Perinatal/Reproductive Psych career advice

[krj]

Early in my 1st year as a resident. I came in thinking I wanted to do CAP fellowship due to the positive experiences I had in med school. Then I started learning a lot more about perinatal/ reproductive psych since starting residency a few months ago and have been loving it. What are y'all opinions about where this field is going? Right now it has an unofficial fellowship. What are the benefits (beyond obviously becoming more of an expert in the field) vs pursuing CAP with split time in perinatal and children? Are there financial benefits? Does it seem like it will become a board certified specialty in a few years? Besides the MONA conference in the fall, is there another place that these psychiatrists get together to talk about the field?

Thanks!!

P.S. heard of some people doing C&L fellowship in order to get into this field. Is that required? Not really looking to do more than 1 fellowship

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[Sushirolls]

Niche, even in an academic center. Possible to get partial FTE doing just that, but would be quite the exception to make it a 1.0FTE

Might be able to carve something out if you approach a large OBGYN group and they hire you on to be their go to psych.

 

[clausewitz2]

You could probably patch together 2-3 FTEs doing just this in our system but as a matter of practice it is split between like 8 people because specializing in this is (sometimes) a way to mostly see bourgie white ladies. Not saying that's you, OP, but that is a reason why it might be hard to do that and just that unless you are pursuing a research career.

 

[Mass Effect]

Large academic centers may hire you to do it full time. There are Women's Mental Health departments at these places that need directors, particularly if the place has a fellowship in it. Also agree with doing an integrated care model in a large OB practice.

 

[FlowRate]

You could probably patch together 2-3 FTEs doing just this in our system but as a matter of practice it is split between like 8 people because specializing in this is (sometimes) a way to mostly see bourgie white ladies. Not saying that's you, OP, but that is a reason why it might be hard to do that and just that unless you are pursuing a research career.

It's weird because, at least in academic centers, it's a field that a bunch of women want to practice. So it doesn't seem to pay off in terms of building a rare niche. Not sure how many people in PP market themselves this way or whether it's useful.

 

[splik]

What are y'all opinions about where this field is going?

There is tremendous scope and interest in this area particularly within academic medical centers and large health centers. Many OBs would like psychiatrists to work with these patients for pre-conception, during pregnancy, and in the postpartum period. There is also significant scope and growth for treating addictions in pregnancy, in managing high risk OB patients with complex psychosocial situations and comorbidities, in working with patients with chronic pelvic pain, infertility, and pelvic dysfunction, and in doing pre-operative surgical evaluations e.g. BSO for PMDD.

As clauswitz alludes to, there are psychiatrists who specialize in treating rich white women with minor misery during pregnancy and other transitions, but there is also a demand for psychiatrists with this interest to work in public settings with high risk patients.

Another related area is using integrative medicine/CAM with this patient population.

At my institution we are often looking for psychiatrists with interest and training in reproductive psychiatry/women's mental health.

Right now it has an unofficial fellowship. What are the benefits (beyond obviously becoming more of an expert in the field) vs pursuing CAP with split time in perinatal and children?

Some fellowships in women's mental health can be done as a 4th yr (i.e. you can 'fasttrack'). The benefits of fellowship will depend on whether you do a chief resident year, whether you have the opportunity to get enough training and exposure to all the facets during your residency, and whether you would like to spend a year getting more dedicated training and experience with this work. It would also depend on doing a strong fellowship which gave you a breadth of experiences and training you may not otherwise not get. The question you should ask yourself is "will this fellowship give me something I wouldn't get just being an attending and doing this?" If you are able to get a wide diversity of experiences and significant mentorship that you would not otherwise be able to get or you are able to market your training for jobs or private practice, it may be worth it. If not, then you can just get a real job in this area and get "on the job" training and mentorship.

I'm sure its possible to combine CAP and perinatal work as one great thing about psychiatry is it is quite possible to do different things at the same time, but this would be unusual and usually would be distinct jobs.

Are there financial benefits?

