The path to becoming a mental health practitioner is fairly standard: Go to school, get a master's or doctorate degree, pass a licensing exam. With that, graduates demonstrate their readiness to identify and treat patients in their field of study, whether it's social work, psychology, or counseling.
But when it comes to dealing with reproductive and maternal mental health, many of those graduates – now practicing professionals – are actually quite unprepared, says Wendy Davis, PhD, executive director of the nonprofit organization Postpartum Support International. Despite the large number of women affected by perinatal mood and anxiety disorders (PMADs), infertility, miscarriage, and plain old parenting stress, most graduate programs do not explore these topics in depth, if at all.
"It's a rare university that [provides] adequate education about perinatal mental health," says Davis. It is admittedly not easy to back up this statement with statistics: There is no official subspecialty for maternal and reproductive mental health, no requirement for graduate programs to teach it, and no real database of schools that do.
But one thing is clear: For training practitioners, there's no guarantee they'll be exposed to these important issues through academic coursework alone. That makes postgraduate training so important for today's professionals – and advocacy for better education so important for tomorrow's.
What's missing in grad school
Kimberly Zittel, PhD, had been a practicing social worker for six years when she gave birth to her first son in 2000. She knew something was wrong – she experienced anxiety and what she thought was the "baby blues" for months – but had never heard of postpartum mood disorders.
"Three years later, a friend at church mentioned she had gone through postpartum OCD," she says. "I went home and looked it up and was amazed to read about all the different kinds of postpartum issues, including ones that were clearly what I had experienced."
Zittel was shocked that she hadn't been introduced to these issues during school. "I thought, 'How can this be?' I specialized in two areas of social work where postpartum issues are very likely to arise – medical and mental health – and I did not have one ounce of training."
So she did her own research and in 2010 published a book, Postpartum Mood Disorders: A Guide for Health, Mental Health, and Support Providers. She's now chair of the social work department at Buffalo State College and teaches undergraduate electives on women's mental health and PMADs. (Her department does not offer a graduate degree.) "I want my students who go on to master's programs to know that this exists," she says.
Why it's being overlooked
Two decades after Zittel's own grad school experience, the medical community and general public are certainly more aware of postpartum depression. But she says, PMADs and other perinatal mental health issues still aren't being taught to graduate students as much as they should be. There are several reasons why, she says. For starters, it's not required.
"We have a pretty extensive list of populations we need to cover in our courses," she says, "but they are characterized very generally, like 'disabilities' or 'mental health.' It's really up to the students or the professors to decide what areas within those they want to focus on."
Requirements for other mental health programs are similarly broad and nonspecific. While graduate students in psychology are expected to learn about a variety of different pathological conditions, there is no established list of which specific conditions must be covered. The same goes for programs in family counseling and clinical mental health counseling, whose accreditation standards are equally vague.
The fact that PMADs are not a separate diagnosis in the Diagnostic and Statistical Manual of Mental Disorders presents another barrier, says Zittel. "We try to touch base on all of the diagnoses in the DSM, but since postpartum is just a sub-diagnosis within depression, it gets left out of those top-level discussions."
Sarah Best, LMSW, a staff psychotherapist at Seleni, agrees. "The state of the science of reproductive and maternal mental health – as specialists know it – isn't yet represented in the general psychological literature. So if schools are teaching from the DSM without specialized texts, the wide range of diagnoses associated with PMADs won't be covered. And this means that many new therapists simply aren't prepared to meet the needs of the 1 in 7 childbearing women who will experience a PMAD."
Academic curriculum may just take a while to catch up to emerging and recently established science, says Davis. But she's optimistic it will catch up, just as it has for other subspecialties of psychology, like issues such as substance abuse, developmental disabilities, and trauma-informed medical care, for example.
"For all of these, academic institutions were a little slow to integrate them into curriculum," she says. Often, she says, the pressure for change comes from social support organizations (groups like Alcoholics Anonymous) leaning on the medical community for increased awareness and education. "It happens first in postgraduate training, but then it filters down and makes its way into med schools, nursing programs, and grad schools.
Now is the time for maternal mental health to see that type of change, she says. "When we have research that shows that 1 in 7 mothers has postpartum depression symptoms, and, according to one study, 1 in 5 of those women has bipolar mood disorder, it really is an error not to include this when we're teaching students about basic psychology and sociology."
The good news: It's (slowly) getting better
Not all graduate schools are neglecting maternal mental health, says Davis. A growing number are integrating it into their curriculum. "Wherever it is happening, it's because there's a pioneering faculty member who says, 'I know how common and how important this is,' and finds a way to teach it."
Aurélie Athan, PhD, is one of those pioneers. The Sexuality, Women, and Gender Project she cofounded at Teachers College Columbia University will soon offer a Reproductive and Maternal Well-Being curriculum, along with its current masters- and doctoral-level certification programs and a master's concentration within the clinical psychology department.
And while she agrees that her program is unique, she says the landscape is changing elsewhere, as well. "There's a lot of good work being done," she says. "I wouldn't say that training is absent; sometimes it's just scattered."
An interested student might take electives or find mentors in other departments, she suggests, such as women's studies, psychiatry, public health, or nursing. (Although maternal mental health training is also limited in psychiatry, there do seem to be more examples of medical schools doing it well.) "The very nature of the subject is interdisciplinary," she adds, "so it can be challenging to consolidate it as part of a core curriculum."
Davis, who teaches postgraduate training through Postpartum Support International, says the future of maternal mental health education is promising. "I've watched this next generation of leaders come to trainings and get excited and go back to their institutions and create good curriculum," she says. "It's only going to get better."
Advice for students, professionals, and patients
For students considering graduate school, there's no database for institutions that cover reproductive or maternal mental health. Your best bet, says Athan, is to research individual schools: Ask about professors' areas of research and expertise, opportunities for related internships, and any electives that may be available.
Even if a school doesn't offer an official program, she adds, you may be able to create one by looking outside of your department. "Sometimes students have to get creative and stitch together a tapestry of expertise across disciplines," she says.
Fortunately for professionals who didn't receive training in school, there are postgraduate options available.
Postpartum Support International provides two-day certificate courses for PMAD training and online webinar trainings for individuals, hospitals, and insurers in collaboration with the 2020 Mom Project (formerly the California Maternal Mental Health Collaborative). The Postpartum Stress Center holds 10-hour postpartum depression trainings at its headquarters in Rosemont, Pennsylvania and offers additional training resources on its website.
Seleni also offers training for mental health professionals, including a free online course in PMAD screening, as well as more intensive training in PMAD treatment, perinatal loss, and maternal mental health.
For women dealing with perinatal depression, anxiety, or stress, seeking out professionals with these types of postgraduate certificates may be the best way to know you'll get the help you need – at least until graduate schools recognize the importance of teaching these topics in the classroom. Postpartum Support International has local support coordinators and hosts a warmline, where women and their families can find referrals to maternal mental health experts in their area.
"There's nothing wrong with continuing education post-graduation. We should all be doing that, no matter what our profession," says Davis. "However, we wish that this education started much earlier. We need every doctor, nurse, therapist, and counselor to understand these issues better, whether they seek out postgraduate training or not."