Perinatal Psychiatry Research Articles

A population survey of prevalence rates of antenatal depression in the Irish obstetric services using the Edinburgh Postnatal Depression Scale (EPDS).

Ireland has the second-highest birth rate in Europe and poorly developed perinatal psychiatry services. There are no screening services for antenatal depression and no data available on prevalence rates of depression among women attending the Irish obstetric services. The aim of this study was to assess the prevalence rates of depression during pregnancy in a population sample in Ireland using the Edinburgh Postnatal Depression Scale (EPDS) as a screening tool. Pregnant women during all stages of pregnancy were recruited from five maternity hospitals throughout the Republic of Ireland. Approximately 5000 EPDS questionnaires were collected. Information on the participant's age, gestational week, gravidity, parity, and level of education attained was also collected. A score of > 12 was used as a measure of probable depression. Overall, 15.8% of pregnant women scored > 12 in the EPDS. There was a significant association between gestational week and rates of depression, with increasing rates occurring with advancing pregnancy (p< 0.001). Overall, higher socioeconomic groups were over-represented in the sample although we replicated the well-established findings of higher EPDS scores in women with lower educational attainment (p< 0.005). This study demonstrates that prevalence rates of probable antenatal depression are high among women attending the obstetric services in Ireland and highlight the importance of increasing awareness of antenatal depression. These high rates of antenatal depression may be related to certain conditions that are specific to an Irish setting: the absence of screening for depression in the context of grossly under-resourced perinatal psychiatry services. These findings provide indirect confirmatory evidence for the need for streamlined mental health services within reproductive health services.

Familial History of Psychiatric Disorders Key in Predicting Postpartum Risk

Back to table of contents Previous article Next article Clinical and Research NewsFull AccessFamilial History of Psychiatric Disorders Key in Predicting Postpartum RiskMark MoranMark MoranSearch for more papers by this authorPublished Online:13 Jun 2018https://doi.org/10.1176/appi.pn.2018.6b13AbstractThe risk of experiencing a postpartum psychiatric episode was highest when mothers had a first-degree relative with bipolar disorder.A family history of psychiatric disorders, especially bipolar disorder, is an important risk factor for postpartum psychiatric disorder, according to a population-based cohort study published May 7 in AJP in Advance. iStock/bgwalkerCo-authors Anna E. Bauer, Ph.D., and Samantha Meltzer-Brody, M.D., said that questions related to female and male first-degree relatives with bipolar disorder are of the highest importance and should be added to routine clinical screening guidelines to improve prediction of postpartum risk among pregnant women.Bauer is a postdoctoral research associate in the Department of Psychiatry at the University of North Carolina (UNC) at Chapel Hill School of Medicine. Meltzer-Brody is director of the perinatal psychiatry program at the UNC Center for Women’s Mood Disorders. Their colleagues included researchers at the National Center for Register-Based Research at Aarhus University in Denmark and other international institutions. The researchers analyzed Danish birth and psychiatric treatment registers to evaluate familial risk of postpartum psychiatric episodes in a national population-based cohort. The primary exposure was a diagnosed psychiatric disorder in a relative.The final population-based cohort consisted of 362,462 mothers who gave birth to their first child in Denmark between 1985 and 2012. The mean age of mothers was 27.0 years at time of delivery. Of these mothers, 2,603 (0.7 percent) experienced a psychiatric disorder within six months postpartum and 4,085 (1.1 percent) within 12 months postpartum.Overall, the risk of experiencing a psychiatric disorder within the first six months postpartum was higher among mothers with a first-degree relative who had experienced any psychiatric disorder compared with those whose relatives had not experienced any psychiatric disorder. The risk of experiencing a postpartum psychiatric episode was highest when mothers had a first-degree relative with bipolar disorder. Familial risk was also elevated for those who had a first-degree relative with schizophrenia, unipolar disorder, or other mood disorder.The authors also found associations of family history of psychiatric disorders to be stronger among women without a personal psychiatric history, indicating that family history may be particularly helpful in a risk-assessment tool for new-onset postpartum psychiatric episodes among women with no record of psychiatric disorders. “Previously, a woman who has a brother with bipolar disorder but no personal history of mental illness would not necessarily be identified as being at higher risk for experiencing a postpartum psychiatric disorder,” they wrote. “However, this research provides evidence that such characteristics may identify novel risk groups to which clinicians could direct additional screening efforts, earlier education about symptoms, or earlier referral to mental health resources.”Clinical practice guidelines in the United States have recently been updated to reflect a growing emphasis on the importance of perinatal mental health screening, but the current guidelines of the U.S. Preventive Services Task Force and the American College of Obstetricians and Gynecologists do not include family history as a risk consideration for postpartum psychiatric disorders. “Predicting who will experience a postpartum psychiatric disorder is a challenge but also of great importance,” the authors noted. “The results of this study provide compelling evidence that assessment of risk for postpartum psychiatric illness, with a particular focus on history of bipolar disorder, should include inquiring about family history of psychiatric disorders in any male or female first-degree relative.” ■“Familiality of Psychiatric Disorders and Risk of Postpartum Psychiatric Episodes: A Population-Based Cohort Study” can be accessed here. ISSUES NewArchived

