number of talks here this week about women's health, women's mental health, and reproductive health. We're hoping to have the opportunity to talk about some of this from a different perspective in terms of what are some of the things that we need to be doing for the health of women and other individuals with uteruses and other individuals that have the risk of becoming pregnant and becoming birthing parents. So our talk today is called We Are All In This Together, Expanding Psychiatrists' Responsibility for Reproductive Health Post-Roe. I'll be starting with the introduction. My name is Dr. Garrett, and I work as a general and child and adolescent psychiatrist in North Carolina and manage Medicaid, currently overseeing the lives of 400,000 Medicaid recipients. I've worked in a variety of community mental health settings with all ages with particular focus on chronic developmental trauma and child-parent dyadic services for historically marginalized populations. I'm currently the incoming president-elect for the North Carolina Psychiatric Association and immediate past president for the North Carolina Council on Child and Adolescent Psychiatry. Also presenting with me today is Dr. Camila Arnauto, who's an addiction and perinatal psychiatrist based in Bloomington, Indiana. She's the medical director of an addictions IOP and spends part of her clinical time in a collaborative care program with an OB-GYN practice. She is adjunct professor and the psychiatry clerkship director for the Bloomington Regional Campus of the IU School of Medicine. Most recently, she's helped launch a statewide phone psychiatric consultation program available to all prescribers in Indiana. Also with me today is Dr. Mary Morial, who's a professor of psychiatry and the director of medical student education at Wayne State University School of Medicine and the chief of psychiatry at the Karmanos Cancer Center. She has published extensively on psychiatric education and the importance of maintaining our scope of practice to include a variety of non-psychiatry specific interventions including care for women's health, the full scope of psychiatric medications including use of MAOIs and older more complex medication regimens as well as medications to manage medical complications of our psychotropics. And lastly, we have Dr. Katherine Gunnison who's a board certified OB-GYN who has recently transitioned her practice to addiction medicine. She's currently practicing medication assisted treatment at Health Rights 360 and the Haight-Ashbury free clinics. She has a special interest in perinatal substance use disorder and the overlap of women's health and addiction and will be starting a primary care addiction fellowship at the Hazleton Betty Ford and Eisenhower Health Fellowship. None of our presenters today have any relevant financial relationships to disclose. Our objectives for this morning are to discuss, identify and describe most common oral and long acting contraceptives, medical eligibility considerations for different contraceptive options, demonstrate the use of one key question in patient engagement with patients with behavioral health or substance use conditions in conversations about their reproductive life plans. Also learn to initiate suitable contraception when applicable and provide patients with education related to adherence and efficacy as well as develop a plan for referral to primary care or OB-GYN for continued contraception. Also discuss educational options for integration of reproductive health curriculum into psychiatry resident training. And lastly, but definitely most important, describe the basics of reproductive rights and reproductive justice and the role of psychiatrists in meeting the reproductive needs of our patients. So first in terms of thinking about and talking about why is this important for us to be thinking about, our patients both have higher risks of unintended or mistimed pregnancies and also have worse outcomes. And so as we're considering what our role is, we need to understand both the risks related to physical health, related to pregnancy and perinatal period as well as the impact of mental health and substance use disorders on pregnancy and childbirth. In the US, about half of pregnancies are unintended and when we're looking at adolescents, a diagnosis of depression increases the risk for adolescent repeat pregnancies. So it's gonna be important for us to be talking to the teens and adolescents with whom we work about this. When looking at patients with severe mental illness, there are worse maternal and neonatal outcomes with higher rates of maternal gestational diabetes, postpartum hemorrhage, higher rates for neonatal need for ICU care and special care nursery and higher rates of preterm birth. Additionally, patients with mental illness have a higher risk of sexual violence including rape and so are at higher risk of pregnancies from sexual assault. Women with schizophrenia have double the rate of rapid repeat pregnancies as compared to women without. Additionally, when we're looking at what happens for parents once they give birth and have children, individuals with severe mental illness have eight times the involvement of child protective services as compared to those without an SMI and they also have a much higher change in living situation related to pregnancy and childbirth, 25 times more likely and we already know that there are risks around housing instability for these groups. Additionally, substance use during pregnancy is considered child abuse in many states in the US and the way in which this ends up playing out is quite disparate. So the individuals who are tested when they come in to give birth or when they come in and are pregnant is not equal across the populations that you're seeing. So when we have black women that are coming in, they're much more likely to be tested and if testing positive, much more likely to have CPS reports and some of the negative outcomes with involvement of CPS. So in terms of thinking about all of this and being aware of where we are as a nation and thinking about what we can do, what we do know is that the most effective way to reduce abortion rates is to prevent unintended pregnancy by improving access to consistent, effective and affordable contraception. However, when thinking about this, we need to look at what kind of access do the populations that we serve have to contraception and to talking with individuals around sexual and reproductive health. Who are the populations with limited access? They include adolescents, they include those without health insurance, those who are from historically marginalized populations, those who have needed to trade sex for money or drugs and those with either a current or a history of IPV. Given the limitations for many of our patients on primary care or OB-GYN access, providing these patients with discussion and with provision of contraceptive care in a psychiatric setting follows ethical principles of equity and broadening access to a potentially life-saving treatment. It allows us to improve access at the same time as we're able to work with our patients around reducing coercion and provider bias. For adolescents, depending upon the state you're in, there are issues around parental notification and consent and it's important to be aware of what your local rules are in terms of what adolescents are allowed to consent for. Additionally, a lot of teens that I work with have fears around if they do get services, is an EOB gonna get to their parent's house that is gonna indicate something about the services that they're receiving? Additionally, we know that comprehensive sexual education within the school system is limited in many areas. Many of the youth that we work with have transportation barriers impacting their ability to get to the needed services and in some states there are age restrictions on the types of contraceptives that adolescents are allowed to utilize. In terms of those without health insurance, we see this as an issue across the country but the biggest impact, especially in terms of where we're seeing how this is playing out into unintended and mistimed pregnancies is in states without expanded Medicaid with many of those states being the same states that have put greater restrictions on women's reproductive healthcare and reproductive healthcare for individuals who are seeking out terminations or even just general contraception. Other issues that come into play in terms of when we're thinking about access is not just who are the populations and what gets in the way, but from a geographic standpoint, what kinds of issues come up that prevent our patients from getting to the clinics that they might need to get to. And so this is a bit of a complicated map of the country but if you look here, 19 million low-income women and this is women up to 250% of the population, 19 million low-income women and this is women up to 250% of the poverty line live in contraceptive deserts and 1.2 million of the women live in counties that lack any health center that has the full range of contraceptive methods. So in looking at this map, anything that is yellow, orange or pink are all counties that have zero health centers that provide the full range of contraceptive options. Any of the counties here or areas here that are listed in purple have at least one and the darker purple areas are areas where the ratio of patients to health centers is better. So a darker purple area is an area where there are more health centers per population. In some ways, this looks a little bit strange because there are some areas here where it's like, wow, that's a super rural area. Why is it so dark purple? But if you've got one health center in an area and a small number of people, then that ratio is pretty high but the simplest way to look at this is if there's a purple area, they have at least one health center that provides full range of contraception. Anything that's not purple has zero. So when we're