Hello and welcome to this four-part webinar series on perinatal mental and substance use disorders. This webinar series is a result of the work conducted by a group of clinicians, researchers and clinical researchers from across various disciplines in mental and behavioral health. Before starting the webinar, we would like to acknowledge that this product would not be possible without the partial funding from the Centers for Disease Control and Prevention of the U.S. Department of Health and Human Services, grant number NU38OT000288. In addition, we would like to stress that the contents provided herein are solely the responsibility of the authors and do not necessarily represent the official views of, nor an endorsement by, HHS, CDC or the CDC Foundation. Similarly, the contents provided are solely the responsibility of the authors and do not necessarily represent the official views of the American Psychiatric Association, the APA. We would like to draw your attention to terminologies used in the webinar series. Where possible, we have used inclusive language such as person or persons instead of woman or women. For example, we refer to pregnant persons instead of pregnant women. This has been done consistently throughout the webinar, except in instances where the research we cited specifically stated that there are inclusions of women only in their study population. Similarly, we use the inclusive term parental instead of maternal. In contrast, you will notice that we used the word breastfeeding throughout the webinar. This was done because the studies we reviewed talked about breastfeeding. However, we would like to acknowledge that breastfeeding is a more inclusive term. Other terms of interest include antenatal or antepartum, which refers to before birth. Postnatal refers to after birth. Perinatal covers the pregnancy and postpartum period. Peripartum covers the period shortly before, during, and immediately after giving birth. Postpartum refers to the postnatal period up to one year following given birth. We also use the acronym PANPBH, and this is used to refer to psychiatrists and non-physician behavioral health when referring to the practitioners who participated in the focus groups and surveys associated with this initiative. So, why is this topic and webinar series important? Well, studies have shown that mental and substance use disorders are associated with poor obstetrical outcomes, as well as poor outcomes for a fetus or child. Despite these findings, the rate of psychiatric treatment in the perinatal population of psychiatric treatment in the perinatal population remain low. Furthermore, there is limited research on best practices for the treatment of perinatal mental and substance use disorders. Compounding the issue of low rate of treatment and limited research on best practices are the findings that there is inadequate training of psychiatrists and non-physician behavioral health practitioners in the United States. Understanding the factors that contribute to the inadequate training of psychiatrists and non-physician behavioral health practitioners is important for the field of perinatal mental health care. Osborne and colleagues and their 2015 survey of psychiatry residency training directors found that only 36% of directors believe that their residents required competencies in this area. These directors cited lack of time to teach a topic as the primary barrier. These observations, plus the anecdotal reports by persons with mental and substance use disorders of having their clinical care dropped by their behavioral health practitioners once they become pregnant, was the impetus behind the project that resulted in this webinar series. The project aimed to investigate if the anecdotal report was supported and to try to identify potential causes and consequences as well as strategies to address this issue. A number of methods were utilized to address the issue with the goal of developing a perinatal psychiatric toolkit, which includes this webinar series as well as to formulate educational and training recommendations. Methods used included separate focus groups and surveys of pregnant persons and psychiatrists and non-physician behavioral health practitioners and their trainees. Similar to the 2015 survey of psychiatry residency training director conducted by Osborne and colleagues, we surveyed program chairs and training directors of mental and behavioral health training programs. But in addition to psychiatrists, our sample included clinical psychology, clinical social work, clinical mental health counseling, and advanced nurse practitioner programs. In addition, we conducted literature review on various topics in the broad areas of epidemiology, etiology, and adverse outcomes, clinical management of perinatal mental and substance use disorders, perinatal mental and substance use disorders in vulnerable and underserved populations, and training gaps in perinatal mental health care. The results of the literature review formed the basis for this webinar series with supplemental information from the focus groups and in some instances the surveys conducted. The work was informed by an advisory panel of experts from across various disciplines in behavioral and mental health. This four-part webinar series aims to enhance your awareness and understanding of treatment and training gaps in perinatal mental and substance use disorders and their impact. The series highlights ways to address these gaps. The webinar series include webinar one, epidemiology, etiology, and adverse outcomes of perinatal mental and substance use disorders. Webinar two, which covers clinical management of perinatal mental and substance use disorders. Webinar three, which focuses on vulnerable and underserved populations with perinatal mental and substance use disorders. And the fourth webinar that covers behavioral health education and training in perinatal mental and substance use disorders with a focus on gaps and recommendations. We hope you find each session and the full webinar series informative. Hello, everyone, and welcome to part four webinar series, training gaps in perinatal mental health. My name is Dr. Janine Cross. I am an associate professor at Howard University School of Social Work. I am considered a perinatal social worker as well and I have research interest in maternal child health. I will be presenting this section of the webinar series, which is brought to you by the research team, Dr. Coombs, Dr. Burns, Dr. Vaughn, Dr. Christopher Holloway as well. And thank you for being here. In terms of our disclosures, the presenters have no financial conflicts to disclose