Women’s Mental Health (WMH) Post-doctoral Fellowship Program: A Potential to Increase Trained Human Resources in WMH in India

The origin of women’s mental health (WMH) field could be traced to the texts of Hippocrates, which describe the symptoms of postpartum psychosis. ¹ In the 1850s, Louis Victor Marce meticulously documented the symptoms of postpartum psychosis. ² The emerging research on the impact of maternal illness on the offspring, developmental origins of mental illness, neurobiological evidence of gender differences, and the impact of psychosocial and cultural factors on women has gradually paved the way for the specialty of WMH.

Sub (Super)-specialization Within Psychiatry in India

In India, psychiatry is a growing branch of medicine. ³ A survey among young psychiatrists (<45 years) in India regarding postgraduate psychiatry training has revealed that there is a lack of adequate training in different specific areas within broader psychiatry, such as child and adolescent psychiatry, geriatric psychiatry, brain stimulation techniques, forensic psychiatry, psychotherapies, statistical skills, neuroimaging in psychiatry, women mental health, psychosexual medicine, neuropsychiatry, research, and writing skills. ⁴ In the last decade, many premier institutions such as the National Institute of Mental Health and Neuro Sciences (NIMHANS), Bengaluru, All India Institute of Medical Sciences (AIIMS), New Delhi, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh have started DM courses in addiction and child psychiatry. The King George Medical College, Lucknow, and The NIMHANS, Bengaluru, have started DM courses in geriatric psychiatry. Concerns remain regarding super-specializing over three years after acquiring a degree in the broad specialty of psychiatry. ⁵ As an alternative, post-doctoral fellow (PDF) courses in the sub-specialties of psychiatry provide an opportunity to acquire essential clinical and research expertise within the course period of 1 year. This is advantageous in many ways in terms of time, cost of education, and optimum human resource management. Further, the professional is likely to retain the expertise needed for the practice of a broad specialty of psychiatry along with the respective area of specialization.

WMH has always been of great interest at NIMHANS, with various MD thesis being done in this area and several faculty members conducting funded research in various aspects of WMH. We have had the privilege of hosting international stalwarts in the field, including Prof. Ian Brockington, Prof. Donna Stewart, Prof. Helen Herrman, and Prof. John Cox, who have guided us in establishing specialized clinical services and research. Inspired by these global leaders and by Prof. Sarada Menon, who insisted that WMH needs exclusive focus and training in India, a fellowship course was envisioned. In 2016, NIMHANS got approval from the academic council to start PDF in WMH.

Growing Demand for Specialized Mental Health Care for Women in India

Gender has a crucial role in determining an individual’s mental health and susceptibility to mental disease. Women exhibit a greater prevalence of internalizing disorders, while men have more externalizing disorders. Gender disparities are notably evident in the prevalence of common mental diseases, with women being more predominant. This is because there are distinct disparities in the structural and functional organization of women’s and men’s brains, as well as in their cognitive processing and responses to stimuli. There are distinct differences between women and men in their communication styles, approach to relationships, emotional expression, and response to stress. ⁶ Studies have also noted that mental health risk factors that have a greater impact on women are the pressures resulting from their various roles, gender discrimination and its related issues such as the wage gap, and higher rates of poverty, starvation, malnutrition, domestic violence, and sexual abuse. ⁷ The World Health Organization Report 2001 showed that among individuals with neuropsychiatric diseases, depressive disorders contribute to 41.9% of impairment in women, while in men, the contribution is 29.3%. The primary mental health issues affecting older individuals include depression, organic brain disorders, and dementia. The majority consists of women. Approximately 80% of the 50 million individuals impacted by violent conflicts, civil wars, disasters, and displacement are women and children. The lifetime prevalence rate of violence against women varies between 16% and 50%. Approximately 20% of women experience either rape or attempted rape at some point in their lives. ⁸ A qualitative study among rural women in India regarding their mental health resources, barriers, and intervention needs has shown that women preferred community awareness provided by mental health professionals, and they wanted mental health services and mental health service centers built in the villages. ⁹ Even among urban women, psychosocial factors such as adverse life events disable them from maintaining domestic work, and adverse reproductive events manifest more with somatic symptoms. ¹⁰ During pregnancy and postpartum periods, women have a substantial increase in unmet mental health needs. ¹¹ Overall, there is a lot of demand for mental health needs among women in their life course. However, the training on women’s mental health is considered to be “poor/very poor” among young psychiatrists in India. ⁴ In spite of the high prevalence of mental health conditions among women in India, there is a lack of funding as well as underutilization of available resources, which has resulted in a scarcity of trained mental health professionals such as psychiatrists, mental health nurses, counselors, psychiatric social workers and other paid mental health service providers, making it even more challenging to be able to reach out to females patients. ¹² Hence, focused training on WMH for budding psychiatrists becomes important.