thinking about what are some of the ways to improve access, we need to think about both contraception in a proactive way as well as emergency contraception. So one of the things that we can do is not just be there and be available to provide emergency contraception if someone asks us on the back end, but really providing both within psychiatric care and in primary care settings, advanced provision of emergency contraception, talking with our patients about it. Additionally, there have been some changes due to COVID that are actually positive in terms of how it's expanded telehealth, how it's led to different thinking in terms of how individuals access care. So are there ways that we can look at connecting with and being able to provide same day or early access to OB-GYN or family practice partners through telehealth? Are there times where because of geographic limitations or other kinds of things and perhaps broadband access in our areas where we might be able to have a safe, quiet space within our clinics where folks could connect to primary care or OB-GYN services to be discussing reproductive health options? And just thinking about within your own setting, what are the options that are there? Additionally, another thing that's happening around the country is direct pharmacy access for oral contraceptives. And so 21 states and DC allow pharmacist prescription of contraceptives, and which is wonderful. And at the same time, I think this is where it's incredibly important to be aware of we are doctors, we are physicians, we are able to and should be the ones thinking about talking with our patients about these things and prescribing them. It does fit within our scope of practice. And then thinking about when are the settings in which we might want to consider initiating oral contraceptives. So the focus of today's talk is gonna be on our discussion with patients about reproductive health and contraception, when and if to prescribe emergency contraception, when and if to prescribe or initiate oral contraception, and also how to talk with our patients about reproductive life planning and what to do if we're talking with them and they're interested in getting pregnant. And is it gonna be a different conversation than if they're wanting to prevent pregnancy. It's also to have a deep enough understanding of currently available contraceptive methods and understanding the clinical, political, and legal landscape of your practice community to know how and when to consult and refer to primary care and OB-GYN, and the best ways to support your patients in their own reproductive autonomy and justice. So some of my other colleagues are gonna talk a little bit more about emergency contraception, but I think being sure that you have awareness of it, that you understand how it can be accessed both over the counter and prescription, which kinds are available in which settings, and being aware that despite some of the concerns that have been raised, there is no evidence to support that there's an increase in risky sexual behavior or lower use of proactive contraceptive methods through prescription or provision of emergency contraception. And the other piece that we know is that the same populations that are having limited access to proactive contraceptive methods are the same ones that have lower access to emergency contraception. And we also, as we're regularly interacting with our patients, we are likely to be the ones who are encountering patients who have recently been in a setting where there has been a condom break or unprotected sex or sexual assault or something that has happened that puts them at risk for pregnancy. Dr. Morial is gonna talk a bit more about some of the learning tools available, but these are some great resources to be looking for after the fact. So then lastly, as we're sort of thinking about what are our responsibilities and what are our opportunities, we have regular contact with mentally ill and substance-using patients of reproductive age. We have close relationships with our patients, which allows for confidential opportunities for discussion. And we have training in motivational interviewing and in other areas to help patients explore their ambivalence around pregnancy or around contraception. We can utilize the knowledge that we have about our patients to support decision-making around contraceptive care and provide decision support around management of pregnancy. We should be acting as advocates for our patients with other health professionals. We care for patients with higher risk for maternal mortality and morbidity. And our patients are more likely to have extended gaps in contraceptive coverage and fewer months of contraceptive coverage. And then lastly, we prescribe medications that have high risks of teratogenicity. And so we need to be willing to look at that and discuss how are we ensuring that we are responsible for the care that we're providing. So as you're listening to my other co-speakers' talk, I want you to think about how much you integrate some of this into your workflow if you're not already doing so. What are some of the aspects of thinking about reproductive healthcare that you might consider as universal in your work with patients of reproductive age? What would you need to feel comfortable and competent with prescribing emergency contraception and or starting oral contraceptives? What would you need to feel comfortable in reviewing all of the available contraceptive options with patients, not just oral contraceptives, but implants, IUDs, barrier methods, and others? What kinds of relationships do you currently have with primary care or OB-GYN in your community or practice setting, and what do you need to develop because you don't have it yet? Where do you live, and does the state or local legal landscape in which you live and work impair your ability to address any aspect of reproductive health with your patients? And also, do you work in a religious institution that doesn't allow for the discussion or prescription of hormonal contraceptives? So next up is Dr. Ornado, who's gonna be talking about reproductive justice. All right, thank you so much. So I'm gonna expand a little bit on some of the concepts that were just discussed regarding a little bit more about contraception and social justice, and also the role of the psychiatrist, and like Dr. Garrett said, the opportunity that we have to make an impact in this area. First of all, we need to think about this sort of organizing, these organizing principles in terms of access to contraception. It needs to be free of structural racism, gender discrimination, and socioeconomic barriers. And all currently available forms of birth control should be offered to all reproductive age people. Coercion and intimidation have no place in this discussion. This may seem obvious to us, but historically, what has been offered to different populations has been disequal. People offer certain options. People tend to offer Depo-Provera more readily, for example, to African American patients, thinking that they have biases towards their ability to keep up with pills, or historically, there were recommendations from, for example, like pediatricians not to use IUDs, and then later, for teenagers, then the recommendation became they should be used. And so we're kind of making decisions based on what we offer to people, based on our own biases of what they would accept. And the idea really is to offer people all the options, but then think with them about what it would mean to do any of these options in their actual life. And again, I think that's where psychiatrists, because they know their patients better than a lot of other physicians, have a particular opportunity to help. And then additionally, the decision based on whether someone is interested in being pregnant or not is up to them. So we don't need to be coercing individuals into birth control or into not using birth control. They have to be able to decide based on how they, what they see about their lives. And the other really important thing that I'll be discussing, or I'll bring it up now, is pregnancy ambivalence. So I think we tend to think in black and white terms, like, oh, intended pregnancy or unintended, whereas for most people who have been interviewed on this topic, who've become pregnant, quote unquote, unintentionally, it's not really unintentionally, and again, psychiatrists are well poised to understand this, that there's quite a bit of a pregnancy ambivalence. So people who say they're not intending to get pregnant are also not using birth control. And as a perinatal psychiatrist, I spend a lot of time talking to people about this and trying to understand with them what that means, to say you don't wanna be pregnant, but they are sexually active without birth control. And I think sometimes it means for people that they wanna get pregnant, but they don't feel they can articulate that or say that consciously. Other people, there's many other less positive situations that can be happening, such as the partner doesn't allow birth control or their IPV situations or their sex workers, et cetera. So there's a range of options, but this idea that pregnancies are either intended or unintended is too black or white, and that this is definitely an area where psychiatrists could have a really important role in helping patients to untangle their feelings and make decisions about their reproductive choices and options. Obviously, the benefits of contraceptive care is that it allows people of reproductive age to make a decision and then to follow through on that decision, hopefully. It provides autonomy for survivors of domestic violence, and it helps to manage certain medical conditions. And there's many people who are on birth control not for, or oral contraceptives, for example, not for contraceptive purposes, but to balance hormones or to reduce certain effects of conditions. It also lets people delay pregnancy, or yeah, delay pregnancy so they