Reproductive psychiatry: giving birth to a new subspecialty

What is ‘Reproductive Psychiatry’ and why is it a topic worth knowing about, researching, and teaching about? How is ‘Reproductive Psychiatry’ different from ‘Women’s Mental Health?’ Those of us in the field see Reproductive Psychiatry as one component of Women’s Mental Health, which is far more encompassing and includes the psychological and psychiatric aspects unique to women. These range from the fact that women are more likely to be victims of physical or sexual abuse to the fact that depression and anxiety disorders are much more common in women as compared to men. Reproductive Psychiatry focuses on the fact that treatment of psychiatric disorders in women—specifically during the reproductive years—is complex, requires specialized knowledge, and is itself an area of active research. While men are also being treated for psychiatric disorders during their reproductive years, their treatment does not expose a developing child to medication, and is not subject to the significant hormonal shifts that women experience premenstrually, postpartum, and during perimenopause. Thus, reproductive psychiatry at this time is focused on aspects unique to women.

How is treating psychiatric disorders more complex during the reproductive years? First and most obvious is the management of psychiatric disorders during pregnancy and lactation. Fifty per cent of pregnancies are unplanned in the US today, meaning that all psychiatrists will have female patients who become unexpectedly pregnant while psychiatrically ill and/or taking psychiatric medications. Studies examining the risks and benefits of psychiatric medication use during pregnancy and lactation have greatly increased over the past 10 years—often yielding conflicting results. Understanding and interpreting that literature as a whole, as well as in the context of a particular patient, is one of the main jobs of a reproductive psychiatrist. Further, the postpartum time-period carries with it an increased risk of relapse and of initiation of psychiatric illness, which can complicate attachment and have lasting effects on the developing infant. Research is identifying biomarkers and risk factors for postpartum psychiatric illness and developing specific interventions to minimize risk to both mother and child during this critical time-period. Perhaps slightly less obvious is the treatment of women with psychiatric illness during the premenstrual and perimenopausal time periods. Many women, both with and without psychiatric disorders, notice mood changes premenstrually, postpartum, and then again during perimenopause. These mood changes are thought to be triggered by the hormonal fluctuations that occur during these reproductive time periods. Women with psychiatric illness can destabilize during these time periods as well and specific treatments and approaches to management are being developed to address this common phenomenon. Thus, clinical research into best management strategies of psychiatric illness during reproductive life events is one of the largest components of Reproductive Psychiatry.

From a more basic research perspective, episodes of psychiatric illness that have a particular biological trigger may be a more biologically homogenous group that will allow the identification of the biological cause(s) of a more general psychiatric syndrome. This idea has been termed “reproductive depression” (Payne, Palmer, & Joffe, 2009) in reference to postpartum depression, premenstrual dysphoric disorder (PMDD), and other depressive illnesses triggered by reproductive events in women, but can be extended to other forms of psychiatric illness, including bipolar disorder, psychosis, and anxiety. Significant evidence suggests a genetic susceptibility for both postpartum psychosis (Blackmore et al., 2013; Craddock & Forty, 2006; Payne et al., 2009) and postpartum depression (Jones & Craddock, 2001; Mahon et al., 2009; Murphy-Eberenz et al., 2006; Payne et al., 2008)—both of which may be triggered by the significant hormonal fluctuations that women undergo through labour and delivery. Similar hormonal shifts occur during the premenstrual time-period and can trigger PMDD or premenstrual relapse of an underlying mood disorder in susceptible women. The fact that the postpartum and premenstrual time-periods are really the only times that psychiatry can predict exactly when a woman may become psychiatrically ill means that these susceptible time-periods lend themselves well to scientific characterization. If we can understand the biological basis for postpartum depression, postpartum psychosis, or PMDD then we may be able to extrapolate to the underlying biological causes for psychiatric illness more generally and eventually be able to move towards prevention and more targeted treatments.

Finally, there is the issue of education. Every psychiatrist should and does treat women, and all psychiatrists will have female patients and/or their partners who either become pregnant unexpectedly or experience a planned pregnancy. Someone once said to me that every psychiatrist should be able to manage psychiatric illness during pregnancy and I agree. However, there is a significant lack of education on the clinical art of minimizing a pregnancy’s exposure to both psychiatric illness and psychiatric medications. In recognition of this lack, a task force for developing a national curriculum on perinatal mental health has been established and is working to develop a curriculum to educate all psychiatric residents about Reproductive Psychiatry (Forty et al., 2006). While not yet an officially recognized sub-specialty of psychiatry, Reproductive Psychiatry is an important area of study and education, and the development of a specific curriculum to teach all psychiatrists how to manage this critical time-period is certainly a step in the right direction that signals the importance of the field.

In this issue we have tried to gather a collection of articles that reflects the breadth of this rapidly developing field, from both clinical and research perspectives. We begin with clinical research on the perinatal depression care pathway in the obstetrics setting. This research is important and reflects the growing trend of embedded psychiatric care in obstetrics settings, along with implementation of recommended perinatal depression screening (ACOG, 2015; Osborne et al., 2015). The second article describes an international consortium of clinicians and researchers interested in postpartum depression that collectively is working towards identifying the underlying genetic basis for postpartum depression. The third article focuses on the role of allopregnanolone in reproductive psychiatry—not only on the treatment of postpartum depression, but also on the role it likely plays during other times of hormonal fluctuation—namely during the premenstrual and perimenopausal time periods. The next several articles focus on the effects of maternal psychiatric illness (including perinatal depression and PTSD) on the infant including effects on attachment, neurodevelopment, and the microbiome. The final paper in this special edition is focused on the postpartum time-period and reviews the literature on lithium use in lactating mothers. I hope that this special edition will give the reader an idea of the exciting research that is going on in reproductive psychiatry in both the clinical and basic science realms.

In closing I would like to make the argument that Reproductive Psychiatry is a viable subspecialty of psychiatry. The American Board of Medical Specialties (ABMS, 2019) currently recognizes 14 subspecialties of psychiatry and neurology. The ABMS notes that new subspecialties can be proposed and states that “The area of specialization being considered should focus on a distinct and definable patient population, a definable type of care need, a “stand alone” body of medical knowledge or unique care principles solely to meet the needs of that patient population. It should clearly demonstrate its value in improving access, quality, and coordination of care” (Siu et al., 2016). Reproductive Psychiatry clearly meets these criteria: Reproductive Psychiatry focuses on a distinct and definable patient population and has both a “stand alone” body of medical knowledge as well as an ever-increasing body of literature. There are unique clinical care principles in Reproductive Psychiatry that are quite different from the approach to a general psychiatric patient and which demand specific education for all psychiatrists. The fact that there are now multiple Women’s Mental Health and Reproductive Psychiatry programmes and fellowship training opportunities across the nation (Forty et al., 2006) demonstrates the need and value of Reproductive Psychiatry in the care of women during the reproductive years. It is my hope that we will see the evolution of Reproductive Psychiatry into an official subspecialty of psychiatry, thus emphasizing the importance of a thoughtful approach to the management of psychiatric disorders during the reproductive years of women.

Disclosure statement

No potential conflict of interest was reported by the authors.