with this webinar series. There are five learning objectives for this webinar series. We want to recognize the lived experience of pregnant persons with mental health or substance use disorders. We will also in this webinar series describe current gaps in training across the continuum of psychiatry, psychiatric nursing, psychology, and social work graduate education, as well as continuing education. The third learning objective will be to explain the adverse consequences of limited education and training of behavioral health workforce to address perinatal mental health needs. Our fourth objective with this series will be to outline the lack of accreditation requirements across behavioral health disciplines for training in maternal mental health. And our fifth learning objective will be to review the education and training opportunities in perinatal mental health. And now we're going to talk about the gaps in required training. In a survey of psychiatric residency training directors, only 59 percent of programs require training in reproductive psychiatry. Similarly, only 36 percent of directors believe residents require competence in this area. Licensed psychologists in the U.S. are not required to take full focused coursework in either women's mental health or maternal mental health for their license renewal. We are not at this time aware of any state requiring continuing education on maternal mental health. Unlike requirements for mandated training for qualified health professionals, such as psychiatrists, psychologists, social workers, clinical mental health workers, and so forth, on suicide assessment, child abuse, and other areas depending on the state, such as the Adler Act of 2012. So now we move forward to the pregnant person's lived experience information from pregnant person's focus group. We conducted three focus groups with six to eight pregnant persons. Each were conducted virtually between August and December of 2022. Each pregnant person focus group was conducted in two one-hour sessions to accommodate the needs of new parents, to make sure they are comfortable and willing and able to engage in these focus groups. Participants included persons assigned female at birth, who were either currently pregnant or up to 24 months postpartum, and who had pre-existing mental health and substance use disorders or new symptoms developed during the perinatal population. And that comprised our population for this study, for this focus group. Pregnant persons were recruited through advertising, through the networks of panel members, as well as social media. Focus groups were moderated by the study's principals, Dr. Diana Clark, and the project's advisory panel and co-chair, Drs. Jonathan Alpert and Dr. Mila DeFaria. Pregnant person's lived experiences were eloquently listed, and we will be presenting it here. Here are just some of the quotes that we want to present to you, because we feel that these quotes really help you understand some of the themes that came from the focus group. A non-Hispanic white woman stated, when I got pregnant with my baby, I was in treatment for ADHD. And because there was a lack of surety about the impact of the medication on my pregnancy, I was able to I was advised to go off it with not really any suggested alternatives. I was basically given the suggestion to go off my medication and just kind of tough it out for the nine months, which was really difficult. Second person, a Hispanic woman. I am 24 weeks pregnant and have been feeling constantly sad and anxious throughout this time. I have known I am pregnant. The doctor who has been taking care of me during the pregnancy, an obstetrician, is not validating my symptoms. He keeps telling me that's normal, that's normal, and has not referred me. And I would like to seek help, but do not know how. A third pregnant person with lived experience, a non-Hispanic white woman. This is just a subjective feeling, but it did feel in the sessions that my mental health, even though I was the patient, wasn't as much of a priority as you know the fact that I was pregnant. That being pregnant and sharing my baby was the number one thing for both my OBGYN and my psychiatric mental health nurse practitioner. To that, whereas I feel that if I expressed this when I wasn't pregnant, you know my mental health would have been prioritized higher. And lastly, the fourth pregnant lived person experience. When I eventually had a pregnancy loss, my therapist deserted me completely. Even when I tried reaching out to her through a phone call, I felt quite sad after that. That quote is from a Black African-American or Black or African-American woman. And so hopefully you get a better understanding of the needs of this important critical study and that you get a sense of some of the information that we were able to gather from the focus groups. The populations that we serve, our recruitment measures, as well as the design of the focus group and the participant information that we received. There's a lot more work to be done and we'll be covering more in the upcoming sessions. Thank you. Hello, I'm Ruby Vaughn. I'm a psychiatrist at Montefiore Einstein Medical Center in the Bronx, New York. I'm an associate professor of psychiatry. I'm also the director of psychiatry at the Einstein Division. And now I'll be presenting on the perspective of behavioral health practitioners from focus groups. So we help three different focus groups with six to eight practitioners in each group. These groups were held virtually between August and December of 2022. The groups ran for about two hours and participants included various psychiatrists, psychologists, nurses, counselors, and social workers. And the participants were selected by the APA research team to ensure that these teams, excuse me, the participants were selected by the APA research team to ensure that the focus groups reflected the diversity of mental health providers in our country. So they selected participants based on the various disciplines, how long they've been in practice, their location, and also their practice setting. Each focus group was moderated by Drs. Clark, Albert, and DeFaria. Here's a snapshot from one social worker that really frames the issue. I think one of the biggest barriers is that in my community, there are only a handful of certified specialized perinatal mental health providers. And I'm one of the providers with the most experience, just shy of 10 years, about five of which are perinatal specific. But that means I still have a lot to learn. And I often have to seek consultation outside of my immediate community. That often comes with long wait lists