can complete education, create better financial stability, pursue professional opportunities, and have the desired birth space that they may want for their families. Relating this all back to mental illness, I mentioned coercion earlier to kind of set up for this part of my presentation, that historically, patients with mental illness have been coerced into sterilization. I'm gonna bring up a next slide on North Carolina, but many states have done this. Massachusetts, where both Dr. Garrett and I trained, had some of these laws. Eugenics was a big problem in the United States, and that's part of what drove some of this. And currently, with the overturning of Roe versus Wade, many people are being forced to carry pregnancies to term due to abortion restrictions. There's a lot of misunderstanding. I'm in Indiana. There's people who already think that abortion's illegal in Indiana because of certain bills that have passed, but it's not illegal. People can still access it. So there's people who are carrying pregnancies that they don't want to term, both because part of it has been made illegal, but also because there's a lot of misunderstanding of what's still allowable. So this all means that pregnancy decisions have often been outside of the control of people, of all people, but particularly of people with mental illness. And the use of contraceptive care and prevention of pregnancy may be of even greater benefit for our patients, just as Dr. Garrett had said, because they are at greater risk when they become pregnant. So this is a couple of slides that Dr. Garrett kindly lent me from a pamphlet giving information on some of the selective sterilization that went on in North Carolina that particularly sterilized people with mental illness. So I'm using the term mistimed pregnancies here, again, to kind of bring up the fact that unintended versus intended is a misnomer maybe. But the risks, when you restrict contraceptive access, people tend to become pregnant without thinking about it, and often this tends to lead to delayed prenatal care because they're not really aware that they're pregnant. There's also a greater risk for mood and anxiety disorders. There's increased risk of alcohol, tobacco, and drugs, both during and after the pregnancy. there's decreased rates of breastfeeding, increased risk of food and housing instability and greater financial hardship. But the most concerning risk of restricting contraceptive access is actually maternal mortality. And the reason this is true is in contrast, so first of all, being pregnant in the United States carries a greater risk of mortality than many other developed nations. But more importantly, maternal mortality is one of the leading causes of death for people in the reproductive age. So for non-pregnant women, this is on women specifically, not to exclude trans individuals, just that this is how this particular research was done, but in contrast to non-pregnant women who are on contraceptives and are 15 to 34 years old, their risk of death is one in 1,667,000. So it's about the same risk as being struck from lightning, whereas maternal mortality in the United States is 15 deaths per 100,000 live births. And the risk is higher for black and Hispanic women. In terms of pregnancy-associated deaths, overdose on opioids and suicide are two of the leading causes of pregnancy-associated deaths. And this has been rising, it rose through the pandemic. In some states, it has evened out. In other states, it's still rising because we're still, and also have to keep in mind that the maternal mortality review committees are still reviewing the deaths that were occurring because it's usually a year or two behind, so people are still reviewing 2021, 2022 data. But the bottom line is these deaths tend to occur at higher rates in patients with addiction conditions and mental illness. So again, preventing pregnancy in these populations is particularly lifesaving. Just another graph, this isn't directly about contraception except contraception and abortion restrictions. States that are more restrictive on abortion also tend to have more limited access to contraception, which is a very important reason to have psychiatrists get more involved in prescribing. Where people are not able to access abortions, they're also less likely to be provided with or offered birth control. So to show that in states with access to abortion, there's also higher rates of maternal death, and more importantly, higher rates of maternal death in black and Hispanic individuals. This is just a graph of what I was explaining earlier regarding the lack of access to both birth control and abortion, and particularly for black women. The case of black women is particularly important to consider because there's quite a lot of bias and misunderstanding of their reproductive rights, and importantly, there's a decreased likelihood that they'll present for care, both to obstetricians and also to psychiatrists. This is a piece of art, many of you may have seen the original image of this, which had the black woman whose body Betsy, who was experimented on, and this artist in Alabama has turned the tables on this drawing and has put Marion Sims, the doctor who did all the experiments on black women without being anesthetized, as the subject of the experiments. But the idea being that historically, OB-GYN, the history of OB-GYN has victimized black women. Obstetrics and gynecology really isn't very far behind, and so the fact that they're less likely to present for care, and thus less likely to be offered contraception, is higher. This is the monument to Lucy, Anarka, and Betsy, the enslaved women that were experimented on. In terms of a timeline of racism in the United States and restricted contraception access, restricted... Oh, that's in the next slide. This is a history of coercive contraceptive practices for African-American patients, and we can see... Actually, it's not just for African... Yeah, it is, it is, sorry. You can see here that there was... Obviously during the time of slavery in the United States, there was coercive sterilization without people's knowledge, that continued actually up until the 1970s, and in the 90s, there were states that passed coercive laws requiring recipients of food stamps to accept long-acting contraception in order to access the benefits. In the 2000s, California Department of Corrections paid doctors almost 150K to sterilize women prisoners as well, and we all know that people who are imprisoned aren't really able to give informed consent. In 2017, a Tennessee judge was reprimanded who offered to reduce sentences for patients who accepted long-acting reversible contraception, and then in 2018, South Dakota Medicaid did not cover long-acting reversible contraception if the reason for the removal was to become pregnant, which is the main reason that those are removed, obviously. The idea is, historically, we have not really provided patients with an option of what kind of contraceptive care they want. We've gone in both directions. We've both forced sterilized patients, and then also now forced people to carry pregnancy to term. What should we be aiming for in terms of high-quality health care for contraceptive justice? First of all, it needs to be person-centered, so as I said in the very beginning, the individual coming in for care should be deciding on what they want. It needs to be confidential. It needs to be comprehensive, i.e., providing all the ranges. It needs to be medically accurate. As we know, a lot of the abortion laws, for example, in Indiana, there was a law where you had to tell patients that abortions could be reversed, that you could reverse an abortion. We all know that's not possible, but it's something that they wanted to have patients be told. Doesn't make sense, but it's part of an attack on reproductive rights and choice. It has to be developmentally appropriate. It has to be LGBTQIA plus affirming, so using language that allows people to feel included and not stigmatized. It needs to be accessible, both financially and physically. It needs to be trauma responsive. It needs to be culturally and linguistically affirming. It has to be harm reduction grounded. It needs to be pro-choice, sex and body positive, and challenging of explicit and implicit biases, shame, and stigma. It may sound like a lot, and I kind of broke it up here, but I think the projection, you guys can see it well, so we don't think we need to use these two slides. Even though it may seem like a lot of different areas, it really just means be informed of all the options. Listen to what your patient wants. Many times, a psychiatrist will need to help them articulate what they want, because there is so much pregnancy ambivalence. Not making an assumption, but asking more questions about what they're doing and what their sexual activity is like, to make sure you're making all the appropriate recommendations. That concludes my part of this. Next, Dr. Mary Morreale will speak about what are the educational implications for this. Good morning. I am going to speak to the educational implications, both from the perspective of educators in residency for psychiatrists, as well as our own education, learning how to ask women about their reproductive wishes. I think we can all agree that we, as physicians, have arrived at this post-Roe world with pretty limited planning. I think as we move forward, we have to think as individuals and as institutions and educators how we can plan for circumstances where women are not going to have access to abortions. As Dr. Garrett said, one of those ways is to provide adequate contraception, and thus the title of this lecture, which is We're All in This Together, that we really all need to be a part of this issue and solution. What we know from surveys of resident physicians is that they are interested in providing reproductive healthcare for their patients. The main concern when we look at residents and their desire is that they want