Recommendations for the use of ECT in pregnancy: literature review and proposed clinical protocol.

Psychiatric disorders are common in pregnancy, affecting 15-29% of pregnant women. Untreated depression has negative health consequences for mother and fetus. Electroconvulsive therapy (ECT) is an effective option for the treatment of severe depression, high suicide risk, catatonia, medication-resistant illness, psychotic agitation, severe physical decline, and other life-threatening conditions. To our knowledge, however, there is no literature that consolidates all the evidence on maternal and fetal risks associated with untreated depression, medications, and ECT then translating it into one cohesive protocol that could serve as a management guide and a source of reassurance to health-care providers involved in such practice. Hoping to facilitate ECT access to perinatal patients, the authors combined their multidisciplinary clinical experience (in perinatal psychiatry, neuropsychiatry and neuromodulation, and anesthesiology) at three different centers in the USA (Brigham and Women's Hospital/Harvard Medical School, The University of Chicago, and Brown University) with a careful and critical literature review and propose guidelines for the administration of ECT in pregnancy. A comprehensive review of the relevant literature regarding both ECT and psychotropic medications in pregnancy was performed, including meta-analyses of randomized controlled trials published in general medicine, anesthesiology, psychiatry, and obstetrics journals and guidelines. The indication and appropriateness of ECT in pregnancy must be carefully weighed against the risks of untreated maternal illness and those of alternative treatment options. The safety of ECT in pregnancy has been documented over the last 50years. The adverse effects in pregnancy are similar to the risks of ECT in any individual. The most common risk to the mother is premature contractions and preterm labor, which occur infrequently and are not clearly caused by ECT. The rates of miscarriages were not significantly different from that of the general population. There have been no associations of ECT with congenital anomalies, either morphologic or behavioral, and no neurocognitive disturbances in the child. ECT is a reasonably safe and effective treatment alternative for management of many psychiatric disorders in pregnant patients. The authors provide recommendations for treatment modifications in pregnancy-based physiologic changes that occur during that period and consolidate them into a protocol that can assist clinicians in improving access and safety of ECT for pregnant patients.

Co-located perinatal psychiatry clinic: impact of adding a psychologist on clinical quality improvement metrics

Purpose: To describe the impact of adding a psychologist (the intervention) to a co-located perinatal psychiatry clinic (PPC) in terms of effects on clinical quality improvement (QI) metrics.Methods: Six-month pre- and postintervention study design with measurement of QI metrics: number of unique patients treated; number of new and established visits; percent no-shows for new and established visits; and mean wait time to new visit.Results: Number of unique patients treated by the psychiatrist increased by 30%, from 90 preintervention to 118 postintervention (p = .06). Total number of visits completed by the psychiatrist increased by 20% from 174 preintervention to 208 postintervention. Mean wait time for new visits for a physician decreased from 20 days preintervention to 14 days postintervention, with a mean difference of 6.4 days (p = .0015). Percentage of no-shows for new visits increased slightly from 23% preintervention to 26% postintervention (p = .72). The percentage of no-shows for established visits decreased significantly from 22% preintervention to 10% postintervention (p < .005).Conclusions: By adding a psychologist to the co-located PPC, we improved quality of perinatal mental health care by improving efficiency, timeliness and patient-centered care. The psychiatrist saw a greater number of unique patients, decreased wait time to new visits and decreased no-show rates for established visits, likely by better matching patient needs with provider services. A psychologist could be a valuable addition to a PPC, given the shortage of psychiatrists in the United States.

