Awareness of perinatal and postpartum mental health issues is growing dramatically. Yet there remains no formal reproductive psychiatry certification for medical school residents. The lack of training means that only about 500 reproductive psychiatrists nationwide care for the roughly 800,000 women in the U.S. who experience maternal mental health complications each year.
Approximately 13 percent of pregnant women take selective serotonin reuptake inhibitors (SSRIs), but about 80 percent of women are prescribed these SSRIs by OB/GYNs, Dr. Maria Muzik, a professor of psychiatry and obstetrics and gynecology at the University of Michigan and the medical director of its Perinatal Psychiatry Clinic, told me recently in a sit-down interview. This lack of a formal reproductive psychiatry subspecialty means “[many psychiatrists] might have never heard about reproductive psychiatry,” Muzik said. “They might never have treated pregnant people adequately.” The result is a dangerous lack of specialized care.
What Happens When Expertise Is Missing
These statistics aren’t abstract to me. In 2020, trying to prepare for a potential pregnancy, I began a taper on a selective-norepinephrine reuptake inhibitor (SNRI) associated with a small, increased risk of heart defects in a baby. My husband and I had consulted a reproductive psychiatrist about my medication regimen’s safety in pregnancy, but this specialist’s recommendations had gotten lost in the shuffle between her and my regular psychiatrist. I ended up communicating them to the latter according to memory. My psychiatrist told me that we’d start a taper on the SNRI—at a rate she thought safe, not what the specialist had suggested.
Six to eight weeks later, I was a wreck: episodes of wild sobbing, deep depression, even suicidality. One day, as I was standing at the kitchen counter making dinner, my mind kept flashing to the safe upstairs, where I keep my medication—I knew it was unlocked. I pictured pouring pills into my hand, swallowing one after another after another. All I wanted to do was sleep forever.
I couldn’t do this to my beloved husband. I walked into his home office, where he sat in front of his multiple screens, one of our rescue cats in his lap: “Babe, I think I need to check myself into a hospital.”
I had experienced a care gap, a dangerous one. Even at the time, I understood that what had happened wasn’t simply a bad medication taper. It was what happens when highly specialized care is unavailable or poorly coordinated.
The Problem With One-Size-Fits-All Advice
Mothers with mental health issues are at higher risk for preterm delivery, preeclampsia, and low birth weight. Untreated depression in pregnancy is even associated with behavioral problems and developmental or social-emotional delays in children as they grow. Together, suicide and homicide are the leading causes of maternal mortality, with approximately one in 20 maternal deaths occurring by suicide.
The statistics on pregnancy and depression illustrate the dangerous lack of specialized maternal mental health care. The number of peripartum women who take antidepressants is significant. Yet many women discontinue these medications during pregnancy: fully half, according to a 2024 study. Misconceptions about the safety of selective serotonin reuptake inhibitors (SSRIs) and SNRIs abound among the public but also among healthcare professionals.
I certainly thought I needed to stop many of my medications, convinced they’d hurt a baby. And perhaps the specialist had advised me to taper off the antidepressant. But perhaps she hadn’t. Perhaps she weighed the risks vs. the benefits, as skillful reproductive psychiatrists do, and decided that the dangers to me of discontinuing the antidepressant outweighed any small risk to a baby.
This is the question Muzik asks herself in every case she treats: “I always ask, ‘Is the medicine effective and necessary?’ And then I ask myself, ‘What is the adverse effect of this medicine on the person, and in case of pregnancy, also on pregnancy outcomes and the [fetus]?’ And it has to be a right balance. It has to be, as we call it, appropriate risk-benefit ratio.”
Pregnancy Essential Reads
Researchers don’t do gold standard studies on psychotropics in pregnancy: Randomized controlled trials would be unethical in cases of pregnant women. But case reports on psychiatric medication use in pregnancy have been widely gathered for decades, Muzik explained. And the data is largely in about antidepressants: “I would say that in general we can say we have now a reasonable amount of data suggesting that certain medicines, like antidepressants, if dosed appropriately [in serious depression], are beneficial and also safe,” Muzik said.
Psychiatric Medication in Pregnancy Requires Specialized Care
Despite this growing evidence of safety and efficacy, antidepressant and other psychiatric medication use must be monitored carefully in pregnancy. Pregnancy causes significant physiological changes that alter how medications are absorbed and metabolized. Some women might need higher dosing or dosing schedule changes.
Pregnancies in cases of more serious mental health issues, such as bipolar disorder and schizophrenia, require a high level of specialized psychiatric and obstetric care, but also sometimes wraparound social and family case-management. In this area, Muzik is also a leader: She has developed the Strong Roots Curricula, group-based interventions for parents that include perinatal dialectical behavior therapy (DBT), attachment-based parenting psychoeducation, and enhanced social support designed to address trauma-induced barriers to healthy parenting.
The Consequences of an Inadequate System
The human cost of the current reproductive psychiatrist shortage is the failure to address these complex needs. Medical professionals untrained in reproductive psychiatry sometimes encourage abrupt discontinuation of psychiatric medications, perhaps even all that a woman takes, as an OB/GYN once advised me. Women sometimes receive conflicting advice as they cycle through appointments: The OB/GYN says one thing, the psychiatrist another, the general practitioner a third.
Relapses, hospitalizations, and even suicide result from the lack of integrated, accessible, and competent reproductive psychiatric care in the United States today.
A Path Forward for Maternal Mental Health
A solution is taking shape, however—a national effort to create a formal reproductive psychiatry subspecialty. Leaders from across the country, including Muzik and led by Dr. Lauren M. Osborne at Weill Cornell Medicine, have formed a task force to establish a year-long, accredited fellowship in the field that would be a part of every residency program across the country. If the effort is successful, psychiatrists sitting for their board exams will also be able to test in a reproductive psychiatry specialty add-on and become formally certified in maternal mental health care, a medical advance that would address the dire shortage of reproductive psychiatrists. The result would be a highly skilled reproductive psychiatry workforce that, in the end, could better care for me and the countless women like me.
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