Opinion: Mentally ill women deserve more support to have children

A friend once told me approvingly that someone she knew had talked his schizophrenic adult son into having a vasectomy. Though I read “talked into” as “coerced,” I didn’t say anything. Oh my god, I thought instead, maybe I shouldn’t be a mother. I’d had a break with reality after stopping my antipsychotic 10 years before, frustrated with weight gain. I had returned to taking medication and my mental health had stabilized long before this conversation. But I was now pursuing pregnancy. Despite my master’s and a writing career that included Psychology Today essays, my successful marriage, and a 10-year history of treatment adherence and stability, I wondered if I would be too unstable to parent. I’d overdosed multiple times while psychotic, including twice within two weeks. In one incident, I ran away from the group home where I had been institutionalized, eating Benadryl tablets like M&Ms and knocking them back with Budweiser, then drove in a blackout. The last thing I remember — My hands on the steering wheel as I accelerated up a freeway on ramp. While psychotic, I’d been a danger both to myself and others. Would I become a danger to a child? The maternal mental health needs of women like me have been badly under-prioritized in American society. It takes a tragic case like Lindsay Clancy’s for people to realize reproductive psychiatry is even a medical field, much less recognize its critical importance. When she started spiraling into postpartum psychosis, Clancy’s husband, Patrick, didn’t understand the danger, as he said Sunday night in a “60 Minutes” interview: “I could piece together what it was like to be really, really anxious or depressed. But I didn’t know how to manage a postpartum illness.” Many women with a history of mental illness get pregnant; others who were previously healthy experience symptoms for the first time while pregnant. Thirteen percent of all pregnant women use selective serotonin reuptake inhibitor antidepressants (SSRIs), according to Maria Muzik, a psychiatry and obstetrics and gynecology professor at the University of Michigan and the director of its Perinatal and Reproductive Psychiatry Clinic. Eighty percent of them obtain their prescription from an OB-GYN rather than a psychiatrist, she told me. And, though the experience of severe mental illness and motherhood remain almost invisible in popular discussion, more than 100,000 women with severe mental illnesses have children every year in the United States. Most women with serious mental health conditions like schizophrenia and bipolar disorder are mothers. These women often experience gaps in care like Clancy’s. Average inpatient psychiatric hospitalization stays are five to seven days. Many outpatient psychiatrists and therapists don’t take insurance. When they do, copays can be a significant barrier. Vast areas of the country, particularly rural regions, are deserts for psychiatric care and reproductive psychiatric care. Muzik estimated there might currently be six to 10 practicing reproductive psychiatrists in the entire state of Michigan. Only 6% to 8% of women with peripartum depression receive adequate psychiatric treatment, and suicide and homicide combined are the leading cause of maternal mortality in the United States. After deciding to start a family, my husband and I sought prenatal counseling on the safety of my medication regimen in pregnancy and my potential for relapse at a university medical center. But this potentially lifesaving prenatal care remains out of reach for many women with serious mental illness, 20% of whom are uninsured. To fill the gap in reproductive psychiatric treatment, practitioners are developing a workaround — maternal mental health consultation hotlines like UMass Chan Medical School’s Lifeline for Moms or the University of Michigan’s MC3, with a phone line Muzik staffs every Friday. These hotlines are a critically important innovation, allowing primary care physicians, nurse practitioners, and OB-GYNs to receive real-time guidance from specialists, improving clinician confidence. But they have become a substitute for the specialized workforce the country has never built. Imagine asking primary care physicians to manage leukemia over the phone because oncologists were so scarce — we’d recognize there was a problem. Even more damagingly, women often receive care from practitioners who declare they are specialists but have no real reproductive psychiatry training, according to Lauren Osborne, the vice chair of clinical research in the Department of Obstetrics and Gynecology at Weill Cornell Medicine. “Anybody can hang out a shingle and say, ‘I’m a reproductive psychiatrist,’ and there’s nothing to say that somebody is or is not,” she said. “People who have more severe versions of these [mental health] disorders, who are seeking out help and expertise, find somebody they think is qualified, and that person isn’t, and things get missed, and there can be tragic consequences.” Training in reproductive psychiatry is inconsistent, with expertise remaining concentrated at universities. Despite the complexity of treating psychiatric illness during