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Sarah Krajewski, CNM, PMHNP-BC, PMH-c & Carla Braga, CNM
Brockton Neighborhood Health Center
Div. Reproductive Psychiatry

Healthcare can feel like a rocky boat nowadays. Facilities have a new focus on trying to address patient’s healthcare barriers. Screening for social determinants of health (SDOH) may seem like a foreboding undertaking but it has never been more important. In the context of pregnancy and family dynamics, these factors are even more critical, as they directly affect maternal health, prenatal care, and the overall health of families.

One of the most pressing and complex issues in recent years has been the role of immigration policies in influencing health outcomes, especially for pregnant women and families. The separation of foreign-born parents from their American-born children, a byproduct of the policies implemented under the Trump administration, has had far-reaching consequences on both the immediate and long-term health of these families. The Trump administration's "zero tolerance" policy, which was introduced in 2018, aimed to criminally prosecute individuals who crossed the U.S. border illegally. As part of this policy, parents were separated from their children, many of whom were American citizens, while their parents’ faced prosecution or detention. This policy not only had devastating psychological impacts on families but also created a cascade of health-related issues that continue to affect them today.

One of the most significant consequences of family separation is the psychological toll it takes on both parents and children. For pregnant women, the trauma of separation and the uncertainty of their family’s future can have severe consequences for their mental and physical health. Pregnancy itself is a vulnerable time for a woman, and the added stress of family separation exacerbates existing risks. Stress during pregnancy is associated with premature birth, low birth weight, and developmental delays for the child. For parents, especially mothers, the mental strain of being separated from their children can lead to depression, anxiety, and post-traumatic stress disorder (PTSD).

A study published in the American Journal of Public Health found that children who experienced family separation were at higher risk of developing mental health disorders, including depression, anxiety, and attachment issues. These mental health issues can expand well into adulthood, affecting the ability of children to function in society and form healthy relationships. Under the Trump administration, the implementation of policies such as the “public charge” rule, which penalized immigrants who used public assistance programs, discouraged many from seeking necessary healthcare services for fear of jeopardizing their immigration status. This is particularly problematic for immigrant women, who may face difficulties accessing prenatal care and other maternal health services essential for a healthy pregnancy. These authors can report that our federally qualified health center (FQHC) has seen a dramatic reduction in patient visits. When we survey our community, we hear back again and again it is the fear of encountering U.S. Immigration and Customs Enforcement’s (ICE) at our facility that keeps them away. The lack of access to care not only affects pregnant women but also has significant consequences for their children, who may not receive appropriate medical care after birth, especially if they are born into families with limited resources or in unstable conditions.

Under U.S. law, children born on U.S. soil are automatically granted citizenship. However, many of these children, especially those with foreign-born parents, were subjected to the trauma of being separated from their parents during the Trump administration's crackdown on immigration. American-born children who experience family separation face unique challenges. Research shows that prolonged separation can lead to developmental delays, behavioral issues, and emotional trauma. Children may experience feelings of abandonment, confusion, anger, and fear. These children may also struggle with attachment issues and have difficulties reintegrating with their parents once they are reunited. In some cases, these children may be placed in foster care, further disrupting their sense of stability and security, along with adding more burden to our overly stressed foster system. One of these authors has first-hand experience as an immigrant child who was separated from her mother at just 11 years of age, and can attest to how traumatic these experiences can be. She stated, “The experience forever changed me, both psychologically and emotionally.” Experiencing familial separation and deportation as a child creates a psyche of distrust and anxiety. Although, her family was able to return to states and have what many other immigrant families would consider a “happy ending,” they will never forget those experiences that have now shaped our relationships and lives. She stated “This country has granted us immense opportunities, but with much sacrifice. It is extremely challenging to be able to pinpoint all the feelings felt during that time and its effects. But reality is that many children are living similar experiences and despite each one being unique, we are all left with continued unparalleled challenges.”

As families continue to rebuild after the trauma of separation, they may face ongoing economic difficulties, barriers to healthcare, and other challenges related to their immigration status. The ripple effects of these policies are likely to be felt for generations to come, as children of immigrant families may struggle to overcome the emotional and social consequences of their early experiences.