to be able to protect women from teratogenic drugs. There was a case in our residency program where a woman came in who was inherited by one of the residents who was prescribed Depakote and was not taking any birth control. As we all know, that is one of the potentially most problematic medications that we prescribe for teratogenicity. If there is not access to a quick referral for contraception, then we should be able to provide that, and in doing so, protect our patients and potential children. Education in psychiatry residency at this point in time is not standard. I certainly didn't receive any education on this. The existing literature supports that psychiatric residents are not comfortable prescribing contraception. I was actually surprised that a third are. To me that seems like a high number. I don't know if that was right after medical school in the first year of residency where there still is some comfort with clerkships, OBGYN clerkships, or perhaps electives taken during the fourth year. Residents cite limited training, no surprise, limited knowledge, and lack of clarity regarding drug-drug interactions between oral contraceptives and the drugs that we prescribe. Due to lack of training, it's not surprising that residents are also not confident in prescribing contraception. And in both of the articles cited, so it was by Macaluso and Zatloff, residents voiced concern that this is just not in our scope of practice, that should we be doing something that we don't consider to be in our scope. So is this in our scope of practice? It's already been discussed that in multiple U.S. jurisdictions, pharmacists can prescribe contraception without a relationship with a physician, and that the majority of countries around the world offer oral contraception without a prescription. There is good news related to this. The FDA is actually strongly pushing for one medication to be approved as an oral contraceptive over-the-counter. So it looks like we are moving in this direction. And I think it was brought up, we are physicians. Theoretically it is in our scope of practice to prescribe all medications. We're physicians. And I think it's a matter of this discomfort and lack of confidence that's getting in our way. So how do we support psychiatrists to feel that this is in our scope of practice? I was in two lectures. You were actually also in one of them I believe where we discussed this, that we would love to have a clear statement from the American Psychiatric Association saying, it is appropriate, it is right for us to be discussing contraception with our patients and prescribing it when applicable. And I think that there was some positive response from lecturers that are in that work group that that might be something that will be considered. For residents, we need to send the message that this is appropriate. And that message is sent by education. If we educate residents to prescribe contraception, then we are certainly giving them the tools with which they need to do so. And then finally, for those outside of residency programs, I think that there should be advocacy for hospital policies where our institutions are saying that it's okay for us to be prescribing. And again, this case of the woman who came with Depakote to our resident clinic, the residents actually wanted to prescribe contraception before the patient, because it wasn't going to be a that-day appointment where she was going to be seen. And the attending physicians who were working with her did not feel comfortable supporting that because they believed that it wasn't in scope of practice and it was not hospital policy for psychiatrists to be prescribing. So how do we start asking women about their reproductive wishes? The Oregon Foundation for Reproductive Health developed one key question to help us do this. And it's been studied in primary care populations and been shown to increase rates of contraceptive counseling. It's simple. It's the question, would you like to become pregnant in the next year? So we should be asking all of our reproductive-age patients whether or not this is their desire. And then depending on their answer, we will make a plan with them. So if they answer yes, for psychiatrists looking at the ACOG guidelines, there are areas that are pertinent to us. So for example, we can be prescribing folic acid. And we can be reviewing current medications that they're taking that could be potentially problematic, as well as tobacco use and substance use. And then finally, we could refer to an obstetric practice. We should refer to make sure that their healthcare needs are met and that they're involved in appropriate care. If a woman says a clear no to this question, then we should be inquiring, what are you using for birth control? Is this a safe and effective method? And if there's no current contraception that the patient is taking, then we should either help them to make an appointment in the office that day with either OB-GYN or family practice. And if that's not possible, our argument is that that's when we should be prescribing, that it should start right there. If a woman is ambivalent, so if she answers, I don't know, I'm okay either way, then we need to further explore. We do know that, and this is not surprising, that women who answer this with uncertainty are more likely to have an unwanted pregnancy. In this circumstance where a woman is unsure, she should also be offered folic acid supplementation. And if not using a current birth control method, we would go back to that no. We would either get her in to see somebody as soon as possible, or potentially begin prescribing on our own. Finally, we are not saying here that psychiatrists should be prescribing birth control for the long-term. We are suggesting that in situations where it is at the best interest of our patient to meet their reproductive needs, if we can't get them quick care to do so, that we begin that process. But the goal would be to establish care with either an OB-GYN or family practice. I say OB-GYN and family practice because their ACGME requirements both include prescription of contraception, not to say that an internist or somebody else wouldn't be doing that. So for those, there's just one slide here about education for those who may be interested in that aspect, residency education. People have discussed this in the literature. And the bottom line is that any curricular efforts for our residents should involve both psychiatrists and either OB-GYN or family practice, again because of those ACGME requirements. And the reason for this is that residents should be taught to prescribe contraception with our patient's needs in mind, thinking about the medications we prescribe, thinking about potential capacity issues, and perhaps cognitive impairment and issues pertaining to consent. Curriculum would ideally begin early on in residency where residents can build on the knowledge that they developed in medical school. And potentially there should be some sort of relationship ongoing with OB-GYN or family medicine where when a resident is in a bind and doesn't know what to do in a particular patient situation, there can be a way to contact members of those departments for immediate assistance. So additional resources, the CDC does have a free app. It's the Contraception app that can be downloaded from the App Store. This has concrete recommendations for choosing and initiating contraception. It talks about specific characteristics and medical conditions. The University of California San Francisco has a program called Beyond the Pill. It's a free online course for clinicians that includes education on many types of contraceptives. And then in my opinion, it would be ideal to have some sort of portable or online curricula available for residents and physicians where we could access something that would give us some quick guidelines for prescribing. Perhaps this could be with ACOG and the APA or just ACOG, but both for individuals and to integrate into residency curricula. Because not all residents are in systems where there is broad resources from other departments for education. And then finally we have Dr. Gunnison. »» Hi, I'm Katie Gunnison. I am an OBGYN and my portion of the talk is going to be about pregnancy prevention, specifically the basics of prescribing contraception. And I'm also going to talk a little bit about maternal death rates and why this is important right now. So I think we're all familiar with these events. June 24th of 2022, there was a Supreme Court case, Dobbs v. Jackson Women's Health Organization, where the U.S. Supreme Court determined that the Constitution does not protect a pregnant person's right to abortion. As a result, prior Supreme Court cases like Roe v. Wade and Planned Parenthood v. Casey were overturned. So this sent the power back to the individual states to regulate their policy on all aspects of abortion. So this is a map I got from CNN. It's from dated March 20th of 2023. And it depicts by color the abortion policy in the 50 states. So green is where abortion remains legal. This light tannish color is where policy is still in limbo. The lighter orange is legal with gestational limit of 20 weeks or less. And the red state, the reddish orange is where abortion is banned or severely restricted. I'm sorry. Yeah. Florida is 20 weeks? It's only six weeks. It's probably changed. This is dated. It says 20 weeks or less, but it's March 20th of 2023. And North Carolina and South Carolina have both also changed since that time. North Carolina a couple of weeks ago switched to 12 weeks, except for with severe fetal anomalies it can be later. And then South Carolina, I haven't read about this, but I've seen there's some recent articles that I think literally this week they passed a six-week ban. Yeah, so this is, you know, an ever-changing process, but, you know, based on this map, we have 14 states in this country that have completely banned or severely restricted abortion, which is significant. I