually thinking that I wanted to be a child psychiatrist and spent a lot of time early on in pregnancy exploring that. I like developmental systems. There's something just inherently hopeful about them. And the capacity for change is obviously quite large for children.

What I started to notice the more I worked with kids is that when kids were suffering, their moms were suffering, and when moms were suffering, their kids were suffering. And when I started to really look into what I could do about this, I was much more interested in working with the moms. So, I focused there for a while and found that when I could get the moms better, the moms were much better at helping their kids than I was. So at the same time, I was lucky enough to be at Columbia where they had just started a fellowship in Women's Mental Health and had an opportunity to apply and work with Betsy Fitelson and Meg Spinelli and all sorts of other great faculty members there, learning more in depth.

Host: And you guys both trained together. Am I right about that?

Dr. Alison Hermann: That's right.

Dr. Lauren Osborne: We did. We were one year apart in residency, and I actually did my clinical Women's Mental health fellowship training during my fourth year of residency, which was the same year that Alison was doing her Women's Mental Health fellowship under Betsy Fitelson at Columbia.

Host: And here you guys both are back at Weill Cornell, which is very lucky for us. Well, I want to talk about Reproductive Psychiatry. I've used that term and alluded to what it is, but I actually think it could stand some defining in our conversation. So, can you tell our audience what exactly Reproductive Psychiatry is?

Dr. Lauren Osborne: I think the simple way to define it is is to say that it's the field of medicine that deals with symptoms of psychiatric illness that arise at times of reproductive hormonal transition. And so if you pick that apart, you discover that what that means is psychiatric illness or symptoms that arise at the time of menarche, which is the pubertal transition, so when girls first get their periods, that arise around the times of pregnancy and postpartum, around the menstrual cycle, and around the time of the menopausal transition.

Host: Well, these are important transitions for more than half of the population, yet, as I alluded to in the introduction, this is a subspecialty within psychiatry that really has emerged over the past 30 years. So, I was wondering if you could tell us how it's impacted our general clinical practice in Psychiatry.

Dr. Alison Hermann: So, pregnant and lactating women used to be considered a "special population" within general psychiatric practice. Certainly, when I entered residency, this was something considered to be very much off the side, something special. However, as our field has matured, it's become increasingly recognized that this really is a substantial proportion of most people's psychiatric practices. The majority of people who seek mental health services are pregnant, recently pregnant, planning a pregnancy or at least planning a pregnancy some time prior to the termination of their services. Eighty percent of American women will have at least one pregnancy in their lifetime and half of those are unplanned.

So really, if you are a clinician working with a potentially pregnant person at all, it's just the responsible thing to do to educate yourself and know what to do in case of pregnancy. Beyond that, there's been an increasing recognition, not just pregnancy, but also in other times of reproductive transition. Things like the menstrual cycle and menopause can hugely affect how psychiatric illness presents itself and how we might approach the treatments.

Dr. Lauren Osborne: I think that leads us into, you asked about changes in clinical care, and as this field has grown and we've recognized more and more the need and the fact that there are these 80% of American women who will have a pregnancy, we've realized that the mental health workforce has nowhere near the capacity to to handle that, and that has led to a lot of creative solutions involving people from other specialties, and particularly a lot of interest around involving OB-GYNs in treating these illnesses. Very few women will actually approach or go into psychiatric care without being prompted or pushed in that direction, but 98% of pregnant women do have some degree of prenatal care. So, that's the frontline. That's where we can identify these women, diagnose them, and make sure that they're getting into treatment.

So, one of the major things we have done is start to have what we call collaborative care programs where mental health services are embedded within the OB-GYN setting. And what it does is asks our obstetrician colleagues to learn how to treat people who have mild to moderate symptoms, people who have, you know, not complex psychiatric illness, but more garden variety anxiety and depression. And we work together with our OB-GYN colleagues. We have a program like that here at Weill Cornell, where I serve as a psychiatric consultant. I guide and teach my OB-GYN colleagues how to treat mild to moderate symptoms. I have behavioral care managers who work with short-term psychotherapy with patients and then, we can escalate over to folks in the Psychiatry Department when we have a greater need that's too complex for the OB-GYNs to manage. And that allows us a stepped care where we're preserving the resource of the trained reproductive psychiatrist for the most complex cases and spreading that expertise out across a wider population.

