How can we help our patients discuss their mental health? And if they do, what then? I’m confident that all of us in obstetrics and gynecology readily acknowledge the importance of our patients’ emotional wellness. We understand that a new parent’s mental health is key to a baby’s ability to thrive. We know that patients’ depression and anxiety are serious impediments to individual and family well-being. Yet how we can realistically address patients’ mental health needs remains, for many physicians, a largely unanswered question. Typically, obstetric and gynecologic training focuses on medicine, surgery, and primary care. Little attention is paid to mental health.
My own training was unusual in this regard. I always wanted to practice obstetrics and gynecology, but when I migrated from Pakistan to the United States, a psychiatry residency was the only opportunity available to me at that time. This initial exposure shaped and informed the rest of my career in obstetrics and gynecology. That first serendipitous opportunity is why my ACOG presidential focus, so many years later, is Minding Mental Health. Over decades of patient care, I developed an approach designed to normalize and destigmatize mental health conversations. I aimed to increase the likelihood of my patients sharing their struggles so I could validate their needs and steer them toward support. Here’s what that looked like.
Helping Patients Navigate Their Own Emotions
Like many physicians, I believe in normalizing patients’ experiences. So, in my clinical practice, I would tell my pregnant patients in advance that they might experience symptoms related to the physiologic changes of pregnancy—a racing heartbeat, feeling flushed. This way, they wouldn’t panic when they noticed these. In the same spirit, I told them, “When this baby is born, you’ll be taking care of a brand-new human with 24/7 needs. It will be normal to feel depressed or anxious, to wonder whether you’re doing the right thing or you even have what it takes.” Most new mothers have some manifestation of the baby blues. So, I would tell them that it was okay if they didn’t always feel joy, and it was okay to also address their own needs. I informed them that “normal” can be a mixed bag. Normal can contain joy along with sadness. It can contain a sense of being in control (even if just for a moment) and a sense of feeling overwhelmed.
Sometimes, in addition to normalizing, I would personalize. Incorporating psychiatry practice into obstetrics and gynecology, I told my patients, “I too have felt anxious or out of my depth, and I want you to know that’s okay.” I told them that when I first started my training, in addition to having a toddler son and being pregnant with my second child, I was a new immigrant. I did not know American culture or how medicine was practiced here. So I too sometimes felt inadequate and anxious and couldn’t focus on the job at hand. For the new mothers, that job might be their new babies. I learned to put those feelings into their proper context and to look for positives. I would say, “When babies cry, they’re trying to communicate their needs, but this is also helping them take deep breaths, clear their lungs, and get good oxygen. So, crying is not always a bad thing.”
When a physician says, “I also don’t have all the answers,” it can be easier for patients to understand that their own experiences are not abnormal. Sometimes patients said, “I was able to manage because I remembered what you told me. I now understand that it’s okay to feel mixed emotions—that in addition to the joys of motherhood, addressing my family’s and friends’ expectations, and all the confetti and glitter, it is okay for me to feel sad. I learned from you I can have both and still be normal.” My goal was to never leave these things unspoken. Even though each patient did not go through this to the full extent, I brought it up so that if it happened, they knew it was OK to discuss it.
Helping Patients Know When to Seek Help
First, I gave patients mile markers. I would say, “If sadness is persistent, steady, or escalating, and you can’t shake it off after a few days, seek help.” I explained that anxiety can also accompany postpartum depression and that the sadness would typically wane over a few weeks.
Second, I emphasized that whatever they were going through was important to share. I explained that I preferred saying, “It’s okay, don’t worry,” versus “I wish I had known this earlier.” This made it easier for patients to communicate their concerns.
Supporting Patients with Mental Health Issues
At the postpartum visit, although patients are asked how they are coping and adjusting, this is not depression screening. Most obstetrician–gynecologists are not trained to screen for postpartum depression, nor to interpret the findings and make appropriate referrals. Mental health screening should apply not only to postpartum patients but also to those dealing with infertility, menopause, and aging—across the spectrum of their lives.
If patients screen positive for depression or anxiety, instead of receiving a referral to another obstetrician–gynecologist, those patients should consult a psychiatrist; psychologist; or a social worker, nurse practitioner, or physician assistant who specializes in mental health. An obstetrician–gynecologist can prescribe medications to tide the patient over until the appointment.
It is unrealistic to expect obstetrician–gynecologists to have expertise in mental health care in addition to everything else they have to manage. But screening for common mental health conditions is a necessary skill, which can be learned through CME programs, publications, simulations, webinars, and social media. ACOG’s perinatal mental health tool kit and maternal health resources can help health care professionals learn more about how to improve patient screening, diagnosis, and referral. It is essential to teach our patients that feeling anxious or depressed is normal—and that we are receptive to hearing about and helping them address their emotional experiences.
Dr. Hoskins is the 73rd president of the American College of Obstetricians and Gynecologists. Dr. Hoskins is clinical professor and director of patient safety in the department of obstetrics and gynecology at the New York University (NYU) Grossman School of Medicine and specializes in maternal–fetal medicine.
Disclaimer: The thoughts and opinions in the Frontline Voices initiative reflect experiences of individual ACOG members and do not represent official organizational opinions of ACOG.