Curriculum for PDF in WMH at NIMHANS

Broad Objectives of the PDF in WMH Course

The curriculum of WMH PDF has been designed to enhance the fellow’s knowledge of sex and gender differences, the influence of the female reproductive cycle on psychiatric disorders, gender disparities in the prevalence and expression of psychopathology, interactions with endogenous and exogenous hormones, pharmacology—including pharmacokinetics and pharmacodynamics—sociocultural influences, treatment response, side effect profiles, psychological responses to phar-macotherapy, and adherence to treatment. One of the major learning during the fellowship is pre-pregnancy counseling for women with pre-existing psychiatric disorders. ¹³ This includes consultation about how to minimize risks of psychiatric illness and medications while trying to conceive, during pregnancy, while breastfeeding, and about alternatives to medication. Learning about attachment disorders in the postpartum period, interpersonal psychotherapy for postpartum depression and perinatal loss, the impact of maternal mental illness on the developing fetus and infant, and the impact of infertility on a woman’s mental health. Another thrust area where the fellow is trained is the effects of gender-influenced trauma, the spectrum of responses to childhood physical and sexual abuse, signs of, and understanding the dilemmas faced by women subjected to current domestic violence, rape, and sexual harassment.

During the course, the fellow acquires the skills of gender-specific communication styles, eliciting sexual and reproductive histories, traumatic incidents from the past and present, including domestic violence, physical abuse, and sexual abuse, assessment of family context, parenting capability, family planning needs, and develop skills to prescribe pharmacotherapy based on pregnancy and lactation. ¹⁴ The skills of modifying electroconvulsive therapy techniques during pregnancy and lactation, gender-specific psychotherapy techniques, and psychotherapeutic techniques in treating short- and long-term sequelae of trauma, including sexual abuse, sexual assault, physical abuse, domestic violence, and perinatal loss are learned during the fellowship. A few other skills learned during fellowship are infant health and developmental assessments ¹⁵ and many forms of psychosocial rehabilitation that are relevant to women with major mental illness, such as sexual education and parenting rehabilitation techniques. ¹⁶

It is anticipated that the WMH fellowship will result in changes in a fellow’s values regarding gender roles as well as his/her attitude toward gender-sensitive role stereotypes and their effects on diagnosis and treatment. It also includes training in a collaborative approach to mental health issues in women, family members, other health professionals, social services, child welfare staff, and significant others to collectively improve the quality of life of women who seek services. It also fosters an understanding and awareness of the social, cultural, practical, and financial obstacles to mental health services for women.

Clinical Training Sites

The clinical knowledge, attitude, and practices of PDF in WMH are provided through the following services: (a) Outpatient Perinatal Psychiatry service: The clinic is run once a week on Fridays. (b) Mother-Baby Ward: An inpatient service that is offered to mothers with severe mental illness who are admitted with their babies and a family member. Structured assessments and comprehensive management are provided to mothers with mental illness during the postpartum period. A multidisciplinary team provides care to the mothers. Assessment of infants regarding their health, growth, and bonding is also being done. ¹⁷ (c) Joint Clinics with obstetricians and gynecologists: A service that provides mental health service at the obstetrics and gynecology clinics. (d) Psychiatric Rehabilitation Service: A service that provides Rehabilitation services for both outpatient and inpatients. Various training sections facilitate training in a particular vocation. (e) Somatization Clinic at NIMHANS Center for Well-being: A service that offers comprehensive services to women with medically unexplained symptoms and somatoform disorders. The services also include training health professionals. (f) AWAKE clinic and Trauma clinic at NIMHANS Center for Well-being: A service that offers psychotherapy and support to women who have gone through intimate partner violence or sexual assault. The services also include mental health intervention, counseling, and support groups. (g) Behavior Therapy Unit NIMHANS: The service offers treatment for female sexual dysfunction. (h) Center for Addiction Medicine: The service offers multidisciplinary treatment for women with addiction-related problems. There is a specialized inpatient facility for women with substance-related problems. (i) NIMHANS Digital Academy: A digital platform to conduct online training program

