Nicole Pacheco, MD, is Working to Promote Diversity in Reproductive Psychiatry

As much as Nicole Pacheco Tchalim, MD, finds joy in helping patients manage mental health challenges, she doesn’t stop there. Dr. Tchalim also devotes her tireless energy to the education of new providers who will grow the field of reproductive psychiatry.

As a reproductive psychiatrist at Columbia’s Women’s and Reproductive Mental Health (WARM) program, Dr. Tchalim provides care for women and birthing individuals across their lifespans, addressing mental health challenges and needs related to reproductive and gender-linked transitions. She also serves as director of Columbia’s WARM fellowship and founded the June Jackson Christmas Fourth Year Medical Student Elective, which helps students from underrepresented backgrounds receive training and experience.

Dr. Tchalim is eager to discuss today’s challenges in reproductive psychiatry, as well as her thoughts on improving diversity and expanding the reach of the field.

For anyone who isn’t familiar with this field, what is reproductive psychiatry?

This specialty deals with any impact that reproductive and hormonal transitions have on a woman’s mood or behavioral health. At the Columbia WARM program, we take a reproductive lifecycle longitudinal view that examines psychological distress during menstruation, pregnancy, postpartum, and menopause. Although there’s an important hormonal component to reproductive psychiatry, I want to be careful not to overstate it. We take a holistic approach to psychological transitions (such as identity shifts during the postpartum period) and the best way to support each individual.

How did you arrive at this specialty?

I’d originally planned to become an OB/GYN because, unfortunately, someone in my family received an obstetrical procedure without her consent, which had been a common practice where she had lived at the time. It’s clear that discriminatory practices and other systemic factors, such as the lack of proper translation services, played into the event. It therefore felt very important to me as a person of color to join the obstetrical field so I could be a voice for individuals who would face similar challenges.

I went to med school and loved my OB rotations, but I realized that the special moments in my heart came from talking to the moms. When I started my psychiatry rotation, I actually tried not to like it because I was still focused on OB. But at the end of my rotation, I thought, “Who am I kidding? Psychiatry is amazing!” After that, I learned that reproductive psychiatry was a field but it wasn’t well-known yet. So, I started looking into different residency programs that offered it.

Why do patients need this specialty?

There are so many ways to answer that. My mind goes to the recent New York State Department of Health data on maternal mortality from 2018, which found an increase in the rates of maternal death within the first year postpartum. We suspect some of this rise to be linked to maternal mental health illness and substance use. In fact, the New York Maternal Mortality Review Committee found mental health conditions to be the third leading cause of pregnancy-associated deaths. They also found that these deaths were 100 percent preventable. It’s therefore very clear how important psychiatric care during the perinatal period is.

How do you hope to address these issues?

For myself as a reproductive psychiatrist and fellowship director, one of my biggest priorities is making sure clinicians are trained to provide this type of treatment. I believe that every single psychiatrist should be able to treat individuals who are pregnant or postpartum. Unfortunately, current studies indicate that many prescribers feel uncomfortable treating pregnant individuals. It’s not uncommon to see prescribers recommending that people discontinue all psychiatric medications in pregnancy, and this often stems from a lack of knowledge on the provider’s side and less from any clear evidence of the benefit of discontinuation for that individual and their potential child. It’s important to state that for many individuals, the risks of taking medications in pregnancy outweigh the risks of untreated psychiatric illness. It’s important to provide patients with accurate risk information so they can make the best decisions for themselves and their families. I see my role as both creating specialists who can handle more complex issues—like how to manage a pregnant patient on lithium—and also providing broader training for general psychiatrists.

What are some other challenges in the field of reproductive psychiatry?

One issue that patients face is bias when it comes to the idea of hormones being related to any kind of psychological distress. For example, individuals struggling with premenstrual dysphoric disorder (severe depression, anxiety, or irritability in the week or two before a period starts) can be told they’re overblowing it. Same thing with menopause. Patients who bring these concerns to mental health providers often aren’t being heard, and there’s a mismatch between an individual’s true experience with these hormonal changes, and what doctors say about this. So that’s a barrier we need to work on.

How does promoting diversity come into play?

As a woman of color, I’m a big believer in more diversity in the field. We know that when we have more diversity among providers, we see better patient care outcomes. I am happy to say, though, that I have seen a huge improvement in the diversity of providers in this field over the last few years. If I’m being honest, back in medical school, there weren’t many people of color in reproductive psychiatry, and I was hesitant about going into the field because I wasn’t sure there was a place for me. Today, I don’t feel that way at all because the field has grown immensely, and there is a clear emphasis on the importance of diversity.

What gives you the most joy about this work?

So many things come to mind. Sometimes patients who had been struggling with feelings of being a bad mother or worrying about bonding with their baby will come on screen for telehealth and be playing with their baby and just be smiling, and it’s so meaningful for me to see them doing well.

For the educational piece, seeing the residents towards the second half of the year and feeling like, “Oh, they got this,” is so rewarding. I know I’ve done my job, and they’ll go out and teach others, as well. Sometimes they come back and do some teaching with us, so it’s been a really beautiful system and a beautiful growing community. We’re all committed to educating the next group.

Could you talk about Columbia as a home for this work?

Because Columbia is a large and diverse healthcare system, it creates a range of opportunities for the fellows: We have fellows in community settings supporting patients who are unsheltered; we have fellows working in a more traditional outpatient model through our faculty practice; and we have fellows at the hospital doing Ob-Gyn consultations and supporting acute substance withdrawal in pregnancy. Not every hospital system would be able to provide that breadth of experience, and it’s just wonderful.

Regarding disparities in this field, what progress do you hope to see?

We all know we need to do more in terms of diversity within this field because often, we see the patients who need this specialty the most are those who tend to be underserved.

Even just in the last two to three years, knowledge and interest in reproductive psychiatry have really grown. Among our own fellows, there has really been a demographic shift to more diversity. This year, we have a fellow who was born and raised in the Washington Heights community. Next year we’ll have two students who identify as underserved minorities who will be part of our fellowship. And I think this is happening in many different programs because the field is better known, which is wonderful to see.