Host: This is a really helpful definition and expansion on what Reproductive Psychiatry is and does. And I think an important component of what you're both talking about is education. Obviously, there's the clinical care, which is, as you said, Lauren, a limited resource in terms of the number of clinicians.

But I know, Alison, when I was a trainee and you were a supervisor, learned a lot about how to manage things during pregnancy. And I think even called you a few times after I became an attending. So, I want to touch on this idea of education. And in fact, the two of you were coauthors on a commentary in the American Journal of Psychiatry back in 2015. And you described a gap between the clinical need versus the amount of education that was provided in Reproductive Psychiatry. So, I'm wondering if you guys could tell us about this gap. And then also, that was written in 2015, have things gotten any better?

Dr. Alison Hermann: For being the most common complication of childbirth and a very common presenting condition, in general, psychiatric practice, it is not the standard for most residency programs, either in psychiatry or in OB-GYN, to teach their residents how to manage psychiatric illness over the course of pregnancy and lactation, or at other points in the reproductive life cycle. So, it's not so common at all for residents to have the opportunity to learn here.

Dr. Lauren Osborne: And I would say that, you know, you asked what's changed since 2015, when we first wrote that paper, we pointed out that Reproductive Psychiatry is not a requirement from the ACGME for education in either psychiatry or OB-GYN, as Alison mentioned. It still isn't nine years later. But what we do know is that residency directors are increasingly interested in this. We did a survey of residency directors that showed that everybody thought this was an important area, but that there were a lot of barriers to treatment. One being that it isn't a requirement, and there are so many others. And another being that they felt they didn't have qualified faculty to teach.

What we have seen in the nine years since we published that commentary is a huge explosion in the number of post-residency fellowship programs for women's mental health. The first one was founded in 1998. The next one not until 2006. And we now have, I think, it's 19 or 20 is the current number of fellowships across the country and a growing interest on the part of residents to demand this education and a significant number of residency programs that despite the ACGME do require it. Here at Weill Cornell, all of the third year residents rotate through Alison's program. So, there is increasingly teaching, but we have to get to that next level of making it required.

Host: And as a training director, I can emphasize that. And I know that our residents value this highly. It happens that a number of them go on to become reproductive psychiatrists in no small part, I think, because of the great mentorship and teaching.

Dr. Alison Hermann: I would say for that, I know,. Lauren, one of the barriers cited in your study of program directors was not having enough available faculty with the right expertise to be able to teach the residents. So certainly, it's something that both Lauren and I have been working very hard at over the last decade, trying to increase the numbers of people out there that have this expertise that can go out into their own careers, their own settings beyond Cornell and Columbia to teach others.

Dr. Lauren Osborne: So, I can't resist putting in a plug here for an educational program that I'm involved in and that Alison was involved in at its inception, which is called the National Curriculum in Reproductive Psychiatry. We started this because we found that one of the other barriers that residency directors mentioned was not having materials to teach, but not wanting their residents to just go on a computer and learn something. So, a group of us who are passionate about it created a web-based curriculum that's meant to be downloaded and used in the classroom teaching in residencies. And anybody can teach it who has a mental health background. You don't have to be a reproductive psychiatrist because we give you all the answers.

And that curriculum has really taken off. It's used in a modular fashion in a number of residency programs. And it's also recently been morphed into a three-day CME event that we have once a year, as well as a virtual didactic program for Women's Mental Health and Consultant Liaison Fellows. This year, we had about 50 fellows from around the country participating in a year-long didactic series to learn this curriculum. And it's standardized and every one of those programs is getting the same teaching, which we think is a crucial thing that we need to do out there, because all of these fellowships have arisen without any kind of accreditation and standardization, and we need to make sure that people are learning what we think they should be learning.

Host: This is amazing because you guys actually wrote that article in 2015, and then you helped close that gap with all of this work that you're talking about. I want to pivot to another area that's important, which is research. Can you talk about some of the most notable discoveries that have been made in this field?

Dr. Lauren Osborne: Absolutely. I get really passionate about education, but a much larger part of my job is doing research and conducting research, and there have been some really exciting developments over the last few years.