Women tend to get paid less, and women treating women tend to get paid less still. In my area the psychiatrists in private practice who specialize in this area are cash only and charge a lot of money (i.e. $550-600 for an intake) but they do not have full/closed practices as there is a limited pool of people who can pay these fees regularly even in major metropolitan areas.

if you are willing to treat patients with real mental disorder (e.g. puerperal psychosis, bipolar I disorder) this will add to marketability as many of the psychiatrists out there who do this wont see anything beyond depression and anxiety.

Does it seem like it will become a board certified specialty in a few years?

No. It is considered part of C/L psychiatry and historically the fellowships were a subset of C/L but most are now just non-accredited fellowships. Board certification is a scam however so I would not be concerned about this.

Besides the MONA conference in the fall, is there another place that these psychiatrists get together to talk about the field?

the Marcé society is the main one, but ACLP (the C/L psychiatry society) also has an interest group in this area which meets and organizes sessions duirng the annual meeting. You might also be interested in ASRM (HOME - American Society for Reproductive Medicine) they have psychosocial sessions during their meetings (more psychologists and therapists), and NASPOG (North American Society for Psychosocial Obstetrics and Gynecology - Home).

 

[downwithDTB]

I see two routes that you could go in here and may be of interest to you:

Perinatal psych as described above and infant psych and they don't have to be mutually exclusive.

Perinatal: focuses on the care of mental illness in pregnancy (or pre-pregnancy) and post-partum period. For an academic position you probably need the "creds" of a CL or repro psych fellowship; however, it's perfectly reasonable to get adequate exposure during residency if you are in a program that accommodates elective time and you seek it out. You could then easily market to OB practices as described above in many areas and bill yourself as having that area of specialization. Seperately, many (most?) CAPs see a number of adults so there is no reason why you couldn't focus on perinatal adults and practice general CAP (although it might be harder in a siloed academic system).

Infant psych: This work focuses more specifically on parent child interactions to promote healthy development in kids at risk for neglect and abuse, either due to acute parental mental illness, socioeconomic factors, poor parental coping skills, ect. This work is often housed in a "theraputic nursery" within a CAP program and targets the infant as the primary "patient," is therapy heavy with a family approach to a diad or triad (although postpartum psychopharm could be included in practice). Most of the jobs here would be either community mental health or academic (i.e. pay cut).

If academics is your thing, you might find some nice niches available either combining the two (probably via CAP fellowship with a theraputic nursery and seeing every pregnant patient you can in residency). You could also choose to specialize on the father/infant diad, a gaping hole in practice and academia.
This certainly won't fill a practice but may make you a competitive grant applicant since you wouldn't have much competition. Certainly there are enough fathers out there whose lives could be enriched and whose children's lives could be enriched through facilitation of a positive role/treatment of perinatal mental illness. Finally, you could focus on perinatal psych in adolescents after a CAP fellowship (again, probably would have to be through a huge cachement academic center or community program).

Conclusion: You may be able to combine your interests in perinatal and CAP. I wouldn't not expect to get paid extra doing any of this vs. what you could make doing anything else in psychiatry.

 

[Merovinge]

Perinatal absolutely is an area of CAP, there were multiple presenters on this area at AACAP this year. I have no doubt that C/L approaches these issues as well. I have a colleague who does exactly what you describe including part-time women's psychiatry and part time CAP work which adds a huge diversity to their work schedule. Everyone above is correct that this is mostly an academic area and while it could lead to a small niche for PP, I would not enter this area expecting a higher paying career.

 

[meow1985]

Early in my 1st year as a resident. I came in thinking I wanted to do CAP fellowship due to the positive experiences I had in med school. Then I started learning a lot more about perinatal/ reproductive psych since starting residency a few months ago and have been loving it. What are y'all opinions about where this field is going? Right now it has an unofficial fellowship. What are the benefits (beyond obviously becoming more of an expert in the field) vs pursuing CAP with split time in perinatal and children? Are there financial benefits? Does it seem like it will become a board certified specialty in a few years? Besides the MONA conference in the fall, is there another place that these psychiatrists get together to talk about the field?

Thanks!!

P.S. heard of some people doing C&L fellowship in order to get into this field. Is that required? Not really looking to do more than 1 fellowship

Those talking about it being a "niche" specialty, hold the phone... At any given time, at least half of your patients will be women. Many of these women will be of reproductive age. A woman of reproductive age can either decide to start a family or end up with an unplanned pregnancy any day of the week. And then it'll be real useful to know what the risks of meds in pregnancy are, and how you can expect psych conditions to change.