wanted to go bring up this article, the maternal mortality consequences of losing abortion access. It's a study out of UC Boulder in June of 2022. Using national and state abortion incidence data, the authors quantify the increase of maternal death that would occur as a result of a total abortion ban. So as stated, this figure is representative of a total abortion ban across all 50 states, which we do not have, fortunately. It demonstrates a 24% increase in the number of maternal deaths, and for non-Hispanic black persons, a projected increase of 39%. And the authors note that although we don't have a total abortion ban, the states with the highest maternal death rates have the most restrictive policies in general. So I wanted to go over, I know Dr. Arnotto touched on this, the U.S. maternal mortality rate. Out of all of these countries, high-income countries, the United States has the highest maternal death rate of 23.8 per 100,000 live births. Looking at countries like Japan, it's 2.7 out of 100,000. New Zealand is the closest behind us, and it's 13.6 per 100,000, and again, non-Hispanic black women are disproportionately affected with a rate of 55.3 per 100,000 deaths. So why am I highlighting this? Why is this important? Well, I think we all know that abortion is a controversial topic. It's become political. But at its core, it's actually a medical procedure that can save women's lives. Without having access to abortion, many lives are going to be lost as a result of this. So that's sort of the purpose of this talk. We need all hands on deck in terms of preventing pregnancy. I think it's really important work right now, given what's going on. So I also wanted to mention this study. It's called the TurnAway Study. It's out of UCSF, the Bixby Center for Global Reproductive Health, which also runs Beyond the Pill. And it's looking at the effects of unwanted pregnancy on women's lives. And the study is to describe the mental health, physical health, socioeconomic consequences of receiving an abortion compared to carrying an unwanted pregnancy to term. So denying a woman abortion creates economic hardship and insecurity, which lasts for years. Women turned away from getting an abortion are more likely to stay in contact with a violent partner. They are more likely to raise the resulting child alone. The financial well-being and development of all children in the household is negatively impacted when their mothers are denied an abortion. And giving birth is connected with more serious health problems than having an abortion. So I think it's pretty evident that being denied an abortion not only affects a woman's physical health, but also her mental well-being and level of functioning. This is a great handout. It's from the beyondthepill.ucsf.edu. These handouts are available to print. I emailed the program to ask, because they did mention they could send handouts. But they're backordered right now. So printing is probably your best option. So in the top row, in the orange, we have the contraception that works, quote, really, really well, five stars. These are the long-acting reversible contraception, and then also permanent sterilization, the implant, the hormonal IUD, and the non-hormonal IUD. These are obviously not things that we would expect psychiatrists to be doing in their office. They involve a procedure. So the ones I'm going to focus on are this row of four stars, pretty well, work pretty well. This is our hormonal contraception. We have the combined oral contraceptive pills. The patch, the ring, and progesterone-only pills. Then the Depo-Provera shot is again not something that would be expected to be given in a behavioral healthcare provider's office. On the bottom row, these are the three stars, they don't work as well. So the pull-out method, cycle tracking, and barrier methods, although barrier methods are protection from STDs. There's this little fact in the bottom right-hand corner that just kind of caught me off guard maybe because I'm not really a young person anymore, but 90 to 100 young people without using contraception will get pregnant within one year. So I wanted to take a minute to go over the contraindications and this is certainly not an exhaustive list. It's just the ones that when I'm prescribing, especially contraception with estrogen that I think about. And that's anything that's going to increase your risk of blood clots. So obviously a history of a blood clot is going to be an absolute contraindication. One that comes up a lot and I've seen myself and colleagues kind of skip over this one is migraine with aura. Migraine with aura does increase risk of clots and is an absolute contraindication to contraception with estrogen in it. Hypertension and smoking are relative contraindications. It depends on the control. It's kind of a risk-benefit conversation with the patient. And then another one, breast cancer, it affects one in eight women. So it's an absolute contraindication. For more information, this is the U.S. Medical Eligibility Criteria for contraceptive use. It's on the CDC website. On the X-axis we have like the different types of contraception. And then here on the Y-axis, sorry to get mathematical, we have like the different medical conditions. And then looking at the chart, a green is going to be no risk and a red is going to be like an absolute contraindication. There are a lot of medical conditions on here, but again, for behavioral healthcare providers, it's not expected that you would handle contraception in a woman with complex medical problems. That would go to an OBGYN or a family practice physician. I wanted to take a minute to talk about side effects. So the most common side effects are probably nausea, headache, breakthrough bleeding or bleeding between cycles. And there's one more, mood changes, which is relevant to psychiatry. But usually what we do is just continue the contraception for two to three months if it's a tolerable side effect and see if it goes away. But again, if there are complications, side effects, it would be totally appropriate to refer out to OBGYN or family practice. These are some basics on starting contraception. So for oral contraceptive pills or even the patch or the ring, I should mention the patch is applied weekly for three weeks and then the patch is left off for the fourth week for menses. And the same with the ring. The ring goes in the vagina for three weeks and then is removed on the last week. So for greatest effectiveness, we want to try to start the contraception on days 1-5 of menses. But it's only five days out of a 30- or 31-day month or a 28-day cycle. So a lot of women are going to come in and they're not going to be in this part of their cycle. So you can do a quick start where you can start contraception at any time during the cycle. It's just recommended that the patient would use a backup method for seven days and you want to get a negative pregnancy test. And then just a word about progesterone-only contraception or pills. They are safer because they do not have the estrogen. They do not increase risk of blood clots. But they are less effective. It's very important that they're taken at the same time every day. So usually I just have my patients set an alarm. And I know this is another handout from Beyond the Pill. It's about emergency contraception. The most effective is the copper IUD, obviously not going to take place in the office. And then there are two pill forms of emergency contraception. So Ella is a progesterone antagonist. It prevents ovulation. You can use it within five days. Over 195 pounds, it's less effective. And then Plan B, it's a progesterone agonist. It's about 89% effective. If used within the first 72 hours, you can — I'm sorry, Ella is the one you can give up to five days. But with Plan B, over 165 pounds, it may be less effective. So Plan B is available over-the-counter. You can get it on Amazon. But it does cost $40-$50 out-of-pocket. I think most insurances are covering Plan B. I know the Medicaid in California, Medi-Cal, definitely covers it. So it's free to the patient. So I think, you know, it's something that is important to prescribe if a patient asks for it. I think that's it. »» So Dr. Gunnison, before you sit down and we start the panel discussion, one of the things I wanted to ask you about is many of us trained during a time when pelvic exams were part of the standard of care before prescribing oral contraceptives, at which time it was appropriate for a psychiatrist to not be doing this because we should not be doing pelvic exams on our patients. So I was wondering if you could speak to, at this point, sort of what's the standard of care in terms of any exam that's required before starting contraception? »» So I finished residency in 2015. And when I trained, a pelvic exam was not required for starting contraception. What was required and what I always insist upon is a blood pressure reading just to see where that is. Because as I mentioned earlier, hypertension is a relative contraindication. So yeah, anything that can be taken orally, you don't need a pelvic exam. Obviously if you're going to be doing an IUD insertion, then you're going to need to do a pelvic exam. But you know, not really relevant to behavioral health providers. And the first pap smear happens at 21. So if we see a woman in the office who's 19 and wants oral contraceptives, we do not do a pelvic exam unless there's some kind of complaint. »» And then I actually have a question for you too since you're up there. So from the perspective of if I'm going to prescribe something, for the sake of ease, would it be a progesterone-only oral contraceptive? What would be your go-to for one of us? Where would you suggest we start? »» I would not. If there are no contraindications, I would do a combined oral contraceptive just because they're more effective. I mean, I think most providers have their favorites. Mine is something brand-name Levlin and then it's Levinorgestrel and then ethanol