One that I can point to is a program called PPD Act, which is run out of the University of North Carolina with Dr. Samantha Meltzer-Brody, where they're trying to solve the genetic contribution to postpartum depression. And they created an app, and they have asked women around the country to contribute saliva samples for which they are then looking at the genes that are implicated in postpartum depression. And this is a way of getting a huge number of samples from people around the country rather than the limitations of a local research study. So, that's a pretty exciting development.

And then, I think there's been a lot of great work in neuroactive steroids, which are for our purposes, metabolites of progesterone that can act on the brain. And we all know that progesterone increases drastically across pregnancy and also varies across the menstrual cycle. Progesterone, progest state, right? And so, these metabolites of progesterone have really important functions, and we've had a lot of interesting basic science research in disentangling what are those functions and how are they implicated.

The last really exciting research finding that I would bring up is a team now at the University of Virginia and at the Royal Hospital in Ottawa, Canada have a set of epigenetic biomarkers that predict the development of postpartum depression with a high degree of accuracy. They've replicated this finding I think about seven times and they're now taking it to market as a commercial test, a blood test for postpartum depression. So, I think those are some major advances that have been really exciting in the field. My own personal favorite is the immune system. I just think it's really interesting, and I think we're not quite as far there as we are with some of the other areas, but increasingly having research that shows that immune dysregulation may also play a part.

Host: Wow, a lot going on. And I want to talk about how some of that translates into treatments, because there's been some big advances in that area. Alison, could you maybe speak to some of the exciting treatments that have emerged from Reproductive Psychiatry?

Dr. Alison Hermann: So, Lauren mentioned neurosteroids and that's been really a hotbed of new treatments is that area. New drugs that have been developed and approved by the FDA over the last few years, brexanolone and zuranolone are two new neurosteroid treatments that have been FDA approved for the treatment of postpartum depression. There are others that have been studied and there are some neurosteroids that have been studied in other kind of reproductive mental health conditions like premenstrual dysphoric disorder and perimenopause.

The cool thing about these treatments are we've known that neurosteroids have been relevant to the formation of depression and the treatment of depression for some time, both in men and women. But because they have such a significant role in reproductive depression, we were able to see a very robust response in our postpartum population. So, it's opened up all sorts of opportunity for treatment and all sorts of new research questions. Why so much more in this population than others? Why so much more in some populations of women than others? The cool thing about these treatments is that unlike other treatments for depression, they can be episodic. You don't have to take them every day over a long period of time, and they're extremely rapidly acting. And so, for people who are interested in a very quick response and a response that they don't have to continue over months or years, it's something that's very enticing.

Dr. Daniel Knoepflmacher (Host): Quick responses and short term treatment. That is not the norm in psychiatry. So that is a really exciting development in our field. I want to ask you about another more recent aspect of this.

and that's the transition from these medications being delivered as infusions to them being available as oral medications, which I think is an exciting development as well. Can you speak more about that?

Dr. Alison Hermann: That's right. So, brexanolone is an infusion, a 60-hour infusion that requires a 72-hour monitoring period. It doesn't necessarily need to be inpatient, but it does need to be monitored the whole time. And so, that's been logistically challenging to treat a psychiatric condition that requires that amount of medical monitoring. With zuranolone, we've been able to overcome some of those barriers. So, this is an oral formulation of pretty much the same neurosteroid. And the advantage obviously is that it can be taken in the home. It doesn't have to be in a medically monitored setting.

Host: Thank you. We could do a whole episode just on this topic. But I want to turn to the two of you, given we've talked about breakthroughs in research and practice and clinical work. Can each of you share a project that you're working on that's really exciting to you in this field?

Dr. Lauren Osborne: So, I think the project I'm working on right now that I'm most excited about is a project looking at the role of extracellular vesicles in perinatal mood and anxiety disorders. And you know, I mentioned earlier that the immune system is my personal favorite. But a lot of the research in that area hasn't really proved what role the immune system has. There have been different studies using different markers and different ways of measuring the mood and anxiety disorders. So, we can tell there's a role, but we can't quite tell what it is.