to join consultation groups and high consultation costs because I'm consulting with the best of the best in the field. I think easy access to affordable expert level consultation in the field would help overcome this barrier. I also can't think of anyone I could name freely who is specialized in maternal mental health and substance use disorders. And that would be the only time I would debate sending a client to another provider because I do not consider myself to be a substance use disorder provider. And we want someone with additional training to serve to service that case. Here's some quotes about preparedness for caring for this population. I came out of residency feeling so unprepared. I still remember during residency of a patient's pregnancy test turned positive. We were all panicking, said one psychiatrist. A psychologist shared, I had some exposure to working with mother and child during my child fellowship, but no formal training. It would have been helpful to have had an option to work with this population during training. It would also be good to have an optional internship placement in a NICU. Now we'll review some of the polling results from clinicians at a national health service conference. So this conference occurred in October, 2022. It was the mental health services conference, which brings together many different mental health providers who are focused on collaborating with practical advice to influence system level change for their patients. The title of the presentation that was given was identifying and addressing treatment and training gaps in perinatal mental health care. After the three presentations, there was a Q&A session. Some of the highlights were unmet needs of perinatal persons with mental and substance use disorders, comfort and attitudes of mental health professionals in treating perinatal persons with mental health and substance use disorders, and then training gaps and resources. Poll Everywhere was used during this session to obtain real-time responses to questions. So the first question was the background of the participants. About 55% of participants were psychiatrists, followed by 19% who described themselves as other, 16% social workers, and 3% advanced NPs, counselors, and physician assistants. The majority of the participants, at 58%, had been in practice 0 to 4 years, while 23% had been in practice for 10 to 19 years. Then there was a minority, 12%, with 5 to 9 years of training and 8% with over 20 years of training. The response is to the following question. How many pregnant persons did you treat in the past 12 months? 59% said 1 to 4, 22% answered none at all in the last year, 7% said 5 to 10, 7% said 11 to 30, and 4% were seeing 31 to 50 pregnant patients in the last year. The next question was how comfortable are you in treating existing patients with substance use disorders who become pregnant? A little over a third said that they were somewhat comfortable, 22% said that they were somewhat, oh excuse me, I messed that one up. I'm going to start the slide again. So the next question was how comfortable are you treating existing patients with substance use disorder who become pregnant? A little over a third said that they were somewhat uncomfortable, 22% said that they were somewhat comfortable, followed by 17% who felt very comfortable, 14% felt neutral about this query, 8% felt that this question wasn't applicable to them, and 3% felt very uncomfortable treating this population. The next question was how comfortable are you treating existing patients with serious mental illness who become pregnant? About a third were very comfortable, 24% were somewhat comfortable, the other 24% were somewhat uncomfortable, 12% were neutral, and it was a split between 4% for very uncomfortable and not applicable to their practice. How comfortable are you treating patients who develop serious mental illness during their pregnancy or postpartum? 31% were very comfortable, followed by 23% who were somewhat uncomfortable, 19% were very uncomfortable, 15% were neutral, 8% were somewhat uncomfortable, and 4% felt it wasn't applicable. Then when we asked participants how comfortable they were treating patients who developed substance use disorders during pregnancy in the postpartum period. The vast majority, at 43%, were somewhat uncomfortable, followed by 17% who were comfortable, 14% at very comfortable, 14% for very uncomfortable, 6% at neutral, and 6% felt it wasn't applicable. What are some of the barriers that these providers found in treating pregnant patients with substance use disorders? Here, the participants were allowed to check as many answers as they felt applied, with the most common being lack of training, followed by lack of resources, lack of expert consultation, then lack of time for patient complexity during the visit, feeling ill-prepared came next, liability concerns, followed by lack of time for training, and 1% found that there were no barriers to caring for this population. What were some of the barriers that these participants found in treating patients with serious mental illness who are pregnant? The majority said lack of resources at 20%, followed by lack of training, feeling ill-prepared, tied for lack of time for patient complexity and lack of expert consultation, 8% felt that there were liability concerns, 6% found no barriers whatsoever, and 3% felt that lack of training was a major barrier. In summary, we've reviewed data collected from pregnant persons, psychiatrists, non-physician behavioral health practitioners, as well as training program directors, and what we learned is that some pregnant persons are experiencing, excuse me, what we learned is that some pregnant persons experience mental health and substance use disorders or symptoms perinatally, and they're not currently getting appropriate care. Data collected from two different sources, so attendees at the APA's Mental Health Services Conference, as well as providers who were recruited for the Maternal Mental Health Survey, showed similar results, which are that clinicians have varied levels of training and comfort in managing perinatal mental health and substance use disorders. Secondly, the clinicians also have had to seek out training for perinatal mental health disorders on their own, and often don't know how to find these resources for further training. There's also a lack of specialized perinatal mental health providers to match the need. Now I'll turn it over to our next speaker. Hello, everyone, and welcome. I am Dr. Christy Christopher Holloway. I am excited to present this section for you today. I am a licensed professional counselor in