To address the health disparities that have been exacerbated by immigration policies, it is essential that policymakers and healthcare providers work to dismantle the barriers faced by immigrant families. This includes expanding access to healthcare, ensuring economic stability, and providing trauma-informed care to those who have experienced family separation. Immigrant Legal Resource Centerhas created an online resource for immigrants and refugees that includes a comprehensive Family Preparedness Plan. This document can aid families navigating the complex immigration system and assess their specific needs. Legal reforms that protect immigrant families from unnecessary separation and promote family unity must be prioritized to ensure that the health and well-being of future generations are safeguarded.

The separation of immigrant families under the Trump administration’s immigration policies has had a profound impact on the health and well-being of parents and children alike. The trauma caused by family separation has led to lasting mental, physical, and emotional consequences that continue to affect immigrant communities today. By addressing the social determinants of health and implementing policies that prioritize family unity, it is possible to mitigate the negative effects of these policies and promote the health and well-being of immigrant families in the United States. It is critical that the voices of affected families are heard and that the necessary resources are provided to help them heal and thrive.

References

1.            American Academy of Pediatrics. (2018). "Detention of Immigrant Children and Family Separation." Pediatrics, 142(6), e20182804.

2.            American Journal of Public Health. (2020). "The Impact of Family Separation on Immigrant Health: A Public Health Crisis." American Journal of Public Health, 110(2), 157-159.

3.            Amnesty International. (2019). "USA: 'You Will Be Punished': The Impact of the U.S. Family Separation Policy."

4.            National Immigration Law Center (NILC). (2020). "The Public Charge Rule and Immigrant Families' Health."

5.            Sastry, N., & Gregory, J. (2020). "The Long-Term Effects of Family Separation on Child Health." Journal of Child Psychology and Psychiatry, 61(7), 839-850.

6.            U.S. Department of Health and Human Services (HHS). (2020). "Trauma-Informed Care and Mental Health Services for Immigrant Families."

7.            U.S. Government Accountability Office (GAO). (2019). "Family Separation and Its Effect on Children: A Federal Health and Legal Analysis."

8.            Rosenblum, M. R., & Siskin, A. (2020). "Immigration and Public Health in the U.S." Migration Policy Institute.

9.            Rosenberg, K. D., & Hamilton, A. (2018). "Maternal Health and Family Separation: What We Know About the Impact on Immigrant Pregnant Women." Journal of Immigrant and Minority Health, 20(2), 293-305.

10.          UNICEF. (2019). "Children in Immigration Detention: The Impact of Family Separation on U.S.-Born Children."

11.          Boston Medical Center – Resources for Immigrants and Refugees: https://www.bmc.org/immigrant-refugee-health-center/resources-for-immigrants-and-refugees. Immigrant Legal Resource Center | ILRC 

Webinar: Breast Cancer - The Emotional, Psychosocial, and Sexual Impacts of Care
Date: January 23, 2025

Join Dr. Ellie Proussaloglou as she explores the emotional, psychosocial, and sexual challenges faced by breast cancer patients. Gain valuable strategies for providing holistic, compassionate care.

Register at the link below:
https://us06web.zoom.us/webinar/register/WN_no2KbwKVTZW6VVeje5LWkQ

Job Postings

The Harris Program in Child Development and Infant Mental Health at the University of Colorado School of Medicine Department of Psychiatry announces the availability of 5-7 psychology postdoctoral fellowship positions for the 2025-2026 training year. The Harris Program provides clinical training, consultation, advocacy, and research opportunities in perinatal, infant, and early childhood mental health.
Link to the Full Job Posting Here

Pediatric flex psychologists provide urgent, short- and long-term clinical coverage across two primary care clinics and 18 multidisciplinary subspecialty medical clinics at Children's Hospital Colorado. The service was developed to support all attending and supervising psychologists across the Integrated Division to allow them to request time off and take extended leaves of absence without interfering with patient care, disrupting clinical supervision of trainees, or jeopardizing the level of integration in multidisciplinary medical subspecialty clinics. There are additional clinical opportunities to build a small caseload of short-term behavioral health patients determined by clinical interest and expertise serving the patients and families seen in the clinics covered. Flex psychologists hold a faculty appointment in the University of Colorado School of Medicine’s Department of Psychiatry with opportunities to participate in teaching, supervision, program development, and scholarship, including collaboration on grants and contracts with hospital and community providers.
Link to Full Job Posting Here

The Developing Brain Institute (DBI) at Children’s National seeks a psychiatrist with expertise in perinatal/reproductive health to join its successful DC Mother-Baby Wellness Program. This psychiatrist will join a multidisciplinary team caring for perinatal individuals in Washington D.C., and performing community consultation and training, clinical research, program development, and advocacy.
Link to Full Job Posting Here