estradiol. I don't know. You can kind of, any of them are acceptable. You can just see which ones your patients like the best. »» So it would be if there was a contraindication to that, then it would be acceptable to use a progesterone-only. »» Okay. »» Yeah, just with appropriate counseling about taking it at the same time every day and that it's not as effective. »» Okay. »» I have a question. I have a question too. Can you talk about if psychiatrists did decide to prescribe some of the emergency contraception that you talked about at the end, can you tell us like what the contraindications to those are and sort of how you might tell the patient what to expect? I know people can have a lot of side effects and feel pretty ill. So if a patient came in and said I had unprotected sex, I really want one of these things. We know Plan B is available over the counter, but we're going to tell them, okay, here's what you would do. How would you talk to someone about that? »» I think, you know, Ella is a progesterone antagonist. And then with Plan B, which is a progesterone agonist, it is levonorgestrel. It's just in a very high dose, which is a common progesterone that's used in oral contraceptives. I would just counsel them the same side effects as birth control, but maybe, you know, more significant nausea, headache. They will likely have bleeding. They should have bleeding. You could also prescribe some like ibuprofen or Zofran contraindications. Off the top of my head, I would think some history of cancer, like that would probably be something, but I'd honestly have to look it up. »» Do you tell them anything about like amount of bleeding? Just because I know for a lot of our psychiatric patients, they have a lot of anxiety about things related to their body. When I work in the OB-GYN clinic, a lot of these patients talk to me about how much bleeding they're having from various things because I find that OBs are not very impressed by bleeding. I mean, they are a little bit, but they're not nearly as impressed about vaginal bleeding as the patients are. So I spend a lot of time sort of hearing about how much bleeding they're having and then relaying it back to my colleagues. So in terms of if they take one of these Plan Bs or Ella, how much bleeding should we tell them? Like if it's more than this, you know, what should we say to them? »» Our rule of thumb is always one pad per hour, like soaking a pad per hour for more than one hour straight. »» Okay. Thank you. »» That's like a normal size pad, not a panty line. »» Thank you. »» Yes. »» So we're recording this. And so if you can go up to the microphone because we want to make sure that anybody who's hearing this after the fact, here's your question. »» I had a question and a comment. So I was medical director at a large community mental health center. We treated thousands of patients, you know, like 35,000 a year. And I was involved with the liability carriers during every renewal period. And they were very clear. We had to specify what our scope of practice was going to be. So as outpatient providers, the physicians, nurse practitioners, we were not to go beyond the scope of practice. Otherwise the coverage would not apply if we did, you know, seizure management or birth control or even hypertension or anything like that. Because you know, we know our outpatient seriously mentally ill patients do not take care of themselves. They have metabolic problems, they have high blood pressure, they do not go to their PCP. But our liability carrier wouldn't cover us beyond the scope of practice except for places like the inpatient unit. So in the CSU, if we were continuing what they were taking or we started them on something, that was okay. We didn't have to specify that. So how do you, you know, how do you approach that? What do you do for that? »» So Dr. Saha, I'm glad you brought that up because I think that's a really important point and something that we've talked about. And actually my hope would be perhaps next year at APA to have PRMS or the other malpractice agency up here with us on stage kind of talking about from the malpractice standpoint what do we need to be considering and what do we need to be including. I think that at this point we have more positioning to be trying to argue with the malpractice carrier on the front end. Like if you're in that position as a medical director of a community mental health agency or others, as some of these things also are becoming over the counter, right? They're becoming over the counter and they're within the pharmacy scope of practice. I would be interested in sort of going toe-to-toe with them on like emergency contraception in specific. Like I don't see where that should be considered outside of our scope of practice. At the same time, I think there are a lot of people that are afraid of prescribing some of this. I know in one of the large physician Facebook groups recently this person posted anonymously which was probably good given the response that they received. But it was a primary care doctor who had posted, I had a patient call. They recently had unprotected sex. They wanted to get emergency contraception and they say that their OB-GYN has retired and so they don't have one. Should I prescribe it? I don't feel like I should. It should be the OB-GYN. Thankfully, that person basically got roasted in the hundreds of comments after the fact because it's like, yes, you're a primary care doctor. You 100% should be prescribing emergency contraception and should be comfortable with this and the fact that you are saying, I don't know, maybe it should be OB-GYN is reflective of a problem in general in how we treat sexual and reproductive health. I think it speaks to that, oh, it's got to deal with a uterus so let's push this onto this very narrow group of people. I think that's where with the malpractice situation, I think we have the opportunity to advocate. That's where with, if we're looking at APA and then making a statement, a position statement or a white paper, I think the more that we can be able to show that this is the standard of care, like if APA had a white paper position statement and malpractice is saying, hey, you shouldn't be doing this, I think being able to show actually this is the standard of care within what our professional organizations are saying that we should be doing. And I think too, in the short term, documenting conversations with OB, so my patient, we're going to put our patient on Depakote, they can see the OB in a month. In the meanwhile, we've collaborated with our colleague, that is their main thing. They're recommending we go ahead and start this until they can be seen. We've done the appropriate recommendations in terms of contraindications, et cetera, to say this is not a long-term solution, but in the short term, we're going to look at risk benefit and best interest of the patient. We're not saying that we're now OBGYNs and going to take over all prescribing for all term. But obviously, if your specific malpractice company has said you may not do this, and it's explicit, and you're in the contract with them, I understand that you can't go against that. But if that's not explicitly stated in your malpractice, I agree with what Dr. Garrett is saying, once APA officially makes that recommendation, and then until then, if you come into situations where it's in the best interest of the patient, I would document. And that's actually the same thing that OBs do now. I run one of the perinatal access programs, so we do phone consultations with OBs. So sometimes they're doing things that their malpractice might think is outside the scope of practice, for example, bipolar treatment. Again, we live in Indiana. We have a psychiatry desert for the entire state. We have many counties without psychiatrists. And OBs have to sometimes do bipolar care for pregnant people, which even psychiatrists won't do. Psychiatrists stop their meds. The OB now has to do it. I had a psychiatrist recently start a person who has bipolar, took them off their stabilizer and put them on Zoloft, which absolutely makes no sense. The OB called me and said, I think the psychiatrist doesn't know about this. What should I do? So the OB is now doing bipolar care. And of course, their malpractice is not going to be very excited about this. So we are providing, we provide documentation of recommendations so they can say, hey, we reached out to the psychiatrist who provides the statewide consultation. They document our recommendations. And then, of course, we work to get the person into an appropriate psychiatrist. But in our state, that can be many months before that would happen. And again, some refuse to provide care for people who are pregnant. So I think a lot of the specialties are facing this. And I think the pushback with the malpractice companies goes back to what was stated in the very beginning. We are physicians. Technically, we can prescribe any medication. we all went to med school and just getting it doing it appropriately and helping each other out when there are so many physicians physicians or shortages doing it responsibly. And we just have to advocate and figure out how to have it all included within our practice. And Dr. Morial, I know you had spoken a little bit earlier about hospital policies and some of that. And so I'm wondering if because I would imagine it could come up similarly within a hospital setting where folks might be told by their departments what they're allowed to prescribe or whether they're allowed to prescribe. And I think, again, that's similar to what Dr. Arnotto was saying. I think if we had a statement, then we would say this is this is being remarked. You know, this is our scope of practice. Why is it not in our scope of practice? And I think that that's sort of the the bottom line here is that that I think we're all coming to terms with the fact and in the previous lectures that we went to that I've gone to, it came up in two. So I think this