A new study that I've been involved in though has sort of pinpointed that by looking instead of at circulating immune markers like cytokines, we looked at extracellular vesicles that are circulating in the body, so very easy to measure in the blood. But they have blebbed off of immune cells, so they're telling us more what's going on in the immune system. The particular ones that we studied were derived from monocytes and macrophages. And what we found was an extraordinary difference in the kind of mRNA communication that's going on in those extracellular vesicles for women who were euthymic in pregnancy and either did or did not develop postpartum depression. And it was a very large effect size, so we were able to see it with a very small number of women. And it was, again, a biomarker. It's something that predicted the development of the illness, so something that could be turned into a clinically useful test in the end if we replicate it appropriately. We don't right now know if it's something specific to pregnancy or if it's a marker of impending mood episodes across the board. And so, we're conducting research now to try to make that determination.

The reason that I think something that could turn into a clinically useful biomarker is so important, is that we have such a stigma against mental health in this country. And people think of psychiatric diseases as not real diseases. They think of psychiatrists as not real doctors often. And having something like a blood test that shows that there's a biological component to these illnesses will go a long way toward combating that illness. It's also going to go a long way toward helping us treat people. Because right now, only about 3% of women with postpartum depression are actually treated to remission, which is a shocking statistic. We don't accept doing that badly for any other kind of illness. And if we could predict better who is going to become ill, we might do a better job of hooking people up to services. Access is a big problem. Availability of services is a big problem. And if we could make that match a little closer with a predictive test, I think that would go a long way toward helping women.

Host: So, the dream would be this would be part of like a prenatal panel.

Dr. Lauren Osborne: Exactly. You could just get the blood test when you get all those other screening tests in pregnancy, and that could predict whether you're at risk. We already look at whether people are at risk for gestational diabetes or preeclampsia or other complications of pregnancy. Postpartum depression is another one of those complications.

Host: Amazing. And Alison, tell us about some work that you're doing.

Dr. Alison Hermann: So, the project I'll talk about is something I'm doing in collaboration with Jonathan Powers and his lab. So, Jonathan is a physician scientist who's very interested in imaging work and particularly interested to see if he can find a biosignature for reproductive depressions, you know, within the neural circuitry. He and I have partnered because I'm also very curious to see what reproductive depressions look like in neural circuits, but also how that relates to what I'm seeing in the clinical realm. So, I know I'm talking about research here, but I spent 80 some odd percent of my work one on one with patients doing clinical work. It's been a point of frustration for me over my career that reproductive depressions, as well as reproductive anxiety disorders, look differently than these illnesses look when they're not associated with hormonal changes. And that has not been recognized in any sort of formal way in our field. The DSM, even though it has a specifier for postpartum onset for depression, there's no separate criteria or no separate sort of description as to how to recognize these illnesses.

So, what Jonathan and I are doing to try to improve that is we've developed something called an ecological momentary assessment tool. It's a digital qualtrics survey that we're able to push out to folks on a daily basis just to check in on what are they experiencing from a mental health perspective, what are they experiencing physically over a period of what we know will be a reproductive transition? So, they have a project going in pregnancy and lactation. We also have one going across the menstrual cycle, and we plan to do this as well across the menopausal transition. And we already are seeing some fairly reliable patterns when it comes to how sleep deprivation affects certain psychiatric conditions; how weaning, for example, can trigger dysphoric reactions, et cetera. And so, I'm hoping as we gather this data, we may be able to submit it for more formal recognition.

Host: So, the DSM-5 or whatever, six, we come to would identify these as a separate entity and as a diagnosis potentially.

Dr. Alison Hermann: We talked earlier about education in this area, but some of this education just comes from the codification and something like the DSM. It's not so easy to recognize a reproductive mood or anxiety disorder without having seen it a bunch of times because it's not described anywhere, right?

Host: And you're teaching it directly to our residents, but this is wider than that. Well, thank you guys. I know that's not all the work that you're doing, but those are both really exciting examples. I want to pivot to the treatment side of things and think about listeners who might be out there who could really benefit from the wisdom that both of you hold as they're navigating challenges that arrive during phases of reproductive hormonal change. So, I'm just going to go through a few of them, which you guys have mentioned, and ask you to respond. So, what advice would you have for women who are planning a pregnancy?