Beating the Heat: Novel New Option for Vasomotor Symptoms
Sarah Krajewski, CNM, PMHNP-BC, PMH-c 

December may seem to be a strange time to talk about trying to find relief from the heat, unless you are a middle-aged woman. Hot flashes, hot flushes, temperature tantrums, or short personal trips to the tropics are all names associated with vasomotor symptoms (VMS). This near-universal experience of the perimenopausal/menopausal period is reported in 60-80% of women² and is often seen in combination with a cluster of symptoms seen in the menopausal transition. In addition, new research suggests that many women can experience vasomotor symptoms (VMS) for five or more years.¹Hormone replacement therapy (HRT) has been a mainstay of treatment since the 1940s-50s to address that cluster of symptoms, improve cardiovascular risk, and provide relief from VMS.

Read Article Here

Sexual Assault Nurse Examiner Case
Melissa Goslawski

Real case redacted from files from 2024 with Discussion Following

Patient presents as a 26 y/o single white female who is currently pregnant at 3w1d. She has a past medical history of bipolar disorder where she takes Lithium, although noncompliant 2-3 days before hospital admission. Patient states she had consensual vaginal intercourse about 2 days prior to exam and assault. She had symptoms of UTI on admit. She was awake to person, place, time and situation. Her gate was steady, with slow cognition. Her affect was slow, and it was difficult to focus patient on topic during exam.

Case discussion

When a patient presents to the ER for evaluation after sexual assault, every case must be taken seriously and methodically. Unfortunately, there are times where patients present with complaints of sexual assault that may be difficult to discern if they were actual offenses or a product of the patient’s delusion. Those with bipolar disorder when manic, often engage in risky sexual behavior. Furthermore, women who become pregnant have a higher risk of becoming manic or depressed (25-30%) with higher rates of illness recurrence during pregnancy after stopping mood stabilizers.

Key points in this case warrant further evaluation by psychiatry. She does appear with slow cognition, and difficulty with concentration during the interview. She also comments on seeing “bears and roaches” on the walls, which show signs of possible hallucinations. Are these pictures or actual animals? More information is needed. Risky sexual behavior can also be a symptom of mania. There are signs too that this patient may be a dangerous to herself, allowing herself to be placed in dangerous situations. There was no evidence of assault on vaginal or anal exam, and no strangulation marks on the neck. While these are difficult to detect, they could possibly have been detected sooner after the assault took place and with a high-definition camera, which was not used in this case.

The patient in this case would be recommended for evaluation of psychiatry and for safety and possible inpatient admission for mood stabilization. Again, many patients in these situations can also be victims of sexual abuse, so even threats of such abuse should be done systematically and professionally. In cases of repeat allegations with a negative physical exam, this provides further evidence to the psychiatric team that the allegations may be a product of the patient’s delusions.

Read the Full Article Here

Incoming President's Letter
Bethany Ashby

Dear NASPOG Members,

I am delighted to write my first newsletter column as your President! My initial NASPOG meeting was in 2014 in Colombus and as an early career psychologist, I was looking for a professional home, a society where my interests in women’s health aligned with the mission and values of a professional organization. I began my career working with adolescent girls, then perinatal adolescents, and then all birthing people and NASPOG was the only society I found that utilized a lifespan approach in understanding women’s health and well-being. At the time, I had few colleagues who had specialized in women’s mental health and NASPOG’s atmosphere of warmth and collaboration, combined with cutting-edge scientific education and presentations, created opportunities for connection with experts in the field – which is not always the case for early career faculty in professional societies. Through NASPOG, I have developed lasting professional collaborations and mentorship relationships that have been invaluable to my career. I hope that you have had similar experiences as a NASPOG member!

As president, I am committed to supporting and advancing NASPOG’s mission to promote the study and clinical application of the neurobiological and psychosocial aspects of women’s health and well-being across the lifespan. I have two additional goals for my presidency:

• 1.       to expand and promote the multidisciplinary membership of NASPOG, such that psychologists, psychiatrists, ob/gyns, midwives, master’s level mental health clinicians, and other health professionals, including learners, are active and engaged in the mission of our organization.
• 2.       to continue NASPOG’s work in advocacy, equity, and justice on behalf of women at all stages of life.