Georgia. I am also a licensed clinical mental health counselor in the state of Utah, and I am in private practice where I work with women that are experiencing infertility trauma, birth trauma, reproductive loss, and issues related to perinatal mood and anxiety disorders. So let's jump right into this section where we will discuss the behavioral health practitioner's perspective. So we're going to take a moment and just look at the surveys, the survey answers that were given as we talk about this population. So this first slide shows us a snapshot or an overview from psychiatrists and non-physician behavioral health practitioners. So what did they say when we talk about this population? We had 377 participants, and so by discipline, the majority of the participants were social workers, so licensed clinical social workers. We also had psychologists at 17%, psychiatrists at 22.3%, physician assistants, we can't see the number, but I believe it was 1.6%, and counselors, so such as LPCs or licensed professional counselors, licensed marriage and family therapists, clinical mental health counselors, that came in at 20.2%. And then we also had advanced mental health nurse practitioners. So this made up the population that was surveyed and who answered the questions as we get ready to take a look at the next few slides. So the proportion of psychiatrists and non-physician behavioral mental health or behavioral health practitioners, we wanted to find out what was their comfort level in treating individuals that had a pre-existing mental or substance use disorder and who became pregnant. So the question, I believe treating individuals with pre-existing mental and substance use disorders who become pregnant is too complex and challenging for me to treat on my own. When asked this question, this group, we had a lot did agree, they disagreed, right, very much disagreed, but we also see that 4% agreed that this was too complex for them to work and treat on their own. 18% said that, hey, somewhat agree, I somewhat agree that this is too complex or it's challenging for me. 6.9% were neutral. They were just kind of in the middle. It's not too complex. It kind of is complex. I guess maybe it just depends on the situation and what the presenting factor or factors were. And then 32.1% said that they somewhat disagree that treating individuals with a pre-existing mental or substance use disorder who then became pregnant was complex or too complex and challenging to treat on their own. Then looking at if one of their existing, so one of their own existing patients with a mental or substance use disorder wanted to become pregnant or did become pregnant. So looking at what their comfort level was and working with that patient or that client that they already had. 1.3% said that they were just going to refer out or that they did refer the patient out and that they would stop treating them. 38.7% would still work with the patient. However, they did seek consultation from someone that had more experience or that was considered an expert within this realm or within the field. And then 59.9, so about 60%, the majority of the folks said that they would continue to treat or that they do keep treating the patient on their own. So again, this is looking at their existing patients. So someone that they've already have a rapport with, someone that they've been working with that they know the history with. When we move forward with that though, and look at their comfort level in treating patients who were referred to them. So perhaps there wasn't a rapport, someone that there's not much history or information on or someone that they're getting to know. So referred a patient who has a mental or substance use disorder that preceded the pregnancy. So perhaps they've come to them pregnant, but they've had some type of mental or substance use disorder that preceded them being pregnant. We can see that those comfort levels do change with 4.8% referring the patient out and not treating the patient or stopping treating the patient. 40.6% do obtain expert consultation, but will continue to work with the patient. And then 54.9, so the previous slide that showed their existing patient, we saw that keep treating the patient on their own was about 60%. Here when we see that it is a referred patient that it is 54.6%. And as we continue with the slides in this training, you will see that what some of that has to do with would be perhaps training, education, and just the knowledge and experience that's needed. So let's take a look at some of the barriers. So in this population, again, we were looking at these practitioners who felt that, you know, who do treat this population, what were some of the barriers that were present for them when working with pregnant persons with mental and substance use disorders? So let's start at the bottom here, where we see no barriers whatsoever. So about 34% said that there were no barriers. They were fine and working with this population. They did not have any issues, any complications, any barriers, or anything that stood in the way or put a gap in working with this population. However, going back to the top, lack of available expert consultation should a problem arise. So one of the barriers was, hey, perhaps I just don't know who that I can reach out to, should this become a little more than I am well versed in or more than I, you know, know what to do. In this as well, the survey participants were also able to select all that applied. So perhaps they felt that they did not have anyone that they could consult with, but then also looked at perhaps they did not have time to complete, or I'm sorry, to address their complex presenting problems. So maybe it's based on the setting that they work in, the type of time that they have with the client or the patient, perhaps the patient's presenting issue or issues. So lack of time to address those complex presenting problems looked at 19.4%. 