pregnancy and the severe need, the United States still has no formal reproductive psychiatry subspecialty or standardized national training pathway. The American Board of Psychiatry and Neurology requires that a general psychiatry subspecialty reach a certain number of fellowships and trainees in those fellowships to be formally approved, Osborne told me. At least 25 fellowships with 50 trainees enrolled are needed; 18 programs, nearly all of which have a single trainee and all of which differ, currently exist in reproductive psychiatry. “It’s probably 15 or 20 years, even as quickly as the specialty is growing, before we could reach that [threshold], and maybe even longer because there’s no money to support these fellowships,” Osborne said. If they become pregnant, women who experience psychosis often have little support. And psychosis is a uniquely traumatizing condition. My husband and I sometimes laugh about my delusions: how, during my psychotic break, I believed a fellow psychiatric patient with religious delusions was a Vatican assassin, hunting me down, her repetition of the word “tray” code for “prey.” How I thought my grandmother plotted to kill my cats, so I packed them in their carriers, put them in the backseat, and attempted to cross the Blue Water Bridge from Michigan into Ontario without a passport. These stories are funny — and not. People experiencing such devastating delusions deserve humane, quality care. With such care, we are capable of leading rich, fulfilling lives — And even being good parents. A solution is taking shape to the maternal mental health care crisis. Realizing they can’t wait 20 years or longer, Muzik, Osborne, and other leading clinicians and advocates have founded a nonprofit organization that is working to establish its own board certification exam. Many other specialties, including obesity and breastfeeding medicine, have followed a similar path to certification, Osborne told me. This nonprofit, the North American Board of Reproductive Psychiatry, is beginning to establish a set of standards. For instance, to be eligible to sit for the exam, a clinician will have had to complete a fellowship in reproductive psychiatry or consult-liaison psychiatry, or have substantial clinical practice and some continuing medical education, according to Osborne. “We’re hoping eventually that money earned from that exam can then be fed back in to form more fellowships,” she said. “We would eventually love to see this be something where, to be a qualified reproductive psychiatrist to sit for that exam, you have to have done [a] fellowship, but we need a pathway to increase the numbers of fellowships. Our approach was to tackle the board certification first and use that as a path to then create more fellowships.” Osborne also directs the National Curriculum in Reproductive Psychiatry, what amounts to a fellowship-length education for reproductive psychiatry. Osborne estimates that most of the fellows from the currently established reproductive psychiatry fellowships are now training in it, along with many fellows from the related consult-liaison specialty, an important step to regulating this care in the United States. The North American Board of Reproductive Psychiatry is actively fundraising to mount the first exam and publicizing its work. The reproductive needs of women with serious mental illness deserve to be considered, our right to make decisions for ourselves honored. Clinicians should be working to support us, not fumbling incompetently or making paternalistic determinations. With proper support, we can make informed reproductive choices. My husband and I pursued parenthood for several years before choosing not to have children: We both had serious reservations about my ability to handle intense stress and insomnia. However, I recently sustained what might have been a miscarriage: I was showing telltale signs of an accidental pregnancy, too early for a test. It was my mom who said to me, in the depths of my grief: “Meggie, you’re allowed to choose your health.” I remember walking in the bright spring sunlight up and down the street from our little blue house — up and down, up and down — and thinking, My god, I can choose to be well. And that’s, in the end, what I did. Quality maternal mental health care promotes reproductive agency. But consultation hotlines are all too often the only option of providing it. Clinician volunteerism and workarounds are not the answer to the critical need for specialty treatment. Instead, reproductive psychiatry must be treated as a workforce worthy of major investment. Without a significant commitment of resources, pregnant patients with mental health issues will continue to depend on extraordinarily dedicated individual doctors, rather than affordable, accessible care, and tragedies like that of Clancy and her family will continue to happen. Women like me don’t need to be protected from motherhood. We need a health care system that will enable us to make our own informed decisions about it. An MFA in writing and a Psychology Today and HuffPost contributor, Meg LeDuc writes about maternal mental health on her Substack, the Mother Prescription, and is working on a memoir.