Dr. Lauren Osborne: I think the most important advice I have is preconception planning. It's really important if you're a person with psychiatric illness to carefully plan pregnancies so that you can consider what are the effects of any medications that I might take, what are the effects of my illness itself on the fetus, and let's make a plan with the psychiatrist beforehand. You know, a lot of pregnant people and a lot of doctors will sort of knee-jerk stop medications for pregnancy, and that isn't consistent with what the literature shows us. There are many medications that are compatible with pregnancy, but we want to minimize the number of exposures to the fetus. So, we want to have a careful plan about how to make the best use of medications that you're on, and also how to consider the illness itself and exposure that's toxic to the fetus. And those considerations are different for every woman, so that preconception planning is absolutely vital.

Host: And again, the take home-point there that there might be a knee-jerk reaction that medications are not a good choice, but in fact, for the health of the mother and the baby, that actually sometimes medications may be the better choice, which is not always known.

Dr. Lauren Osborne: Exactly. And what I tell patients who come to me with psychiatric illness is there isn't a risk-free decision, unfortunately. They have a chronic illness and that poses a risk in pregnancy, just as diabetes or hypertension or any other chronic illness would pose a risk in pregnancy. Our job, meaning my job as the doctor, and her job as the patient is to figure out what's the lowest risk path forward. How can we minimize the risks to both mother and baby so that we end up with happy mother, healthy baby?

Host: A corollary to this situation that we just discussed is IVF or other fertility treatments, which are quite common and present a hormonal shift. I'm wondering if you could tell us about what to think about in that area.

Dr. Alison Hermann: So, it's enormously stressful to undergo a fertility intervention. And when we look at this population, both men and women who are undergoing fertility treatments have about double the rates of postpartum depression, which in itself is about double the general population. So, this is a population of patients that has a four times the risk for depression or anxiety compared to the general population.

It is important to treat, you know, chronic psychiatric conditions that precede the fertility interventions because just for that person's overall health and well-being and ability to withstand the stresses of fertility treatments, it's important. But also, there can be some negative effects of depression and anxiety on fertility itself. So, going into fertility treatments in the best mental and physical health that you can is important.

That being said, if the stresses do take a toll and there's a worsening over the course of those treatments, which there often is, medications tend to be less helpful than the psychosocial treatments. So, what I would recommend for folks who are starting to struggle with their mental health during a fertility intervention, or maybe even before they start to struggle, is to seek out a psychotherapy or some other social supports or other ways of supporting mental health throughout that experience.

Host: And another area that's common that certainly comes up in all of our work as psychiatrists is thinking about the menstrual cycle and how that can impact somebody's cyclical mental health. Can you speak about PMDD and other related things that come up that you guys deal with as reproductive psychiatrists?

Dr. Lauren Osborne: Yes. And I think this is an area that's confusing to a lot of people. We have a lot of different definitions and something like 80% of women have some kind of premenstrual symptoms. They might be physical, they might be emotional, and women who have some kind of symptoms that don't interfere with their life or their ability to do what they need to do, we would call that premenstrual syndrome. So, they may have mood symptoms, they may have physical symptoms. But then, there are women who have premenstrual dysphoric disorder, which is a much more severe condition. It only affects 3-8% of the population, so a very small number. But it's a very impairing illness, and this is a case where women will not have symptoms at all in the rest of their cycle, but will have severe and impairing symptoms during the luteal phase or during some portion of the luteal phase, so that second half of the cycle after ovulation.

But women who have symptoms in the luteal phase don't necessarily know if they have PMDD or maybe they have depression and it just gets exacerbated or gets worsened in that premenstrual period. Most women who have a mood disorder will have some kind of premenstrual exacerbation. And I think there's a lot of misunderstanding among both patients and doctors about the difference between those two things, and it's crucially important because the treatments are actually different if you have an underlying mood disorder versus if you have premenstrual dysphoric disorder. So, the advice I would give to patients is if you think you have a premenstrual mood syndrome of some sort, seek advice from an expert, seek out somebody who is going to do a really careful job diagnosing it. It actually requires two months of prospective mood ratings across two menstrual cycles to diagnose PMDD. And I think it's really important to do that to understand what the best treatment is.

The other thing that I would advise people is a lot of people say, "Well, this is a hormonal thing. I need a hormonal treatment." Well, in some cases, yes, and in some cases, no. And there are other pharmacological treatments and there are also psychosocial treatments that can be really helpful. Cognitive behavioral therapy, for example, can be really helpful in PMDD as an adjunct to a pharmacological treatment. So, I guess the main thing is go see a doctor who's an expert in this area.