PRogram In Support of Moms (PRISM): a pilot group randomized controlled trial of two approaches to improving depression among perinatal women

Purpose: This pilot study was designed to inform a larger effectiveness trial by: (1) assessing the feasibility of the PRogram In Support of Moms (PRISM) and our study procedures; and, (2) determining the extent to which PRISM as compared to an active comparison group, the Massachusetts Child Access Psychiatry Program (MCPAP) for Moms alone, improves depression among perinatal women.Methods: Four practices were randomized to either PRISM or MCPAP for Moms alone, a state-wide telephonic perinatal psychiatry program. PRISM includes MCPAP for Moms plus implementation assistance with local champions, training, and implementation of office prompts and procedures to enhance depression screening, assessment and treatment. Patients with Edinburgh Postnatal Depression Scales (EPDS) ≥ 10 were recruited during pregnancy, and completed the EPDS and a structured interview at baseline and 3–12 weeks’ postpartum.Results: Among MCPAP for Moms alone practices, patients’ (n = 9) EPDS scores improved from 15.22 to 10.11 (p = 0.010), whereas in PRISM practices patients’ (n = 21) EPDS scores improved from 13.57 to 6.19 (p = 0.001); the between groups difference-of-differences was 2.27 (p = 0.341).Conclusions: PRISM was beneficial for patients, clinicians, and support staff. Both PRISM and MCPAP for Moms alone improve depression symptom severity and the percentage of women with an EPDS >10. The improvement difference between groups was not statistically significant due to limited power associated with small sample size.

Gold Award: Building the Capacity of Frontline Providers to Treat Mental and Substance Use Disorders Among Pregnant and Postpartum Women.

Gold Award: Building the Capacity of Frontline Providers to Treat Mental and Substance Use Disorders Among Pregnant and Postpartum Women.

Comprehensive Integrated Care Model to Improve Maternal Mental Health

In this article, we describe an integrated care model in a perinatal psychiatry program to improve access to care for women who experience mood changes during the perinatal period. A nurse-practitioner trained in psychiatry and obstetrics is embedded in the obstetric clinic, and perinatal nurses, often the first professionals to recognize women who are experiencing mood changes, can easily refer women for follow-up. Barriers, lessons learned, and goals for implementation are described.

Psychometric properties of the Postpartum Bonding Questionnaire and correlates of mother–infant bonding impairment in Italian new mothers

Objectiveimpaired maternal bonding is a risk factor for problems with infant well-being and development. The investigation of perinatal variables related to disorders of the mother–infant relationship as well as the administration of reliable and valid screening tools to new mothers in the postpartum can help identify early signs of a disturbed mother–child relationship. The Postpartum Bonding Questionnaire (PBQ) has been shown to be a valid screening instrument, but its dimensional structure is still controversial. An analysis of the literature demonstrated the need for research into the perinatal correlates of the quality of mother-newborn bonding as measured by the PBQ, and for information about the reliability and validity of the Italian version of the questionnaire. Aimto (a) carry out preliminary analysis of the psychometric properties of an Italian version of the PBQ and (b) explore how mother–infant disturbances are related to relevant perinatal psychological variables. Designthe research design consisted of a prenatal and a postnatal phase. Settingprenatal education classes delivered in public and private institutions. Participants123 pregnant Italian women were recruited from prenatal education classes. Measurementsin the prenatal period participants completed a questionnaire measuring maternal-fetal attachment; at the postnatal assessment (3 months postpartum) participants completed the Italian PBQ together with measures of mother–infant attachment, the couple's adjustment and maternal psychological well-being. Exploratory factor analysis was used to investigate the factor structure of the PBQ. Internal consistencies were evaluated using Cronbach's alpha. Nomological validity was assessed via Pearson correlations. Findingsa three-factor model provided the most meaningful representation of the PBQ data, with one factor reflecting annoyance and anger towards the infant, another reflecting detachment and rejection and the third reflecting anxiety about infant care. Internal consistencies were good. Impaired mother-infant bonding was negatively correlated with prenatal and postnatal mother–infant attachment and couple adjustment, as well as being positively correlated with maternal depressive symptoms. Key conclusions and implications for practicethe Italian PBQ is a reliable, valid screening instrument and can be used for research, including transcultural comparisons in perinatal psychiatry. It can also be used clinically to detect signs of a disordered mother–child relationship. Knowledge of the variables generally associated with mother-infant bonding problems combined with data from postpartum administration of the PBQ could be used in midwifery to develop preventive programmes based on the specific needs of new mothers.