As part of our advocacy and equity work, NASPOG will hold a 2025 virtual speaker series. Ellie M. Proussaloglou, MD will kick off our series on January 23 at 6:30PM EST! Please join us as Dr. Proussaloglou presents on the mental and sexual health of patients during and after breast cancer diagnosis and treatment . Can’t make it on the 23^rd? We will be uploading Dr. Proussaloglou’s excellent presentation to our NASPOG new YouTube channel.

If you have ideas for our speaker series or would like to get more involved in NASPOG, please consider joining a task force or committee. We value your input and perspective! You can email me directly at bethany.ashby@cuanschutz.edu or reach out to info@naspog.org.

Finally, I am so grateful for the opportunity to serve as your NASPOG president.  I look forward to working with the NASPOG board and with each of you over the next 2 years.

Bethany Ashby

Farewell President's Message
Sarah Nagle-Yang, MD

Dear Members,

As 2024—and my tenure as NASPOG president—comes to a close, I want to reflect on the strength and vibrancy of our community. It has been an honor to serve as your president and to witness firsthand how our collective commitment advances women’s mental health. NASPOG is more than a professional society—it is a community where clinicians, researchers, and advocates come together to share knowledge, mentor one another, and build lasting networks. It is a place where you can grow, contribute, and find support.

This year, we have experienced tremendous momentum. From the success of our biennial meeting to the robust engagement within our committees, it is clear that NASPOG plays a critical role in advancing our field. We are poised to build on this strong foundation with exciting opportunities ahead.

In this newsletter, you’ll find details about an upcoming series of webinars focused on key intersections between women’s health and mental health. These sessions will feature expert speakers and interactive discussions, providing valuable insights to support and expand your work. I hope you’ll join us for what promises to be an engaging and thought-provoking series.

Looking further ahead, I am excited to announce that NASPOG will again partner with the Marcé Society of North America to present a preconference course at their November 2025 meeting in Toronto, spotlighting critical areas of reproductive mental health outside of the perinatal period. Mark your calendars—this promises to be an inspiring and impactful program.

As we look to the future, I am confident in the strength of the NASPOG community. Together, we are making meaningful contributions to the health and well-being of women across the lifespan. I encourage you to stay involved, whether by attending events, joining committees, or mentoring the next generation of professionals. Your voice, ideas, and energy are vital to our mission.

Thank you for your dedication and the important work you do every day. I wish you a wonderful holiday season and look forward to continuing this journey with you in the year ahead.

Advocacy:

The NASPOG Advocacy Committee is dedicated to improving mental health care accessibility and quality for obstetric and gynecologic patients throughout their lives. We collaborate with local, national, and international organizations to expand our impact and develop effective advocacy strategies. Our efforts focus on interprofessional collaboration, education, and outreach to raise awareness and support for key issues affecting our patients. By promoting innovative research, policy development, and community initiatives, we aim to enhance patient care and foster a more comprehensive approach to mental health in obstetrics and gynecology.

Equity Taskforce:

The Equity Taskforce is committed to enhancing a culture of inclusivity, accessibility, responsibility, and diversity within and beyond our Society. We strive to promote the health and well-being of women and individuals across the gender spectrum during times of reproductive transition. This Taskforce will work to create programming for our membership that will recognize, confront and dismantle structures that perpetuate inequity. Collectively, we aim to:

Recognize: Enhance understanding of the lived experiences of historically minoritized individuals and how to foster change within oppressive systems (e.g., through the NASPOG Book Club)

Connect: Engage with one another via small groups and workshop-based formats to identify how to best advance the Society’s DEIA mission

Dismantle: Partner with Advocacy Committee, national and community-based organizations to advocate for policies and practices that ensure equitable care for all individuals

Call to membership: please contact Equity Taskforce Chair, Sammy Dhaliwal, PhD, MSc, at sammy.dhaliwal@pennmedicine.upenn.edu to join the Committee. We would love to have you at our table!

Scientific Program Committee:

We’re excited to introduce the Scientific Education Committee at NASPOG. This committee is dedicated to advancing scientific knowledge and fostering educational opportunities for our members. Through workshops, resources, and collaborations with experts, they aim to promote continuous learning and innovation in our field. We encourage all members to engage and take advantage of these educational initiatives. We are currently working on creating a NASPOG YouTube channel with videos on a variety of women’s mental health topics. Some ideas that we’ve come up with include weight stigma, substance use, disability, menarche and adolescent mood disorders, and dads/partner support in the perinatal period. For more information or to get involved, please contact NASPOG Office. And if you don’t have the bandwidth to get involved with the committee, but have a great topic or speaker that we should include, please contact the  NASPOG office.