Host: Very, very helpful advice and clarifying. Thank you. I want to talk about later in the life cycle the transitions that come with menopause. What advice is there for this period?

Dr. Alison Hermann: Menopause is hard, right? It's such a complicated sort of life transition. These sex hormones affect every single organ in the body, every single cell functioning. And so, it's a really complex system. Partly because of that complexity, there really is a dearth of research around how to sort through what's normal, what's not normal, what sorts of treatments might be an option, what's not, what works, what doesn't. And there tends to be a lot of individual variation as well. There are few women who will get through menopause with no symptoms at all. This is something that most people are going to have some challenge around, and how much challenge they have is often difficult to predict. It is a period of risk for a resurgent or even new-onset mood or anxiety disorders around that menopausal transition, but it doesn't seem to be a period of risk for everybody. There seems to be a vulnerable population.

And what we do about symptoms when they do come up again is highly variable from person to person. So for some people, lifestyle interventions are the best. Good sleep hygiene, avoiding caffeine and alcohol, making sure that you have regular exercise, seeing friends and doing other stress management interventions can go a really, really long way in this population. Others do best on an antidepressant, particularly if there are vasomotor symptoms like hot flashes or night sweats or if there are anxiety or depressive symptoms, antidepressants tend to be some of the best interventions. And for others, hormone replacement therapy is the best way to go. So, it is important to work with a gynecologist who has some sort of specialty in menopause and/or a mental health practitioner who has some sort of specialty in this area to sort through it all because it's just so complex.

Host: Well, hopefully more research will emerge, because it sounds like it's a ripe area for further exploration. I want to turn to another area that is an area of change and growth in medicine, and that's with the focus on transgender health. There's been an increase in people undergoing gender-affirming hormone therapies. And here again, we're talking about sex hormones, sexual hormones. So given the complex role of these hormones, as you guys have explained brilliantly today in mental health, has this been a focus within the field of Reproductive Psychiatry?

Dr. Alison Hermann: Not so much so far. We are just starting to ask these questions in a more formal way. So, questions are being raised. Answers are largely yet to come. One thing I will say through just some of the clinical experience I've had working with individuals, going through these transitions, I would encourage folks to think about their family planning early on in this process when they're considering a transition, because it can be very helpful to have a consultation with a reproductive endocrinologist to figure out what your options are for childbearing and childrearing in the future.

Host: And do you think there's going to be research or education around this within the field of Reproductive Psychiatry? Do you see movements towards that?

Dr. Lauren Osborne: I definitely do. And I think one perfect example is a few years ago, we created a textbook that was a spinoff of our curriculum. And we have an introductory chapter that's called What's In A name, because the name of the textbook is the APA Textbook of Women's Reproductive Mental Health, but not everybody giving birth identifies as a woman. And we felt at the time the textbook was published, that there just wasn't enough information out there to broaden that. But we recognize that that is an issue and a growing level of concern. We have a new transgender module for our curriculum that's going to be rolled out in the next few months. So, there's growing interest in doing it.

One of the problems with research though is when I enroll people for studies where I'm looking at hormones of the immune system, people who are transgender have a different hormonal milieu than people who are natal women. And so, you can't necessarily mix the same studies. You need separate studies and the population so far is relatively small, so you'd need to do a study that spanned the whole country instead of a local research study. So, we're still grappling with how best to do that research.

Host: So, an area for more development. I've asked you guys questions about all of these specific transitions. I want to pull back and ask a more general question, thinking about somebody who's out there struggling with illness during transitions through their life. I want to ask the question from a different frame, which is when should somebody consider seeing a reproductive psychiatrist?

Dr. Lauren Osborne: I kind of think that there are two answers to that. I think there's the ideal answer and then I think there's the realistic answer with the workforce that we have. I think the ideal answer is anybody experiencing mood or anxiety symptoms at a time of reproductive transition or anybody with psychiatric illness who is anticipating going through such a transition should see a reproductive psychiatrist. But we also know that in this country there are around 20,000 obstetricians, around 20,000 psychiatrists, and my estimate is about 500 trained reproductive psychiatrists, and no certification to tell us who actually has the training or who's just calling herself a reproductive psychiatrist. So, I'd like to say go at all those times. I'm not sure that's realistic given the workforce, so we have a lot more work to do.

