Dr Carrie Ladd, August 2016
GP and RCGP Clinical Fellow in Perinatal Mental Health
@LaddCar
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If parenthood is not what you were expecting, you’re not alone. The tough reality of relentless sleepless nights, seemingly untreatable colic and the colossal physical efforts of looking after someone else’s primal needs ahead of your own is a situation that no antenatal class or parenting guide can ever fully prepare you for.
For up to 1 in 5 women and 1 in 10 men, this time is made even harder by mental health problems – these may be specific to the perinatal time (conception to the first birthday of that child) or conditions that can affect people at other times of their lives.
Mental health problems can affect any parent without prejudice – antenatal as well as postnatal, fathers as well as mothers, health professionals as well as non health professionals, and they can have negative effects on all members of the family unit.
Despite many contacts with health professionals during this time, it is estimated about half of all mental health problems go undetected meaning many people slip through the net without receiving the treatment they need. Early disclosure of symptoms and prompt diagnosis leads to appropriate treatment which gives people the best chance of making a speedy recovery.
The Royal College of General Practitioners have been working on Perinatal Mental Health (PMH) since April 2014 as a priority area to increase awareness of PMH and improve educational resources such as the open access RCGP PMH Toolkit and free on line learning resources for healthcare professionals:
Perinatal Mental Health Toolkit
A key area in this work is helping GPs understand the barriers that women face in disclosure so they can offer more supportive compassionate communication. Stigma, guilt, fear of judgement or being seen as a failure are all often cited as reasons why women do not open up about their symptoms. Women may be worried about what might happen if they do talk to their GP and so in this piece I try to illustrate things from a GPs perspective to help allay some of these fears.
So as a GP what is going through my mind when I see a pregnant lady at a routine antenatal check in my surgery? Firstly, find out what is on her agenda – does she have specific worries I need to address about her baby’s health or her own? These may be dealt with straight away or covered as we go on. Then some housekeeping – Blood pressure, urine check, a check of her bump to help know the baby’s position, growth and heart rate. Then an opportunity for health promotion stuff – exercise, diet, smoking, alcohol advice. In the later months of the pregnancy I ask about her thoughts on infant feeding, delivery location, how they will cope once the baby arrives. If I haven’t already answered her queries now is the time, then to write up the notes on the computer screen and in the blue maternity notes. A large amount of information in just 10minutes I’m sure you’ll agree, it’s no wonder that I run late!
Importantly, throughout this conversation I am picking up cues: verbal and non-verbal, about how that women is feeling – worried, scared, sad and noting if she mentions poor sleep, poor appetite, lack of motivation, lack of energy, lack of enjoyment of usual things, decreased social contact, negative outlook. Asking about mental health problems during pregnancy, a time when society expects unfettered happiness and optimism, is delicate and needs tact and experience to find the right moment and the right words. It takes courage for a woman to start to talk about how they are feeling and when they do, GPs need to validate their symptoms and not dismiss them. I try to normalise the challenges of parenthood but at the same time, look for and diagnose any mental health problems complicating the situation, and then discuss possible treatments.
In postnatal appointments, there is even more ground to cover – infant feeding problems, erratic sleep patterns, concerns over weight gain, is this normal development, have mums bonded with the baby? That’s as well as the mum’s physical health, discussions about the birth particularly if traumatic as she has a higher risk of Post-Traumatic Stress Disorder which may present with flashbacks and nightmares but is often misdiagnosed as postnatal depression. Questions about contraception choices may be met with surprise and bemusement 6 weeks postnatally in a first time mum but are really important as women may ovulate sooner than they think so being at risk of pregnancy ( within 4 weeks if not fully breast feeding). Asking women about any symptoms suggestive of mental health problems is crucial at this check as this may be the only contact I have with them in the postnatal period. As well as all of the above symptoms suggestive of depression or anxiety disorders, I ask about repetitive unwanted dark thoughts or unusual habits and behaviours such as excessive cleaning, which may indicate perinatal obsessive compulsive disorder which affects 2 or 3 women of every 100.
PMH illness describes a spectrum of conditions where the vast majority of cases are not severe and so the risk of serious harm to the woman or baby is unusual. Although a common worry women have, it is actually very rare that social services are contacted, and this is something GPs would only do if they had genuine concern for the wellbeing of the child. Importantly, one situation where GPs may need to involve the psychiatry team quickly to keep mum and baby safe is Postpartum Psychosis which affects 1 or 2 women in 1000. Women may have extreme anxiety, euphoria or psychotic thoughts such as hearing voices or believing bizarre thoughts. It is a condition that needs urgent treatment and has excellent chances of a full recovery.
Many of the same options for mental health problems at other times of their life are possible now – medication, talking therapies, counselling. Also self-directed help with on line therapy, reading and support groups either face to face or on line peer support. However, the right choice for the woman is very individual to her, and what suits one woman may not another. In particular, medication issues in the perinatal time are complex but there are some excellent resources available to help women make an informed choice as there are some options that are safer than others when a woman is pregnant or if she is breastfeeding.
This is often too much to discuss and decide on in one consultation, so I usually give women some information perhaps a leaflet or link to a couple of websites then make another appointment for them to come back and see me in a week or so. Most women come back to tell me they feel relieved they have told someone how bad they were feeling and that although they may have not yet started formal treatment, they feel a little better, knowing they can see a chink of light at the end of the tunnel and we can move forward in arranging the treatment they feel is right for them. So if reading this piece raises concern about the possibility of mental health problems for yourself, or someone you know, please do talk to your GP.