16.4% said that they just had a lack of time in getting that specialized training. And again, as we continue with the training and the slides progress, you will see what is required of training. And then I do not feel well prepared. So perhaps I don't have the training. I'm not prepared. I haven't gotten any experience in working with this population. That was 9.3%. And then 22.8% stated that the lack of training or expertise in reproductive mental health. Moving forward, we want to look at the psychiatrist and non-physician behavioral health clinical training director's perspective. So from the other perspective, we were looking at the folks that do work with this population. Now we want to look at clinical training directors and those programs. What did they say? So a survey, we had 165 respondents in this part. I do want to note that as you are looking at this image or looking at the details here, you will see that social workers and nurse practitioners were not tabulated in the proportions due to those lower sample sizes. So social workers had 10 respondents or samples and nurse practitioners only had two. So here's the first survey question. Does your department or training program have a women's mental health division? They were simply answering yes or no. Overall, 50 folks said yes. So about 30% said yes, they do have a women's mental health division. Psychiatry, we looked at 40%. So 19 in the psychiatry departments or training programs, 19 out of 47 said that they do have a division. In psychology, 33% or 29 said that they have a division. And then when we look at counseling and counselors, just 5% stated that they have a women's mental health division. So we have to understand that women's mental health can encompass a wide range of things, right? So then we had to break that down even further. Does your department or training program have a specific perinatal or reproductive mental health division? Again, they were answering yes or no. Overall, we see that 20.6% said yes. So not only do they have a women's mental health division, they also have a specific training program or department that focuses solely or specifically on perinatal or reproductive mental health. So overall, 20.6%. Psychiatry, 38%. And then psychology, 17.4%. And then in counseling, still seeing that 5%. So again, if you're looking at and comparing the survey questions, having a women's mental health division, we can again see that those numbers are higher. But we want to then break that down even further and see, does the department or training program have specific perinatal or reproductive mental health division? And you can see that those numbers did change there. The next survey question, how many faculty members in your department or training program have specialized training in treating women's mental health issues? So this is looking at perhaps their fellowships, postgraduate training, any of this after schooling, so to speak, this further programming, this further training that's available. Again, 165 respondents. Social workers and nurse practitioners are not tabulated in this proportion. We have an average of 3.17 with the standard deviation of 11.74. So psychiatry, responding number was 47. And so the average was 1.85. So 1.85 faculty members in their department or training program have this specialty training. Psychology, responding number 86. And so an average of 4. And then in counseling, the responding number of 20 and an average of 0.55. So not even a full body. And then the next question, how many faculty members in your department or training program have specialized training in caring for perinatal or reproductive mental health issues? So again, looking at the difference between the questions, we're looking at specialized training in treating women's mental health issues, which again, can be a wide range of issues. And then breaking this down to be more specific and looking at treating and caring for perinatal or reproductive mental health issues. So again, our average is 1.68 with the standard deviation or change of 5.17. Looking at psychiatry, we had 47 number respondents. 1.49 was the mean or the average. Psychology, 86 respondents and 1.59 is the average. And then in counseling, still seeing 20 respondents with 0.40. So again, less than half faculty, less than half of one faculty members in their department sharing this training or sharing the specialized training and experience. So again, as we continue to transition and discuss the slides, we will see what these gaps in training look like, what the requirements are, and even further barriers that may lead to some of this lack of training or specialized experience. Thank you. Hello, my name is Lorraine Burns. I'm a PhD prepared psychiatric nurse practitioner, and I am also certified but retired from practice as a certified nurse midwife. I currently practice in the clinical setting in the Clearwater Free Clinic, Clearwater, Florida, working with women mostly around trauma and other psychiatric disorders. And I am a retired faculty member at City University of New York, Hunter College. Thank you so much for being here and participating in this webinar. We're very happy to have been included in this work. And it's so important that we think about the results of much of the work that we did to improve care to women during the perinatal period. I'm going to, at this point, talk about gaps in training for pretty much the educational system. So there are gaps in quality in training. And so a lot of this work came out of reviewing the literature, surveying practitioners and professionals, educators. And there was a lack of consensus in what was required for competency in delivering psychiatric care for perinatal populations. The available reproductive psychiatric fellowship training programs are not accredited through the Accreditation Council for Graduate Medical Education. There's also a lack of qualified instructors. Most of the advanced practice nurses are educated as generalists, and this leaves a gap in expertise for specialized training. Coverdell et al. cited a lack of qualified instructors as a significant barrier to training. Another barrier is the cost of training, the time involved, and some training requirements. For psychology, and this also applies to social work counselors and advanced practice nursing, the typical cost of a two-day training can be between $250 and $500. This is in addition to submitting documentation that has a two-year requirement of experience working with perinatal populations. In counseling, continuing education in perinatal mental health ranges from three days to months-long intensive trainings, and training fees are also substantial, ranging from hundreds to thousands of dollars. Some of the data that we collected was qualitative, and this is a quote from a social worker discussing gaps in training. Quote, there's so much onus on the clinician to seek out the training on their own, and sometimes I feel like I've been in a bunch of professional developments where I'm like, wow, I could have done something a lot more productive with my time, but I wish, like you know, we had more opportunities to kind of like bring expert researchers or trainers into these like larger community-based organizations. There are gaps in infrastructure and in resources. Many programs currently lack the financial