Host: That's really clarifying. And again, I just want to highlight something really important you said, which is illnesses that emerge during those transitions, or you have a history of mental illness and you're going to go through one of those transitions, that those are two times, because they are different and important distinctions.

Well, I'm going to finish with a question about resources. What do you recommend for people who want to educate themselves? As you pointed out, they may not have access to a reproductive psychiatrist. So if they want to educate themselves on these topics related to Reproductive Psychiatry, where do they go?

Dr. Alison Hermann: For professionals, I recommend trying to engage with a professional society. We do have a few professional societies in Reproductive Psychiatry. So for example, the Marcé Society or the American offshoot of that is MONA, Marcé of North America. Postpartum Support is another good one. It actually connects professionals and folks with lived experience in this area. And so, you not only can educate yourself, but you may also be able to increase your experience working with this population, which is terrific. The Massachusetts General Hospital website has a terrific resource page with a lot of information about reproductive mental disorders and a blog site. Ruta Nonacs is a reproductive psychiatrist who will regularly review papers that have caught the attention of the national media. So if something comes out that is of interest, you can get her take on it and learn from that. Lauren, do you want to talk about some of the resources you've developed?

Dr. Lauren Osborne: Yeah. I think this is primarily for professionals rather than patients, but I mentioned earlier the National Curriculum in Reproductive Psychiatry, which has 13 web-based modules. It's free to access. Anybody can use it. Although it's designed for residency curriculum, you could learn it on your own, and many people have done that.

The offshoot of that, which is the APA Textbook of Women's Reproductive Mental Health, which is the curriculum in textbook form. And then, a new resource that we're developing and should be up on our website this summer, which is that curriculum adapted for obstetricians and gynecologists. We learned in doing it that psychiatrists don't mind lengthy case descriptions and detailed discussions. Obstetricians want bullet points, so we've created something for the obstetricians.

Host: Know your audience, I guess. And what about patients?

Dr. Lauren Osborne: For patients, I think, Postpartum Support International, which Alison mentioned, is the go-to site because it's got information to educate people, but it also has resources like referral sites for every single state in the nation. And then, if you want something like facts about different medications in pregnancy, there's a great site called MotherToBaby that has fact sheets on most medications we use in pregnancy and also a lot of just information.

And then finally, here in New York, we have Project Teach, which is a Psychiatry Access Program, so doctors can call in and get a consultation with a reproductive psychiatrist. But it also has a number of patient-facing materials for people to educate themselves on Reproductive Psychiatry.

Dr. Alison Hermann: I would also add for patients who are interested in this information, consider participating in research. There's lots of research opportunities out there and so much to learn. Many very simple questions that we're still asking can be answered with your help, so see if you can sign yourself up.

Host: Well, that was a wealth of resources and we're going to see if we can get at least some of those, if not all of them, up on the website when we're posting this podcast episode. Lauren and Alison, thank you so much for joining me today on this episode of On The Mind. I mean, I've learned so much. Every time I hear you guys give talks or I speak with you, I always learn things. And I know that all who are listening to this episode are probably emerging with a better understanding of the important role that Reproductive Psychiatry plays in women's mental health across the lifespan and hopefully got some tips on how they can help their patients as they struggle with these transitions.

So, I'm always eager to learn more from you. I'm looking forward to all of the things that you guys have ahead in the future developments in the field. Thank you so much for joining me today.

Dr. Alison Hermann: Thanks for having me.

Dr. Lauren Osborne: It's a great pleasure.

Host: And thank you to all who listened to this episode of On the Mind, the official podcast of the Weill Cornell Medicine Department of Psychiatry. Our podcast is available on all major audio streaming platforms, including Spotify, Apple Podcasts, and iHeart Radio. If you like what you heard today, tell your friends, give us a rating, and subscribe, so you can stay up to date with all of our latest episodes. We'll be back soon with another great episode.

Melanie Cole, MS: We’re so glad you joined us for this special episode of "Women's Health Wednesday.” We hope you'll tune in and become part of a community--and a fast-growing audience--of women looking for knowledge, insight, and real answers to hard questions about our bodies and our health. Please download, subscribe, rate and review Back To Health on Apple Podcast, Spotify, Pandora and Google Podcast.

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