is sort of where we're where we're going and what we're needing. And I think that PRMS. Can you go to the microphone, Dr. Asaha? Thank you. I'm not sure if PRMS and American Professional Agency ensures organizations like the whole Community Mental Health Center. They do individual practitioners. So it might be a little different. But when it comes to a large organization. They're more restrictive. So that does become a barrier, because that's where you're really treating the SMI population. That's where you are, you know, encountering barriers. You know, you cannot really consult with a OB just because, you know, you want to make sure that they'll be OK. It just doesn't happen. They don't go to a gynecologist. They don't go to their PCP. So that's where you really is a place where psychiatrists can become the primary care physician. But then these restrictions are there. So, yeah, and I think I didn't bring this up in my presentation, but some of the data we looked at is people with schizophrenia, you know, and how how sexually active they are and how little they go to any other provider that's not a psychiatrist. So I really do appreciate you bringing up that point. So if there is this major barrier, if this is a barrier for many community mental health centers, then I'm curious about are there ways for the community mental health centers as a, you know, like a national group of providers to start pushing back against this restriction? Like, I know you guys have, you know. Like professional, like, like, right. But it's also cost. Yeah. It's not just, you know, the carrier may say, sure, but then it's going to be another half a million dollars per year. And community mental health centers are, you know, they're just nonprofits and they're struggling. But but from an insurer perspective, I would imagine the cost of of of insuring your physicians to prescribe contraceptives is going to be less than childbirth. And no, no, this is a medical malpractice liability coverage. It's not health insurance. They got it. Got it. A liability to protect prescribers. You know, it's going to be up if your scope of practice is wider. So so they said, well, OK, so you're going to prescribe in CSU. So now it's going to be another hundred thousand per year. Yeah. So for collectively. Yeah. Covering all the prescribers. This is where I think it might be interesting to have some of the similar discussion at ACP, at the American Academy of Community Psychiatry, to see, you know, what are some of the options? You know, what are some ways that we can look at this? You know, when we are stuck with restrictions, what are our opportunities for getting folks more quickly into family medicine, into internal medicine, into OBGYN? One of the from my perspective, at least one of the failures with integrated care so far has been all about integrating behavioral health into the primary care setting, but not the reverse of that. Because when you're talking about community mental health populations and populations with severe mental illness, we are the home as the community mental health center. And so what we need to happen in that setting is are there ways to begin to integrate or connect physical health in that setting? And I know in a community mental health center that I was working in previously, we had we were working on developing a relationship with an FQHC for them to be have one of their doctors over at our clinic, not as frequently as I would like, but a non-zero amount, which led to a number of us trying to then schedule some of these patients that we really needed to connect to primary care OBGYN on those days so that if they were there, then we could say, hey, can we like we've got such and such a doctor here today, can we walk you over to them and, you know, do a direct warm handoff to try to get them connected to the care and the prescriptions and all that they need if it was not something we were able to do? Yeah, I just want to say I think this is really sad. I mean, this is an example of how outside organizations are limiting access to reproductive health care. It's just it's just upsetting, you know, that that it's that it's this difficult in the United States to to have a doctor prescribe oral contraception. And if it's going to be over the counter like ibuprofen, why couldn't any doctor prescribe it? And like I practice addiction medicine, I do some gynecology and I'm initiating SSRIs left and right until I can get my patients into psychiatry. And, you know, I work at an FQHC in San Francisco and the access is just so limited for specialists. So that's all. Hi, I'm Madeline Hicks from Massachusetts. I have one quick question and then a bigger question for the quick question. How much less effective is the progesterone only contraception compared to the combined in in that if there are naturalistic studies? I'm going to give you ballpark figures. So or combined oral contraceptives, I think, with average use are between ninety one and ninety four with perfect use. They go up to ninety eight. And I think progesterone only pills are somewhere in the high 80 percent. I can double check all that. And that's with correct use at the same time every day. Yeah. Yeah. OK. Could you all please summarize where the APA is right now for any clear public statements about Dobbs v. Jackson, about counteracting the misinformation that mental illness is higher or depression and suicidality is higher in women who have abortions? So, for example, the American Psychological Association has a very clear statement, I found, but I couldn't find one. I found a very wordy, very complex position statement from the APA. But that reaches really even in our group, a very minuscule, you know, subset. So for clear messaging to counteract what's going on in society, you could describe to us where we are now and then also what the strategies are to improve that in the coming year, let's say. Yeah, and I think that I remember you bringing this up with the group where the two women were on the the the working group or the task force, whatever the wording was for that. And so I don't know anything more beyond what was said in that room, which is, from my understanding, there is no clear statement. And there was the sort of initial statement that they made after Dobbs, which is pretty easy to find on their website in terms of APA's deep disappointment in the Dobbs decision. I think the bigger question that you ask is, what are the next steps and what are we going to do about it now? And especially as things are continuing to change, just like, as was pointed out sort of earlier on about the slide looking at abortion restrictions around the country, even though that's a slide that was pulled from a picture from mid-March, there's already three states that are incorrectly, you know, labeled on that just because there have been recent changes. So I think that this is something that one statement is not enough or even one decision about what's the next steps. My hope is that this is a place where APA with with all of our encouragement, all of your encouragement, with comments from, you know, folks that are members, comments from folks that maybe are saying, hey, I don't want to be a member anymore because there hasn't been a clear enough statement or clear enough response that we're able to sort of begin to push things forward in terms of, OK, where do we go from here? And how do we continue to work on this issue and address what needs to happen? And some of that will be happening probably at the national level. But some of this also is where I would also recommend going back to the is where I would also recommend going back to your district branch to see what's happening within your state, because what I may be working on with my district branch in North Carolina may be different than what Dr. Arnauto is working on in North Carolina and maybe in Indiana or maybe different than what Dr. Morial is working on in Michigan. So there are there are sort of different levels of organizational psychiatry that you're going to want to be connecting with in terms of figuring out the next step. And in particular, with things having shifted to the state, I think a lot more work is going to need to be happening at the local level and at the state level. And in terms of the legislative piece and the legislative advocacy piece, connecting with your district branch around advocacy, but also connecting with your legislators to be telling them the stories about what's happening for for women and women or pregnant people in your community that are either having difficulty accessing or getting connected to contraception or are dealing with issues around restrictions on termination. I need to correct myself. So for the progesterone only pill, it is 90 percent effective with typical use. And if used perfectly, like taken exactly 24 hours apart, it's 99 percent effective. And then combined oral contraceptives, typical use, they're about 95 percent effective. And then perfect use is going to be the 99 again. Although anecdotally, just working with patients in the OBGYN office, I do see a lot of people pregnant. And maybe that's why you were feeling it was less effective, because you do see a lot of people who get pregnant who say I was taking the mini pill, particularly because mini pill, the the one that's progesterone only is prescribed to people that are breastfeeding. And so they think they have like this double protection of I'm breastfeeding, which makes you less fertile. And I'm taking the the pill and many of them become pregnant. Now, I don't know if it's because they're not taking it as prescribed or there's other, you know, user error. But that just from the number of people I've seen coming in pregnant on having been on it, it sounds like this study population, however, this was studied, that it seems very optimistic. But that's just anecdotally. Some of the psychiatric meds decrease the efficacy of oral contraceptives. Can you go to the