and material support to develop curricula. The majority of residency training programs that do have a curriculum on women's mental health are located in urban areas, which may contribute to disparities for training programs and patients in suburban and in rural areas. Continuing with the gaps in infrastructure and resources, this quote comes from a focus group participant, a clinical psychologist. Quote, I think in general the paucity of information available diagnostically assessment-wise and treatment-wise for this population is ridiculous, and I think in my postdoc training I worked on specifically in one of the only mental health inner city clinics that has a specialty OBGYN where they do the Edinburgh with every patient. There are potential adverse consequences of gaps in training for psychiatry and non-physician behavioral health practitioners. Perinatal mood and anxiety disorders impact 15 to 20 percent of new birthing people. These numbers are even greater in high-risk and low-income populations. Untreated perinatal mental health issues adversely impact well-being, functioning, self-care, attachment, risks for recurrent psychiatric conditions, and quality of life and beyond. A lack of trained mental health professionals across disciplines contributes to undiagnosed or misdiagnosed conditions which can lead to inappropriate treatment. The potential adverse consequences of gaps in training for physician and non-physician behavioral practitioners also includes increased rates of mental health concerns which can recur during subsequent pregnancies. Also, increased costs associated with untreated perinatal mental health disorders. Gaps in training and the potential effects of lack of access to treatment can lead to increase in substance use in birthing people and higher rates of perinatal suicide and infanticide. Untreated depression during pregnancy can lead to birthing complications such as preterm birth, low birth weight, and IUGR. Gaps in training can also lead to increased barriers to access care assessment, differential and correct diagnosis, therapeutic prevention and interventions during the before, during and after pregnancy periods. There was a lack of information on the gaps in training for diverse populations. However, unless we make a focused effort to train psychiatric and non-physician behavioral health providers from underrepresented and minority groups, persons will continue to have limited access to providers who come from their communities. Next, we're gonna talk about accreditation requirements for education and training in maternal mental health across behavioral health disciplines. Accreditation requirements in psychiatric accreditation. The Accreditation Council for Graduate Medical Education does not mandate competency in women's mental health for adult psychiatry residency training programs. Most psychiatry residency programs offer limited training in women's mental health, if any at all. In one survey of 50 residency programs in psychiatry, about 40% of the training programs had no requirements for training for women's mental health. In contrast, about 84% of OB-GYN programs surveyed offered didactic on psychiatric topics taught by OB-GYN faculty. OB-GYN programs that reported didactic led by psychiatric faculty, which was 57.9%, were more likely to have a higher number of mental health didactic in total. The accreditation requirements for nursing. As we said earlier, most advanced practice nurses specializing in psychiatry do so as generalists. The relevant nurse practitioner core competencies are the ability to develop differential diagnoses for mental health problems and psychiatric disorders, to develop age-appropriate treatment plans for mental health problems and psychiatric disorders based on biopsychosocial theories, evidence-based standard of care and practice guidelines, and also to treat acute and chronic psychiatric disorders and mental health problems, but with no specific reference to targeted populations, instead using the terminology across the lifespan. That being said, across the lifespan does include other, you know, populations including geriatrics, pediatrics, but we don't know about the accreditation requirements specific to perinatal mental health. The accreditation requirements for psychology. The American Psychological Association Commission on Accreditation is the primary programmatic accreditor in the United States for professional education and training in psychology. The accreditation process across psychology training does not require competencies in women's mental health in general, or specifically in maternal mental health for graduate students in psychology doctoral programs, for example, clinical counseling or school, or in pre-doctoral internships or post-doctoral fellowships. The accreditation requirements for counseling. Compared to the total number of licensed mental health counselors, only a few are formally trained in assessing, diagnosing, and subsequently treating the range of perinatal mood and anxiety disorders, such as anxiety, depression, post-traumatic stress disorder, obsessive compulsive disorder, bipolar disorder, and psychosis. No specific advanced degree programs exist to provide curriculum training in counseling education prior to the students learning to work with a growing and diverse population of pregnant or postpartum persons with mental and substance abuse disorders who may seek treatment. The accreditation requirements for social work. The Council on Social Work Education provides educational policy and accreditation standards for baccalaureate and master of social work programs. The CSWE sets the core competencies required for social work education. These core competencies are applied across specialty curricular guides developed by a task force composed of national content experts. The accreditation process requires competencies in engaging, assessing, and intervening with individuals, families, groups, organizations, and communities, does not specifically refer to the targeted population. This is an opportunity to develop a perinatal mental health curricular guide to serve as a resource for accredited social work programs. In conclusion, accreditation requirements across the primary mental health disciplines do not include focus requirements on women's mental health in general or specifically in maternal mental health. This is true across all disciplines, psychiatric residency programs, psychiatric nursing programs, psychology doctoral internships, and postdoctoral fellowship and residency programs, mental health counseling education, and social work training programs. I'm Dr. Helen