Even if you don't *just* do perinatal psych, the knowledge is incredibly useful to have. As I said above, any female patient of child-bearing age can become a perinatal psych patient at any time. To increase the chances, you can ask that your practice group funnel their female patients to you. That's what the perinatologist in my department did. You can become the go-to person in consulting your colleagues. You can take referrals others are uncomfortable dealing with.

 

[clausewitz2]

Those talking about it being a "niche" specialty, hold the phone... At any given time, at least half of your patients will be women. Many of these women will be of reproductive age. A woman of reproductive age can either decide to start a family or end up with an unplanned pregnancy any day of the week. And then it'll be real useful to know what the risks of meds in pregnancy are, and how you can expect psych conditions to change.

Even if you don't *just* do perinatal psych, the knowledge is incredibly useful to have. As I said above, any female patient of child-bearing age can become a perinatal psych patient at any time. To increase the chances, you can ask that your practice group funnel their female patients to you. That's what the perinatologist in my department did. You can become the go-to person in consulting your colleagues. You can take referrals others are uncomfortable dealing with.

I don't think (or at least I hope) no one thinks knowing how to treat half the adult population during a huge part of their lives is useless or not incredibly important. Being a sort of informal local expert, the "pregnancy gal/guy/person" in your area - totally a thing and not that hard to do. All you need is a willingness to take these cases and as long as you do okay you will get a rep for being the go-to person in your professional network. What I mean at least when I assert it is sort of a niche specialty is that all that? You are probably doing it as part of a day job that has you doing mostly other things. Pregnancy is a very common human experience, but also most pregnant women who want to see a psychiatrist were probably already seeing a psychiatrist so in terms of specific referrals you are getting the hard cases (which may just mean "I don't know what to do beyond SSRIs and haldol") but not the bulk of pregnant ladies.

So totally a thing that it is good to know about, but not unlike, say, first episode psychosis - it is hard to get a full-time job doing just that outside of an academic center and even then probably grant-funding of some kind will have to be involved.

 

[Armadillos]

Obviously very important to have folks specializing in this area for research purposes, but from a clinical standpoint I sort of feel like working with pregnant women or postpartum women is just a normal part of general psychiatric practice.

That being said, the psychiatrists I personally know working in this field run an amazing clinic that provides excellent care much better than the average psychiatrist, but I sort of feel like it’s mostly because they are compassionate people and excellent psychiatrists overall, regardless of population they decided to work with

Second disclaimer to my initial statement, having the recently approved IV tx for postpartum depression certainly opens up more of a potential specific clinical niche probably not feasible for generalists.

 

[clausewitz2]

Obviously very important to have folks specializing in this area for research purposes, but from a clinical standpoint I sort of feel like working with pregnant women or postpartum women is just a normal part of general psychiatric practice.

That being said, the psychiatrists I personally know working in this field run an amazing clinic that provides excellent care much better than the average psychiatrist, but I sort of feel like it’s mostly because they are compassionate people and excellent psychiatrists overall, regardless of population they decided to work with

Second disclaimer to my initial statement, having the recently approved IV tx for postpartum depression certainly opens up more of a potential specific clinical niche probably not feasible for generalists.

...an IV treatment that did not beat placebo in the subset of people in an SSRI and costs 30,000 dollars...

 

[downwithDTB]

...an IV treatment that did not beat placebo in the subset of people in an SSRI and costs 30,000 dollars...

Oh come on, don't sell it short! You're forgetting the cost of the five day hospitalization !

The best part is that the effect is less durable than esketamine, so you can garuntee yourself repeat business! Sounds like a great business model; you can augment with snake oil... I hear that genesight 2.0 will always have it in the green since it's non cyp450 metabolism.

 

[clausewitz2]

Oh come on, don't sell it short! You're forgetting the cost of the five day hospitalization !

The best part is that the effect is less durable than esketamine, so you can garuntee yourself repeat business! Sounds like a great business model; you can augment with snake oil... I hear that genesight 2.0 will always have it in the green since it's non cyp450 metabolism.