50 years of perinatal psychiatry.

50 years of perinatal psychiatry.

Acceptance and commitment therapy for perinatal mood and anxiety disorders: development of an inpatient group intervention.

Perinatal mood and anxiety disorders are a leading cause of morbidity and mortality for childbearing women. Current treatments, such as cognitive behavioral therapy and interpersonal therapy, have demonstrated modest success in addressing perinatal psychiatric symptoms; however, additional treatment options are needed to address the limitations of current approaches, particularly for women experiencing moderate to severe perinatal mental illness during pregnancy or postpartum. We discuss the use of acceptance and commitment therapy (ACT) as a promising treatment approach that may be uniquely suited for perinatal women due to its emphasis of values, mindfulness, and acceptance; these psychological constructs notably address the significant psychiatric and behavioral health condition comorbidity, somatic symptoms, and stigma associated with perinatal mood and anxiety disorders. In addition, we describe the development of a four-session ACT-based group intervention at the Perinatal Psychiatry Inpatient Unit at the University of North Carolina at Chapel Hill. Sessions focus on core ACT processes of acceptance, cognitive defusion, present-moment awareness, value identification, and goal setting, and we describe how each of these processes is relevant to the perinatal population. Implications for future clinical applications and research investigations are discussed.

La liaison en « Périnatalogie » : des soins entre réseau, liaison et prise en charge mobile

ObjectivesThe pregnancy periods of peripartum and immediate postpartum represent moments of opportunity to access care. Both prevention and therapeutic management can be offered with a better chance of success during these periods. Our specific Consultation Liaison (CL) team PPUMMA was created in order to respond to the need for early detection of psychopathology and rapid implementation of therapeutic management and preventive measure for mother and child. The importance of urgently intervening “on site” seemed a necessity since duration of hospitalization in maternity wards is very short. Women might not know or understand their symptoms or be ready to ask for a referral for themselves but could be ready to respond positively to a team approach where the psychiatrist is part of the Ob-Gyn department. Working with an interdisciplinary approach tends to lower stress linked to the psychiatric side of the consultation and stigma related to psychological or psychiatric issues; therefore, PPUMMA intervenes within 48 to 72hours of birth. It deals with assessment and diagnosis during the peripartum period and orientation and referral for both mother and infant when necessary after birth. The Perinatal Psychiatry emergency mobile unit PPUMMA was created in order to address these issues. MethodsFrom 2008 to 2015, 1907 patients were assessed but data were missing for 90 patients. We therefore analyzed 1817 patient files looking at age, diagnosis origin of referral, time of referral (pre or postpartum) and delay from referral to assessment. ResultsMost patients were between 20 and 40 (81.5 %). One hundred and eighteen patients were under 20 years of age, of whom 64 were minors (3.5 %), and 218 were 40 or more (12 %). These two groups were over-represented close to threefold when comparing with national birth data records. A psychologist had first seen three out of four women. Midwives and Ob-Gyn referred 9 % and 8 % of patients while Social workers sent in 4 %. Two thirds of the women were seen during pregnancy, 50 % were seen the same day and 80 % received a consultation within 72hours. Three out of five of women had an assessment that concluded in a “Neurotic, stress-related and somatoform disorders” type code disorder linked to stress and somatoform disorder in ICD 10 (F40-F49). This is due to a high number (47.2 %) of F43 “Reaction to severe stress, and adjustment disorders”. Twentynine present of women had a mood disorder (F30-39), and close to one third (31.6 %) had a personality disorder diagnosis attached. Schizophrenia, schizotypal and delusional disorders (F20-F29) represented 4.4 % of diagnoses. One third of the population had comorbid disorders: meeting either two (28.5 %) or three (3.7 %) diagnostic criteria for a psychiatric disorder. Most co-morbidity is due to personality disorder (82 % F60-F69). ConclusionThe number of referrals and diagnostic criteria met show how essential a psychiatric CL team assessing and orienting women during pregnancy and immediate postpartum is. Opportunity for adaptation of treatment during the peripartum period and more long-term tailored management of disorders can be organized during this period in a multidisciplinary approach. Knowing how essential maternal mental health is for women, for infant development and for mother-infant interactions, this is a unique window for access to care and intervention. Maternal mental health is a public health issue. Access to psychiatric assessment and care during the peripartum period offers unique possibilities for prevention and care.