Kuhns. I'm a board-certified clinical health psychologist and a professor of clinical practice in the Department of Psychiatry at the University of Colorado School of Medicine. I have the pleasure of serving as the clinical director for our women's behavioral health and wellness service line and have a long history of providing care to persons who are pregnant and postpartum. It's my pleasure today to summarize available education and training options in maternal mental health. After we review those options, we're also going to provide discipline-specific recommendations for deepening the education and training of our workforce in maternal mental health and provide some cross-disciplinary recommendations at the national level. Sadly, we don't have a higher education program that exists in the United States to specifically train professionals across the behavioral health fields in perinatal mental health. Fortunately, we do have training for continuing education for postgraduates and professionals who are working with birthing people. Well, I'm not going to go through each of these opportunities. We have several organizations that are listed that we highly recommend for education and training in perinatal mental health. Shortly, we'll review some of the specific groups and their focus on training in this area. One of the most complex parts of this conversation is that we have different standards of training across prescriber and non-prescriber behavioral health practitioner programs because each of our programs is self-governed. In other words, we have different governing or oversight bodies in psychiatry, psychology, nursing, counseling, and social work. And this clearly presents a problem as we're trying to deepen and dramatically improve the education and training of our behavioral health workforce to serve persons who are pregnant and postpartum. We'd like to review some of the current education and training options that may be of interest to many of you across disciplines. Within psychiatry, one of the most important sources of education outside fellowship is the National Curriculum for Reproductive Psychiatry. NCRP offers a free year-long didactic series for PGY-4 psychiatry residents in reproductive psychiatry tracks and also for interested psychiatry fellows. This is an invaluable training that, by the way, is free. The curriculum covers premenstrual mood disorders, infertility, pregnancy complications and loss, and the perianthropos with an expanded emphasis on the diagnosis and management of persons who are pregnant or postpartum. In addition, a few states across the country have created their own online toolkits that are specifically geared towards providers, especially OBGYNs, but they're entirely useful for colleagues in other disciplines as well. One of the best known is the Massachusetts Child Psychiatry Access Program, or MCPAT for Moms, which provides real-time perinatal psychiatric consultation, referrals and case management support for providers across the state to prevent, identify and manage pregnant and postpartum persons with mental health and substance use issues. We highly recommend that you look for the MCPAT for Moms toolkits and resources online. And while this toolkit is primarily geared towards providers in obstetrical settings, it has helpful information on screening, treatment and referrals for all clinicians involved in the care of pregnant persons. There are also very well-known and very high-quality training available for psychologists and social workers and counselors as well. For example, within ASRM, the Association of Reproductive Medicine, they have the Mental Health Professional Group, MHPG, which offers workshops on mental health aspects of infertility care and consultation. In addition, they offer a mental health certificate for colleagues who want to do a deeper training in reproductive medicine and especially psychosocial aspects of infertility care. In addition, there's impressive training through the National Perinatal Association National Network for NICU Psychologists. And the American Psychological Association offers a range of courses in perinatal mental health, infertility and reproductive care, as well as several important books that have CE associated with the curriculum. For the last 10 years, the Jefferson Medical College has also offered a three to four-day interprofessional training on infertility counseling. And many psychologists and other colleagues are able to seek training in perinatal mental health offered by their state psychological associations and the interprofessional group NASPOG, the North American Society for Psychosocial Obstetrics and Gynecology. These trainings are vital so that we are able to prevent, treat and better respond and manage the mental health and substance use needs of pregnant and postpartum persons. Here are some quotes in women's own voice and person's own voices that really underlie and speak to the need for better training in maternal mental health for our workforce. From a non-Hispanic white woman, an assessment specifically a medication assessment during both pregnancy and postpartum from some colleague who specializes in medication management for pregnant women and especially for lactating women. Just being able to talk with a provider and have an assessment by someone who I knew was an expert like on psychological medication and how it affects pregnant and lactating women would have been hugely beneficial. And from another individual, I wish I had more access to therapy and good services that would have actually helped me refrain from alcoholism. I wish I had more knowledge about postpartum post-pregnancy depression and its sequences and how to prevent them from a non-Hispanic African-American or black woman. I wish there were workshops with fellow pregnancy loss women facilitated by a therapist, a psychiatrist and a gynecologist. This combination would have been a perfect match for my preferred mental health services. Another patient, I would like to have had a referral from at least a therapist. A therapy session would have been helpful after delivery. So hearing person's own voice about their need for mental health and substance use care during pregnancy and postpartum speaks to the need for a vast improvement in our interprofessional training to ensure that our workforce across disciplines is really able to meet the needs of pregnant and postpartum patients. I'm gonna review some of the specific recommendations by discipline and then we'll move to cross recommendations that all disciplines would recommend at this time for further training in maternal mental health. First