Fellowship Structure

The fellowship begins on July 1 and lasts for one full calendar year.

Academic Project

This fellowship emphasizes clinical experience but also includes conducting a certificate course on perinatal mental health ¹⁸ and a scholarly project, the nature and scope of which depend on the fellow’s interests. These projects can range from conducting an independent research project and publishing the results to collaborating on an ongoing research project, co-authoring a journal article or book chapter, peer-reviewing others’ research, or publishing a book review. Those fellows anticipating a career in academic psychiatry are encouraged to submit an article for publication and/or present at a regional or national conference. There are several ongoing research projects in the area of WMH at any given point, and the PDF is encouraged to participate in any of these projects.

Evaluation

Fellows will meet once a week to discuss their clinical activities and receive general feedback from their supervisor. These weekly discussions also give fellows a chance to examine their strengths and weaknesses, thereby creating helpful growth plans and discussing their career ambitions. As the year goes on, the fellow and the coordinator of the fellowship course will have more formal career mentoring and counselling. The program supervisor will complete an official written review at the end of the fellowship, assessing the fellow’s abilities and attitudes. Fellows will also be able to share their opinions on their experiences with faculty and the program using evaluation forms.

Number of Candidates Per Session

Two (from academic year 2024).

Multidisciplinary Approach in the Training of PDF WMH

Learning the life course approach toward WMH has been the agenda of the fellowship program. Within the larger field of psychiatry, the WMH fellow undergoes exposure to psychiatric disorders associated with menstruation, addiction in women, complementary and alternative therapies such as yoga in pregnancy, ¹⁹ mother-baby yoga, ²⁰ and various brain stimulation techniques during the perinatal period. Exposure to forensic psychiatry ²¹ and obsessive-compulsive disorders during the perinatal period ²² happens through cases referred to perinatal psychiatry services. The fellow also takes up regular didactic, case-based teaching to MD psychiatry trainees posted in the perinatal psychiatry services. In the last four years, the fellow has led the training of allied health professionals (obstetricians, primary care physicians, nurses, psychologists, and psychiatry social workers) across India through the NIMHANS Digital Academy. ¹⁸ The fellow is also trained in providing online support through the emergency helpline number and tele-after-care services. ²³

Clinical Psychology

The fellowship program aims to build competency in carrying out psychological assessments and psychotherapies. Fellows are oriented to using clinical interviews and rating scales to assess psychological risk and protective factors, including but not limited to gender-based violence, particularly intimate partner violence and domestic violence, personality traits, quality of marital relationship and interpersonal/family stressors, and social support. Fellows are encouraged to use both qualitative and quantitative assessment methods, as appropriate, appraise the psychometric properties of measures, and learn to choose a suitable measure, weighing their strengths, limitations, and cultural relevance. In terms of psychotherapies, they are taught to use the stepped care framework for mental health care delivery wherever relevant in community settings. Formulating a case for psychotherapy using the four Ps (Predisposing, Precipitating, Perpetuating, and Protective) approach is encouraged, including the use of relevant theories aligning with their choice of therapy. Structured and evidence-based cognitive behavioral therapy techniques (including behavior therapy and third-generation therapies such as mindfulness-based approaches) that can be used across community and clinical settings are taught for the management of common mental disorders such as anxiety and depression in women, stress-related concerns, and life cycle stage related concerns such as perinatal anxiety and depression. Dialectical behavior therapy strategies for use with women with personality disorders and suicidality and managing emotion regulation difficulties across diagnostic categories. Interpersonal psychotherapy and couples and family therapy approaches are also used for women experiencing depression due to significant interpersonal concerns. Conjoint sessions with the husband and other family members from her family of origin or procreation are held to educate, modify interactional patterns, and enlist support for the woman. Alternative approaches, such as supportive psychotherapy and narrative therapy, are used in contexts of acute distress, grief, and bereavement. They are encouraged to receive psychotherapy supervision and thereby learn also to provide supervision in the future.