microphone? Yeah. Thank you. Some of the psychiatric meds decrease the efficacy of oral contraceptives. And that appears to me hidden information, which is really concerning. Is that something that maybe could be improved to align with the education on the risks of Depakote or Valproate? I think Depakote is a great one to bring up because it is it does significantly decrease the effectiveness of the oral contraceptives. Another one is Lamotrigine. It's it's strange because it doesn't it doesn't impact the way you think it's going to. It doesn't make the medicine lower in the blood. It's not it's not like an induction of the CYP450, which people thought it was. I can't remember the mechanism right now, but I have reviewed this many times and it does make the oral contraceptive slightly less effective. But it's not because it changes the drug levels. It has some other effect that I don't remember. But yes, I think that could be an issue of people being on medications that impact the effectiveness. I think it tends to be more due to the changes estrogen levels, I think, not in the pill, not progesterone. So, again, the progesterone pill may may be protected in that in that sense. But that's definitely something with the CYP450 system that needs to be discussed when you're choosing a contraceptive. Well, and so I guess a follow up question that I have for that for Dr. Morial is you had spoken earlier about this being really important for resident education in particular, because residents, especially intern year and PGY2, are most close to their medicine experiences and their OBGYN experiences from medical school. And so I'm wondering what your thoughts are around ensuring that in addition to the contraception piece, that residents are sort of getting the education that they need in terms of some of the impacts that our psychotropic medications have on. And this is why I think that if we're going to develop curricula, it has to be between us and OBGYN. This is, you know, it it's fine. And Danny to say, let's start prescribing. But there are nuances. And I think that we need to this this just shows how important it is for, you know, cross specialty educational efforts. So I think we probably have time for one more question, if there's a burning question there that anybody has. I just wanted to mention that, sorry, in the U.S. medical CDC chart about medical eligibility criteria for contraceptive use, it does have a section on anti-convulsive therapy. Hi, I thank you. This is a great presentation. So if as a psychiatrist, if I find myself wanting to prescribe a birth control pill, any advice on documentation, but what should go into my note that would protect me from. You know, a potential malpractice claim if there were an adverse event? I mean, it sounds like making sure that they don't have a history of thrombosis and those sorts of things. But could you kind of lay out your recommendations for charting? Sure. Thanks. Usually I counsel patients on the risk of blood clots and the conditions that can increase the risk of blood clots, the symptoms of having a P.E. or a DVT that they need to seek, you know, emergency care. Also, the effectiveness, make sure they understand that with typical use, these methods aren't perfect. They can still get pregnant. Risk for STDs, maybe if they're not using a barrier method. Yeah. Yeah. But if you want to protect from STDs. And I think if you decide, if you do, of course, this is like basic malpractice 101, but if you do talk to a colleague about it, you know, of course, documenting, you know, I talk to Dr. Jake, the patient, you know, I'm starting I'm starting them on this based on our discussion. And now they will be continuing it after my initial start. If you do that, Dr. Arnotta, I think one thing you were also saying before that I that I always tried to do, whether I'm looking at contraception or whether I'm continuing somebody's metoprolol until they get connected to their primary care doctor or other kinds of medications is documenting why I'm doing this piece that is outside of my general scope of practice and what my plan is to indicate that I'm not like long term going to try to be a cardiologist or whatever it might be. And so and you had spoken to that. So in particular, with the OB-GYNs documenting why they're doing bipolar medications, for example. So I'm wondering if you had any. No, I mean, I think it's I think it's just like the medical reasoning and the fact that you discuss you consider the risks and benefits. And in the case of this particular patient not taking the action. Right. So that's the I talk a lot with perinatal mental health that there's never no risk. Right. Like the risk of not prescribing SSRIs to someone who's pregnant is often who has a history of significant depression, anxiety, suicide attempts is much greater than any documented risk that there is for an SSRI. And so I think the risk of there's no such thing as no exposure in pregnancies is what I what I say to that. I think similarly, in this case, I would say the risk of having a person with psychiatric illness on psychiatric medications, not on birth control, is if it's difficult, tracheogenicity, you know, or if it's a person does not intend to be pregnant. We know the risk of them becoming pregnant is greater to their health. So just showing that your that your action is meant to prevent these other these other possible risks that are greater than the risk from the birth control would be really important in the documentation. Just just an observation. I think the one reason why you're actually having this talk and why we're discussing these issues is the problem of politics influencing practice. And one of my concerns is that somewhere along the way, a state might pass a law saying that if you have not done a pelvic exam, you cannot prescribe that in a somewhat different setting. I pre in my previous career, I worked in the VA system and in the state of Pennsylvania, there was sort of a law that you couldn't prescribe certain things without having done a physical within a year if you were doing telemedicine. And, you know, this created dilemmas for a number of us because, you know, we're not doing the physical. You know, we may be interfacing with a community based health center. And so these are some of my concerns. And a lot of times what drove those rules have nothing to do with medical practice. They were actually political issues. Prescribing opiate antagonists, that's another one, can very safely be done via telemedicine. But it became an issue because it's a political issue. So, well, I think I think you're right. I think that's a concern. The like the laws in some of our states, Indiana, North Carolina. I mean, they're the laws are just very problematic. And they are they make no medical they make no medical sense at all. Like I said, they wanted to have something in the law saying that you had to counsel the patient, that abortions could be reversed. We actually have in Indiana, additionally, a law that basically it's a criminal offense not to report complications of pregnant of abortions. And one of the complications is crying and being sad. And also another complication is sleep disturbance. So there's a form that you have to fill out if your patient has had an abortion within a certain amount of time and they come to you as a psychiatrist and they report to you that they are crying and having sleep disturbance around the same time. If you don't fill out this form and turn it in, you can be criminally liable. And it's not a malpractice issue. So the hospital and clinics don't protect you because the hospital doesn't is not going to provide legal legal representation to someone who does a crime. So you and this applies to therapists like a therapist would have to fill out this form. And I think in other talks here, people have referenced the OBGYN who did an abortion on a child who was an incest victim in Indiana. And are like the state attorney general tried to was going to sue her, saying she hadn't filled out this complication form, which she had done. And I don't know what's happening with it. But yeah, like if they decide to make an example of someone with one of these criminal laws, they, you know, they can do it. And the question is, how are the rest of what are we going to do to protect each other? How are we going to stand up in those times? Because it's going to happen. You know, is ACLU is going to have to get involved? You know, I am very involved with ACLU in terms of trans rights in our state. And like they are there are some very politically political attacks on on physicians for just doing medical care. So I think you're correct to be worried about that. Well, I think that's where with all of this sort of knowing the legal landscape that you work in, as well as sort of knowing the hospital or clinic landscape in which you work in. And if you are in it, I don't know that there are any states that currently have that requirement. But if there was a state that passed that and you were in that state, then you would need to understand what you were doing in certain situations and whether you were going to choose to. Violate the law or not, and just knowing that, and so I think that that's. Can be difficult because many of us train in states that are then not the state in which we end up practicing in. And so, you know, if you are moving to a new state, not just kind of assuming that you know what the standards of care and the practice situation is, but connecting with your local professional organization, connecting with your colleagues to make sure you get the education that you didn't get because you didn't train there. Thank you guys all for coming. We really appreciate it here.

reproductive health

post-Roe v. Wade

psychiatrists' roles

mental illness

unplanned pregnancies

contraceptive care

marginalized populations

restrictive abortion laws

TurnAway Study

systemic racism

psychiatric residencies

policy reform

patient autonomy