No the best part is that if you look at the breakdown of the MADRS score changed a huge amount of the effect is coming from improved sleep and appetite rather than altering ahedonia or ruminations or anything like that. So...super expensive IV Seroquel you can only get in a hospital!

 

[tr]

Obviously very important to have folks specializing in this area for research purposes, but from a clinical standpoint I sort of feel like working with pregnant women or postpartum women is just a normal part of general psychiatric practice.

Oh dear. I could not disagree more with this. Safety and efficacy of psychiatric medications in pregnancy and lactation is a huge and complex literature, and there are no easily digestible guidelines that are sufficient. The old FDA categories were worse than useless, they were actively misleading, and the new labeling seems like a good idea but is nowhere near sufficient to guide practice for the nonspecialist.

I do repro psych and I spent many years getting a handle on this literature. I do many one-time consultations for women who are pregnant or trying to conceive, send my note to consulting general psychiatrist who is usually very grateful for the input. But I also see plenty of unfortunate management from generalists who decided to cowboy it and then the patient shows up already 5 months pregnant on Clozaril or Rexulti - when other options were available - because the outpatient psychiatrist couldn't be bothered to consult someone who knows the area.

Please save everyone a headache and get a consultation.

 

[tr]

but also most pregnant women who want to see a psychiatrist were probably already seeing a psychiatrist so in terms of specific referrals you are getting the hard cases (which may just mean "I don't know what to do beyond SSRIs and haldol")

For example! SSRIs and Haldol. Many people including myself were trained in an era where Haldol was the go-to for pregnancy because Haldol had always been the go-to for pregnancy. But actually up until the mid-2000s there was pretty much no tabulated data on Haldol (just "clinical experience"), and since then at least some larger-scale observational studies have been done and in general first-generation antipsychotics are pretty bad for the baby, they reliably result in reduced birth weight and can cause extrapyramidal symptoms in newborns. Haldol is not my first, second, or third choice for psychosis in pregnancy.

And as far as SSRIs, most of them are OK but not all are created equal. Paxil and *possibly* Celexa are associated with fetal heart defects.

So if you are still handing out Haldol and Paxil to pregnant women based on your 2000s era training, please, get a consultation.

 

[clausewitz2]

For example! SSRIs and Haldol. Many people including myself were trained in an era where Haldol was the go-to for pregnancy because Haldol had always been the go-to for pregnancy. But actually up until the mid-2000s there was pretty much no tabulated data on Haldol (just "clinical experience"), and since then at least some larger-scale observational studies have been done and in general first-generation antipsychotics are pretty bad for the baby, they reliably result in reduced birth weight and can cause extrapyramidal symptoms in newborns. Haldol is not my first, second, or third choice for psychosis in pregnancy.

And as far as SSRIs, most of them are OK but not all are created equal. Paxil and *possibly* Celexa are associated with fetal heart defects.

So if you are still handing out Haldol and Paxil to pregnant women based on your 2000s era training, please, get a consultation.

Paxil I for sure knew was a no go in pregnancy. What are your more typical go tos for psychosis in pregnancy? Also at this point given neuroleptic prescribing patterns (i.e. people generally not getting started on first gens until they failed second gens) how is confounding by indication addressed?

Genuinely curious, this is stuff I want to know. I do have people I can reach out to for a curbside but still...

 

[tr]

Paxil I for sure knew was a no go in pregnancy. What are your more typical go tos for psychosis in pregnancy? Also at this point given neuroleptic prescribing patterns (i.e. people generally not getting started on first gens until they failed second gens) how is confounding by indication addressed?

Genuinely curious, this is stuff I want to know. I do have people I can reach out to for a curbside but still...

So I wouldn't say I have a go-to, it depends on the individual, their risk factors, and what's worked for them in the past. Seroquel has lower rates of placental passage than other antipsychotics but also is on the higher end for gestational diabetes risk. For a thin person with no other risk factors I might lean toward Seroquel. If the person is already overweight or diabetic I may lean toward something less diabetogenic like Abilify. But prior efficacy trumps almost everything else. I try to stay away from drugs like Rexulti with zero data because they are such a black box, but sometimes the person has already been on six other antipsychotics and Rexulti is the only thing that works, then Rexulti they will get.