Social Media Committee:

The NASPOG Social Media Committee is focused on enhancing our online presence to engage, educate, and inform our community about key issues in obstetrics, gynecology, and mental health care. We use social media platforms to share valuable resources, highlight innovative research, and promote events that foster professional growth and collaboration. Our goal is to create a dynamic online community where members can stay updated, connect with peers, and advocate for improved patient care. By leveraging digital tools and strategies, we aim to broaden our reach and impact, making a difference in the lives of patients and healthcare professionals alike.

Newsletters Committee:

The NASPOG Newsletter Committee keeps our community informed with updates on key topics in obstetrics, gynecology, and mental health care. Our newsletters provide the latest research, policy news, educational opportunities, and event information. We aim to deliver valuable content that supports professional development and fosters a well-connected community dedicated to improving patient care. We’re also excited to introduce new features like Clinical Dilemma and Member of the Quarter, which will be added to our website blog for easy future reference and to enrich our content further.

Are you interested in helping with a committee? https://docs.google.com/forms/d/1iDucfvwoWJ54qlV4wc5UfUDxKz5VQGCDfel50kICUSA

“We are here to help you bridge the gap,” was how the conversation with Dr. Uruj Kamal Haider began when discussing MCPAP for Moms, the nation’s first Perinatal Psychiatry Access Program, for which Dr. Nancy Byatt was the founding Medical Director in 2014. MCPAP for Moms was an expansion of the successful Massachusetts Child Psychiatry Access Program (MCPAP), which was developed in 2004 by Dr. John Straus. MCPAP for Moms’ purpose has been supporting primary care, OBGYN and psychiatric providers with identifying and managing their patients' mental health and substance use concerns in an environment in which reproductive psychiatry has been scarce. In 2022, the White House Blueprint for Addressing the Maternal Health Crisis included the program within its recommended initiatives. Over 30 Perinatal Psychiatry Access Programs across the country have been modeled after MCPAP for Moms. Perinatal Psychiatry Access Programs are population-based programs that aim to increase access to perinatal mental health care. These programs build the capacity of medical professionals to address perinatal mental health and substance use disorders. “We have found since establishing the program that there is a growing confidence in our community.” Dr. Haider explains that services are aimed building the capacity of providers to learn about diagnostic clarity and treatment, but in the process have offered a wealth of knowledge to the communities they support. Over time, questions have grown in complexity and have led to more providers with the confidence and knowledge to treat perinatal mood and anxiety disorders and substance use disorders. The growth of Perinatal Psychiatry Access Programs inspired the development Lifeline for Moms, a program at UMass Chan Medical School that seeks to improve the treatment of perinatal mood and anxiety disorders through evidence-based perinatal mental health tools and resources that help integrate perinatal mental health care into everyday practice. When attending the most recent Lifeline for Moms meeting on its origin, evolution, and lessons learned, Dr. Byatt stated, “It’s all about relationships,” when referring to McPAP for Moms and stressed the importance of developing programs with and for the providers they serve. Legislators, providers and most importantly those with live experience have a wealth of knowledge to give and aid in these programs being successful and McPAP and Lifeline for Moms want to help those voices to be heard. www.naspog.org Lifeline for Moms website has multiple free materials available on their website including a listing of established perinatal mental health access programs (https://www.umassmed.edu/lifeline4moms/Access-Programs/). In addition, if your state doesn’t have a Perinatal Psychiatry Access Program yet and you are interested in consulting with a perinatal psychiatrist, you can also contact the Postpartum Support International (PSI) Perinatal Psychiatric Consult Line online or by calling 877-944- 4773

Sarah Krajewski, CNM, PMHNP-BC, PMH-C

Brockton Neighborhood Health Center

Dept of Social Services & OBGYN

Div. of Reproductive Psychiatry

A 33 y.o. woman with a history of recurrent major depression, after discussion during pre-pregnancy

planning, decides to continue her medication when she becomes pregnant. She wants to have another child, and had taken the medication for postpartum depression prior to seeing you. Since seeing you, she had a recurrence of her depression with significant symptoms and restarted her SSRI. Her symptoms are under good control. She becomes pregnant several months later, and a few weeks after finding out she is pregnant, decides she wants to stop her medication due to the risk of neurodevelopmental disorders, particularly autism. This is something that you had discussed with her previously in regards to continuing the medication and she had seemed clear in her decision, but has suddenly become anxious and doubtful. Of note, her sister’s child has been diagnosed with autism. How do you handle this?

