New tool helps clinicians address sexual and reproductive health in early psychosis care

A team of researchers at the Centre for Addiction and Mental Health, Women’s College Hospital and the University of Toronto have developed a first-of-its-kind intervention to improve sexual and reproductive health in young adults experiencing early psychosis.

The approach, which includes training modules and materials for clinicians along with client-facing materials, is designed to equip both providers and patients with the tools to discuss and address a young person’s specific sexual and reproductive health needs.

According to Lucy Barker, a reproductive psychiatrist at Women’s College Hospital and an assistant professor of psychiatry at U of T’s Temerty Faculty of Medicine, youth experiencing psychosis are at a greater risk of poor sexual and reproductive health outcomes.

As a fellow, she led a series of interviews and focus groups with women and nonbinary young adults experiencing early psychosis and with clinicians to better understand their experiences. She says a number of interconnected factors contribute to the barriers these young people face in accessing information and care.

“When a youth with psychosis receives health care, the focus is often their mental health, and their sexual health gets overlooked,” says Barker.

The experience of psychosis itself — which can manifest as hallucinations or delusions such as paranoia, for example — can affect a person’s sex drive, decision making and trust in health care providers, while medications to treat the illness can have sexual side effects and impact menstruation. Barker notes that trauma and stigma are also important considerations, as is a young person’s ability to navigate multiple appointments within a siloed health care system while managing a complex mental illness.

Barriers also exist on the clinician side.

“Mental health clinicians don’t really have that much training in sexual and reproductive health, and sexual and reproductive health clinicians don’t have much training in working with people with more severe mental illness,” says Barker. “There’s this kind of missing middle.”

To address identified challenges, Barker and the research team, which included psychiatrists and professors Simone Vigod and Juveria Zaheer, formed a working group of youth with lived experience of early psychosis and experts in mental health and sexual and reproductive health. The group met biweekly over 10 months to identify five key sexual and reproductive health topics — relationships, sexual health, reproductive health, sexual orientation and gender identity, and interpersonal violence — and co-design an interactive module to address these topics.  

Each topic contains materials for both the clinician and patient. Clinician-facing materials focus on goals, tips to overcome common challenges, and teaching strategies. Individual-facing materials consist of check-in questions, potential topics to discuss with their clinician, information sheets and tools to identify and access resources.

Barker says the module is targeted for young women and nonbinary adults from their teens to their mid-30s and was designed to give youth the flexibility and autonomy to choose the topics that are most relevant to them.

“The module is about identifying areas of unmet need early and then connecting people to resources to meet that need,” she says. “It’s structured but flexible so youth can decide what areas they want to work on.”

Importantly the module is structured similarly to existing interventions for early psychosis, which the researchers hope will facilitate its uptake and integration into current care. Features of the module — easy integration into clinical settings, inclusive, flexible and broad content structure, and enabling autonomy — reflect key themes and recommendations described in a study published in the journal Psychiatric Services and led by Hannah Kearney while she was a psychiatry resident at Temerty Medicine.

Kearney was part of the department of psychiatry’s Clinician Scholar Program during her residency, and her main research project focused on clinician training to accompany the module.

“It’s well documented in the literature that there are mental health clinicians who would be interested in discussing sexual and reproductive health with youth, but they don’t feel like they have adequate education or time in their clinical appointments to do so,” says Kearney, who is now a staff psychiatrist at CAMH.

To complement the training materials developed by the working group, Kearney and the research team organized a 75-minute workshop that included active learning, goal setting and role play. Both Kearney and Barker say they were surprised when mental health clinicians who attended the workshop told them that while the workshop was useful, they wanted additional training opportunities. The researchers then added multiple optional sessions, including two lectures delivered by Barker, and created case vignettes aligned with each topic covered in the module.

The training and interactive module are now being tested in a pilot study taking place at CAMH’s Slaight Centre Early Intervention Service, with 17 mental health clinicians already signed up. Once a clinician has completed the training, their clients can decide whether they want to participate and use the module.

Kearney notes that prior to their work, a sexual and reproductive health-focused training program did not exist for mental health clinicians.

“As a resident, I was rotating through the early psychosis clinic and seeing clinicians in the hallway, they were just so excited and so happy to have something,” she says.

In response to feedback from clinicians, the researchers are now working to adapt the module for young men and those assigned male at birth. To do so, they are working with youth and clinicians using a similar co-design method to the original module development.

The team is also trying to figure out how to scale the module so that it can be evaluated and shared more widely once the pilot work is complete. Barker says she has already received emails from clinicians at other early psychosis clinics interested in adopting the module at their sites.

“Recognizing that sexual and reproductive health is a core component of someone’s wellbeing, I think the module has the opportunity to prevent some of those adverse consequences, identify needs early and optimize wellbeing for youth experiencing early psychosis,” says Barker.