Personality disorders and perinatal psychiatry: Food for thoughts from perinatal psychiatric department experience

BackgroundPregnancy and postpartum are sensitive unique moments in women's life. Perinatal psychiatry is focused on depression and psychosis, but personality issues is often neglected as well as risk factors for personality disorders instead of being considered causative of onset or recrudescence of psychiatric symptoms in perinatal.MethodsIn total, 129 women were referred to perinatal psychiatric department during their pregnancy or postpartum in the last three years. They were administered SCID II, Childhood Trauma Questionnaire (CTQ), Beck Depression and Anxiety Inventories (BDI and BAI), Edinburgh Postnatal Depression Scale (EPDS) and World Health Organization Quality of Life (WHOQOL). Their interaction with babies was monitored at birth and during follow up. Children's behavioral development is under evaluation through structured tests.ResultsBDI and BAI scored moderate or severe in 31 and 27% of women, EPDS was significant in 36%, while SCID II highlighted 24% of borderline, 17% narcissistic, 4% schizoid, 4% paranoid and 9% obsessive/compulsive PD. Nineteen of them suffered physical abuse during childhood, 26 sexual abuse, 89 emotional neglect and only 15 out of 129 were negative to any kind of abuse during childhood.ConclusionPersonality disorders appears to influence maternal adjustment to pregnancy and motherhood. Abuses suffered during childhood confirm their role as potential risk factor in personality issues which clearly express their effect in adaptation to change in personal role and in emphatic interactions.Disclosure of interestThe authors have not supplied their declaration of competing interest.

Psychiatric training in perinatal mental health across European countries

IntroductionThe aim of postgraduate psychiatric training is to prepare psychiatrists to practice independently. The quality of care provided will depend on the training they received. Pregnancy and childbirth (usually called the perinatal period) are a high-risk period for many women with psychiatric problems. An illness episode at that time can have a devastating effect on women and the whole family, including the child's development.ObjectivesTo understand how perinatal mental health training is organized within Europe and how it fits in the training curricula.MethodsThe European Federation of Psychiatric Trainees conducts an annual survey of all member country organizations. We have asked respondents if they received training in perinatal psychiatry, whether that was optional or mandatory and what was its duration. Where training in perinatal psychiatry was not available we asked if they felt it should be.ResultsData will be presented from the 35 countries that responded in the 2016 survey. Six countries reported that training in perinatal mental health is available. But it is mandatory in only one, with the others offering a mix of theoretical and practical optional training. Of the 29 countries that do not offer perinatal psychiatry training, the majority reported it should be offered and mandatory.ConclusionThere is a gap in the expectations of psychiatrists treating women in pregnancy and after birth, and a widespread lack of training for them to be able to do so effectively.Disclosure of interestThe authors have not supplied their declaration of competing interest.

Developing a curriculum and standards for psychiatric training in perinatal mental health

This presentation will inform the audience about the workforce issues in England in relation to Perinatal Psychiatry. The talk will illustrate the methods being utilised within the Royal College of Psychiatrists to develop the skills and competencies of clinicians. Intensive training courses, curriculum development and an innovative bursary scheme for consultant psychiatrists will be described.Disclosure of interestThe author has not supplied his declaration of competing interest.

IPS travel fellowship in perinatal psychiatry.

IPS travel fellowship in perinatal psychiatry.

Perinatal psychiatry: a new specialty or everyone's business?

SummaryPerinatal psychiatry is a relatively new subspecialty and controversy exists about such specialist provision. Differences can occur in how mental illnesses present in pregnancy, and there is a need to take into account both mother and baby. The risks of not treating perinatal mental illness can be both acute and chronic, and suicide in the context of untreated illness remains a leading indirect cause of maternal mortality. Despite the government's agenda of preventive healthcare, service provision is inequitable across the UK. Advice regarding treatment continues to be complex, and perinatal psychiatrists need to keep abreast of a growing evidence base. This review offers an overview of some current issues in the care of patients in the perinatal period and shows how specialised perinatal services are uniquely placed to meet their needs. Hopefully, it will prove useful to all clinicians responsible for the perinatal care of women and their families.