Another woman who presented with a significant depression, including suicidal thoughts in her first trimester agreed to increase the dose of her SNRI and meet for psychotherapy. Her depression lifted eventually. However, in her third trimester, she decreased her dose as she had been told by her obstetrician that might be advisable given the risks of side effects in the newborn. You had discussed this risk and she had been advised to continue at the most effective dose. Nevertheless, she decided to decrease her dose even though you express concern about postpartum recurrence. What is the best approach?

In working with perinatal patients with psychiatric disorders, we can face dilemmas regarding medications that bring up questions about weighing risks, advising patients, and how strongly to weigh in on the patient’s decision. We want to respect a patient’s autonomy, but are aware of the potential difficulties that can arise if a patient decides not to take medications or wants to change to a “safer” medication. Some women are clear about continuing the medications that are working for them and do not waver. Many women have some initial discomfort and can feel the seriousness of the decision to continue medication and possible risks and need to work through these feelings and anxieties to accept taking medication while pregnant. Some women are clear about the symptoms they will experience and the how detrimental these will be, particularly if they have another child at home to care for.

Nevertheless, as in the cases above, patients can and do change their minds, in surprising ways and make decisions that we wouldn’t necessarily agree with or recommend.

In approaching this situation, we certainly can try to understand their reasons including those that are unique to their situation as well as the more common misconceptions about the risks of taking medication in pregnancy. Even if we know the risks to be low, that is not how our patients may feel.

Many women feel anxious about exposing their baby to any kind of risk of an adverse outcome, and that may be based in their own psychology, family history, cultural beliefs or prior experiences. They may feel like they are a bad or negligent mother for exposing their child to a medication. Whose needs come first, theirs or the baby’s? Some women feel some shame and stigma as someone who needs medications during pregnancy. They may have thought they were clear about their decision, but when they are actually pregnant, they feel differently as the reality of the baby now plays more of a role in their decision making.

As a clinician, it is helpful if we can be clear about our position in regards to these issues and the risks involved. It can feel difficult to ask a woman to take a risk that she perceives to be unacceptable, perhaps bringing up our anxieties about whether the medication we are prescribing puts the fetus at risk. As a perinatal psychiatrist, we are sometimes practicing in a way that our colleagues are not as comfortable with. The patient’s anxieties can be influential. We tend to be more accepting of and tolerant of uncertainties given our experience over time. We are also able to be clear if the data is clear and has led to a consensus in the field in regards to taking a particular medication in pregnancy.

In talking to our patients who have considerable anxiety or may change their minds, we can certainly review again the data that we have about the medication, the consensus as to the level of risk if any that a particular medication poses and the risks of untreated illness. We are also aware of the severity of her symptoms in her recent depression and can raise this. We can explore her reasoning. We have a strong basis for our recommendation to continue medication and want to make this recommendation clearly but with tact. We may have to accept that we cannot convince the patient otherwise. We also may be able to work with the patient to agree to a plan restart their medication or increase their dose again if they have a significant recurrence. We can also remind someone that meeting their needs is meeting the baby’s needs.

It is also important that we consider our relationship with the patient. Even if they go against our advice, it is much better if the patient feels they can still rely on us and is open to our involvement even if they are not taking medications. It can be helpful to see the patient more often to be able to pick up on symptom recurrence sooner rather than later. Many patients will agree to this. Sometimes, if patients become symptomatic, we may also have to bear a period of depression and anxiety with them as they come to terms with their need for medications which may include a sense of failure. We want to preserve our working relationship with our patient, and ultimately need to respect their wishes.

Sometimes, it might indeed work out in their favor, but we want to be there if they need us.

Catherine Mallouh M.D., Associate Clinical Professor, volunteer faculty, University of California, San Francisco. Private practice in San Francisco, specializing in perinatal psychiatry.

This is a first article in a series that will highlight the clinical dilemmas faced in clinical practice. We hope to invite other members to contribute and would welcome responses to this piece. You can send me an email: cmalmd@yahoo.com