for psychiatry, developing a national standardized reproductive psychiatry curriculum and integrating perinatal health within core competencies across training in psychiatry. In addition, creating standardized competencies for all psychiatry residents that are codified by the ACGME, the Accreditation Council for Graduate Medical Education and ensuring that we advocate for advanced training in reproductive psychiatry through fellowships that are actually recognized and accredited by ACGME. And within psychology, our really advancing training in women's mental health in general and specifically in reproductive psychology across the entire continuum of psychology, doctoral training and across our career. So ensuring that both women's mental health curriculum and specifically reproductive psychology is throughout graduate school in coursework and in clinical rotations and continues in pre-doctoral internships and one to two year postdoctoral fellowships and that more training is available through continuing education across our professional lives. It's vital in psychology that we advance both the knowledge, clinical skills and competencies in women's health and specifically reproductive psychology which focuses on a range of issues. A few specific areas include maternal mental health, psychosocial aspects of infertility, NICU psychology and the range of other aspects of women's health and wellbeing across the reproductive years. Within psychology, it's vital that we develop competencies also to screen, evaluate, treat and minimize risks for pregnancy and postpartum mental health concerns in the broad range of marginalized and underserved communities, whether in urban, rural or frontier parts of our country. Another area for training that's vital is that we integrate behavioral health in obstetrical settings and that our psychology workforce know how to provide outstanding interprofessional care in maternal health settings, in reproductive medicine, in MFM, in labor and delivery, antepartum units and the NICU. So this integrated training should have both, should take place in both ambulatory and inpatient obstetrical settings. In addition, we need to deepen our availability of continuing education to include state-of-the-art coursework in infertility, maternal mental health, again, NICU psychology and other areas of reproductive psychology. And we should promote certification through Postpartum Support International's Perinatal Mental Health Certificate Program and certainly ASRM's MHPG Certificate in Fertility. And there are other certifications to consider across psychology as well. Within this discipline of counseling, it's important to integrate perinatal mental health within core curricula in higher education programs and again, create core competencies for working with pregnant and postpartum persons. It'll be vital for counseling programs to develop a standard curriculum that also addresses the complexity of perinatal mental health and the family system and to implement accredited advanced degree programs and evidence-based training in perinatal mental health that require continuing education, focusing on understanding the perinatal mental health period, excuse me, the perinatal period, assessment, screening and treatment. Likewise, in social work, it's essential that social work practice and interventions are created to and taught to improve maternal mental health that must extend beyond traditional health settings into community-based programs. Social work training and education needs to address gaps in perinatal mental health to and to create programs at the university level, at professional licensing level, professional development and continuing education and through professional social work organizations to address these gaps. It's also vital to increase social work research, to evaluate competencies, clinical interventions, healthcare delivery models and certainly education and training in perinatal mental health. And finally, in nursing, psychiatric or mental health nurse practitioner programs should develop and integrate core competencies in perinatal mental health and advance continuing education with integrated models of care that collaborate with a broad range of professional groups. It'll be important to identify and conduct research to again, increase the knowledge of gaps in care delivery to identify best practices in education for nursing professionals and in interprofessional models of care delivery. For nursing to have an increased focus on implementing didactic and clinical education about perinatal mental health, illness and health that's embedded already in existing curriculum and to restructure and incorporate ideas from existing programs such as family nurse partnerships which have training opportunities for nurses and often care for the mother baby dyad. So those were the discipline specific recommendations for deepening education and training in maternal mental health across all of our both prescribing and non-prescribing behavioral health providers. We'd also like to offer some four general recommendations that transcend all of the behavioral health disciplines. And the first is to truly and effectively develop and implement a national standardized women's mental health curriculum and to integrate perinatal mental health within core competencies of training for all of our disciplines at all levels. To create standardized competencies for trainees in all mental health disciplines that are also codified by each of our disciplines accrediting bodies and to advocate for advanced training in women's mental health through fellowships that should be formally recognized and accredited. It is our pleasure to acknowledge the many people who have contributed to this webinar and to the APA and CDC Foundation project it represents. This includes the APA research team and the principal investigator of this project, Dr. Diana Clark, as well as the CDC Foundation team, our science writer, and the panel members of the physician and non-physician behavioral health advisory panel drawn from the disciplines of psychiatry, psychology, counseling, nursing, and social work. Those of you who would like to learn more about this initiative can go to this website, www.psychiatry.org backslash maternal hashtag section four. In addition, for those of you who wish to see the references cited in this webinar series, those are listed in the following slides. Thank you.

perinatal mental disorders

substance use disorders

clinicians

epidemiology

clinical management

vulnerable populations

education and training

psychiatric treatment

pregnant persons

recommendations