Developmental Psychology and Early Parent–and-Family-mediated Interventions for Infants

Clinicians are often asked by mothers with psychiatric illnesses and their family members whether the child is developing well or has any behavioral issues. How can future emotional and behavioral problems be prevented? Is the child physically and mentally fine? How do we optimize growth and development? How do you overcome the fear and anxiety of caregiving? Is there a scope to optimize responsive care? In essence, the concerns of mothers and their family members revolve around the early identification of developmental, growth-related, and behavioral issues in infants, practical suggestions to address these issues, and strengthening the mothers’ confidence and skills in responsive caregiving. These concerns are pertinent in the backdrop of mixed results in the literature about the effects of maternal psychiatric illnesses on infants’ development and well-being and the significance of bonding, attachment, and mother-child interactions for infants’ development and psychological well-being of the mother-infant dyads.^24–27 In this context, the specific training focuses on broadening the practitioners’ insights about the significance of maternal mental health in infants’ developmental outcomes with updated empirical evidence; understanding the key developmental milestones in infants, with a special focus on social and emotional domains; assessing the infants’ development both clinically and with the help of a selected, free-to-use standardized measures^15,28; identifying the bonding disorders and attachment issues based on mother-child interactions and play activities^29,30; identifying the early temperamental difficulties and risk for neurodevelopmental disorders, especially global or transient developmental delays and autism spectrum disorder; identifying the need for therapies and facilitating appropriate referrals; and psychoeducation framework for parents and families on developmental surveillance, optimizing current development of the infants through responsive care, prescribing activities for bonding and attachment issues, and securing practical support from families to mothers in childcare.

Psychiatry Social Work

The PDF in WMH is expected to work with the psychiatric social work (PSW) team and guide them for detailed psychosocial assessment of the mother, mother-infant dyad, family, and all other social milieu. Psychosocial assessment includes understanding the family dynamics and exploring the impact of family dynamics, relationships, and support systems on perinatal mental health and well-being. The PDF in WMH gathers the assessment done by the PSW team on knowledge attitude and practice among family members, socio-economic assessment, pathways of care, caregiver burden, expressed emotions, trauma, risk assessment, domestic violence/intimate partner violence, legal issues, social stigma, and strategizes the engagement of families in the overall care plan. In collaboration with the PSW team, PDFs are trained to understand the influences of cultures, the importance of cultural competency, inclusivity, diversity, and strategies for providing culturally sensitive care.

The PDF learns to conduct group work interventions with caregivers and spouses to enhance support and understanding of women with mental illness. ³¹ Advocacy for the needs and rights of women with mental illness, psychological issues during pregnancy, postpartum, and new parents within the healthcare system. The PDF is taught to ensure access to quality mental health services, maternity care, and social support programs for women with mental illness. Also, facilitating access to necessary support services and resources and liaising with different stakeholders like the Maternal and Child Health (MCH) Program, child protection services, One Stop centers, District Mental Health Programs, Women and Child Development Services, and Programs.

Conclusion

In India, this is the first center to run a PDF course in WMH. We have had an opportunity to train psychiatrists in WMH. The WMH area is expanding in terms of research and services. Most of the post-doc clinical fellowship courses are provided in countries like the USA, the UK, and Australia. It is pertinent to have a course that caters to WMH in the country and highlights social contexts and cultural beliefs. The course is comprehensive and includes clinical, research, and training experiences. This course aims to increase the number of human resources trained at WMH and to establish services across the country. It is also necessary that psychiatrists trained in WMH PDF take the initiative to start specialized services across the country. We also hope that other premier institutes of psychiatry will come forward to start such courses.