Use of Antidepressants During Pregnancy?: What to Consider when Weighing Treatment with Antidepressants Against Untreated Depression.

Introduction Mood disorders impact many pregnant women, particularly those who have experienced symptoms prior to conception, and there are significant barriers, including stigma and access, to seeking and receiving appropriate treatments. Antidepressants are a helpful option in treating perinatal depression, but research on risks and benefits of antidepressant use in pregnancy is difficult given lack of "gold standard" comparative trials. Methods This paper summarizes current state of knowledge on the safety of antidepressants during pregnancy by providing a summary of the literature published in the past 3 years (January 2013-October 2015). We identified 21 reviews and meta-analyses that were included in this summary report. This report is meant to provide a user-friendly, yet comprehensive guide summarizing the abundant, and in part contradicting, literature on risks and benefits of antidepressants during pregnancy, in order to assist busy primary care prescribers in educating their patients. Our goal is also to contrast the risks/benefits of untreated depression in pregnancy versus treatment with antidepressant medication in pregnancy, and in such support prescribers in their decision-making. Results The past 3 years have yielded an abundance of publications on the topic, in part, with conflicting findings adding to confusion and concern among providers, patients, and their families. Many reported studies have methodological problems limiting their impact. Data on adverse effects of medications on pregnancy and fetal outcomes have to be weighed against the impact of untreated illness and poor health habits associated with untreated illness on the same outcomes. Discussion Medical-decision making is often complex and seldom free of risks. Obviously, as providers we cannot guarantee that fetal exposure to antidepressants is totally free of risk, yet this is true for any medicine taken in pregnancy. However, to date, perinatal psychiatry has collected enough evidence to suggest that, if the clinical picture warrants it, the use of many antidepressants, especially the SSRIs, is favorable compared to exposing mother and child to untreated depressive illness.

Support for teenage pregnancies and early emotional deprivation

The perinatal psychology and psychiatry unit of Caen university hospital has put in place two systematic intervention protocols relating to pregnancy: teenage pregnancy and denial of pregnancy. Professionals are particularly concerned with teenagers with a history of early emotional deprivation and mistreatment, with the spectre of repetition. A partnership with a motherhood centre helps all concerned to work together to build resilience.

Treatment of severe perinatal mood disorders on a specialized perinatal psychiatry inpatient unit.

Perinatal patients with bipolar and psychotic mood disorder exacerbations are challenging to treat and often receive suboptimal care. We sought to examine the treatment patterns and outcomes on one of the only US-based Perinatal Psychiatry Inpatient Units (PPIU). Perinatal patients admitted to the PPIU completed self-report measures at admission and before discharge. Retrospective chart reviews extracted history, diagnoses (current and past), and medication treatment. Patients who had discharge diagnoses of bipolar disorder, major depression with psychotic features, or postpartum psychosis were included. Forty-seven met the diagnostic inclusion criteria. Over an average length of stay (ALOS) of 9.96days, there was significant improvement in depressive and anxiety symptoms and daily functioning (Work and Social Adjustment Scale). Psychiatric comorbidity was common. Polypharmacy was utilized in 87%. The most common medications prescribed at discharge were antipsychotics, alone or in combination with mood stabilizers or antidepressants. ECT was performed in 10% of cases. The complexity of patients with severe mood disorders or psychosis admitted to the PPIU supports individualized treatment plans that address both primary diagnosis and psychiatric comorbidities. Our results provide important information that can be disseminated to others to improve clinical outcomes for severe perinatal mood disorders.

Comment soutenir l’arrivée au monde d’un enfant de mère migrante dans une maternité française : entre urgence somatique et urgence psychiatrique, le temps de la reconstruction…

Giving birth in a foreign land can be particularly difficult. The language barrier, medical techniques sometimes opposed to traditional customs, different representations of illness and solitude represent some of the vulnerability factors in young immigrant mothers. This article presents the clinical situation of a dyad under observation in the maternity ward by the pedopsychiatry team. Emphasis is put on the difficult encounter between perinatal psychiatry and culturally encoded postpartum depression. A clinical and therapeutic orientation is discussed. Acquiring more perspective while sharing the experience can lead to a rich clinical and human encounter at the same time.