Confounding by indication is huge and totally permeates this literature. In observational epidemiological studies there is really no getting away from it, but most authors will adjust statistically for diagnosis and, more recently, severity indicators. Comparator groups who have the diagnosis but are not treated with medication are sometimes available and always revealing. One of the more useful studies of antipsychotics came out of China and had a large comparison group of women with schizophrenia diagnoses who were not taking medication. That would be a pretty hard group to find in the West.

 

[Merovinge]

No the best part is that if you look at the breakdown of the MADRS score changed a huge amount of the effect is coming from improved sleep and appetite rather than altering ahedonia or ruminations or anything like that. So...super expensive IV Seroquel you can only get in a hospital!

This might be the single best American/Fee-for-service drug on Earth. Any nationalized or capitated system would laugh and dismiss it before you could blink.

 

[meow1985]

I do repro psych and I spent many years getting a handle on this literature. I do many one-time consultations for women who are pregnant or trying to conceive, send my note to consulting general psychiatrist who is usually very grateful for the input. But I also see plenty of unfortunate management from generalists who decided to cowboy it and then the patient shows up already 5 months pregnant on Clozaril or Rexulti - when other options were available - because the outpatient psychiatrist couldn't be bothered to consult someone who knows the area.

Please save everyone a headache and get a consultation.

I don't know how people aren't terrified of that kind of stuff. Granted, i am currently living in perpetual fear of being sued, but if stuff happens to the baby you can SO easily be on the hook trying to prove that it wasn't the medicine you gave them.

 

[Armadillos]

Oh dear. I could not disagree more with this. Safety and efficacy of psychiatric medications in pregnancy and lactation is a huge and complex literature, and there are no easily digestible guidelines that are sufficient. The old FDA categories were worse than useless, they were actively misleading, and the new labeling seems like a good idea but is nowhere near sufficient to guide practice for the nonspecialist.

I do repro psych and I spent many years getting a handle on this literature. I do many one-time consultations for women who are pregnant or trying to conceive, send my note to consulting general psychiatrist who is usually very grateful for the input. But I also see plenty of unfortunate management from generalists who decided to cowboy it and then the patient shows up already 5 months pregnant on Clozaril or Rexulti - when other options were available - because the outpatient psychiatrist couldn't be bothered to consult someone who knows the area.

Please save everyone a headache and get a consultation.

Maybe I worded that too strongly. Obviously if someone is easily available for consultation there isn’t any reason not to utilize the consultant. More that general psychiatrists need to be comfortable working with this population and be able to consult the relevant texts/literature to answer specific questions as needed given specialized consultation may not always be readily available.

 

[Ironspy]

This might be the single best American/Fee-for-service drug on Earth. Any nationalized or capitated system would laugh and dismiss it before you could blink.

Yes. The proper control would be a night nanny and cook for the same duration as the hospital stay.

 

[krj]

lots of fantastic advice here everyone! I really appreciate it

 

[Mass Effect]

I don't know how people aren't terrified of that kind of stuff. Granted, i am currently living in perpetual fear of being sued, but if stuff happens to the baby you can SO easily be on the hook trying to prove that it wasn't the medicine you gave them.

You're thinking about it wrong and that's likely why you're so fearful. You don't try to prove it wasn't the medicine you gave them, especially because sometimes, it WILL be the medicine you gave them. What you try to prove is that you thoroughly educated the patient on the risks of the medication and that the patient knew this could happen. The patient understood what you were telling her and participated in the dialogue. In the end, the patient decided the risk was worth the benefit.

This is why documentation is always so important.

 

[clausewitz2]

You're thinking about it wrong and that's likely why you're so fearful. You don't try to prove it wasn't the medicine you gave them, especially because sometimes, it WILL be the medicine you gave them. What you try to prove is that you thoroughly educated the patient on the risks of the medication and that the patient knew this could happen. The patient understood what you were telling her and participated in the dialogue. In the end, the patient decided the risk was worth the benefit.

This is why documentation is always so important.

In medicine you can be wrong all day. What you can't be is negligent.