What a difference an hour can make – Training GPs in Perinatal Mental Health

guinea-pigs-playing-ping-pong      Thursday 9th February 2017

Guinea Pigs playing Ping Pong. Not an image I have used in my power point presentations before but it certainly caught people’s attention. Let me explain…

Discussions have been happening for a while between the team at MABIM and Dr Judy Shakespeare (RCGP PMH Clinical Champion) and towards the end of last year things started to take shape. The idea was to develop a training package for GPs and other practice staff in Perinatal Mental Health (PMH) with a view to rolling out the package over the 4 locations in which they work – Blackpool, Gloucester and Haringey & Southend.

PMH has been a priority area for the RCGP for the last 3 years and so Judy and myself (RCGP PMH Clinical Fellow) set about designing the session with the first location being Southend, 7th February. We realised quickly that there was a limit to what we could fit into 1 hour and deciding what to leave out was the tricky part. However, we both passionately believe that by learning a little more, asking questions slightly differently and being aware of the issues around perinatal mental illness, GPs can hugely improve their practice. This will lead to picking up more cases earlier and prompt treatment sooner, meaning less women slip through the net. We know that most women prefer to disclose mental health symptoms to their GP therefore a GP education session really is a golden opportunity for us to encourage behaviour change leading to positive impact, even in just one hour.

The 10 minute slots we had split the session into merged together well and we covered many aspects of perinatal mental illness including discussing 3 case histories (antenatal depression, postpartum psychosis and perinatal OCD). Barriers to diagnoses were suggested on post it stickers and collated to form a helpful discussion of those relevant to women and those to professionals. It was interesting to see many of these matched the findings of the Falling Through The Gaps report.

We discussed the educational resources we have produced with the RCGP including the RCGP PMH Toolkit .  Also  the e-learning for health 5 module series and the NICE Top Tips summary document  http://www.rcgp.org.uk/clinical-and-research/toolkits/~/media/92F73D8AA0014DEAB37B55CDF7F2CE2B.ashx

As many readers will know I am fairly busy on Twitter in the mornings mostly thanks to an early rising pre-schooler. I have met several of my twitter contacts in person and was excited when I saw that this first MABIM session was going to be in Southend as I knew Laura (Clark) (@butterflymum83) and Sarah (Wood) (@LotusPetalPND) lived nearby. I was delighted when they agreed to come and talk to the group. I was also interested to hear more about how  they had set up their own peer support group in conjunction with the local PMH services.. The voices of women with lived experience can be incredibly powerful in improving health services and today was no exception. Laura and Sarah brought to life the slides, case histories and theory we had been presenting by their honest and moving stories. To see two women who had been so unwell a few years ago now having the confidence, passion and motivation to use their experience to help others was truly inspiring and I am sure the audience will remember their words for a long time.

And so to the guinea pigs…We explained at the start of the session that this was a pilot session and so we were trialling several learning methods and tools to see what worked for the audience. Feedback was encouraged via feedback forms and through the usual channels used by Southend CCG –an online survey I understand. Overall we think it went well with a good level of dialogue between speakers and audience, some great questions and a distinct lack of people leaving early/to go to the toilet/to fetch a drink. Perhaps a roving mic would have been helpful as the amp wire nearly caught me out a few times! As many will know, GPs often have a healthy competitive streak and so a quiz was introduced on each table with only eight questions which had one word answers – the first table to complete won a box of chocolates which seemed to be go down well, as did the image of guinea pigs playing pingpong!

@LaddCar

It can be difficult, being super-mum.

Before you raise your expertly plucked eyebrow, please understand I mean that ironically. No-one else expects me to be that toned, honed, all achieving gladiator of a woman, except me. I know I am far from alone in wanting to succeed, to exceed in fact, at everything I do. But despite an 8th day being on my Christmas wish list, last time I checked there were only 7 days in the week.

Successfully combining my role as a part-time NHS GP with being a full-time mum is a challenge and at times, feels harder than it should.  I never considered my life as a binary choice in terms of being a mother or having a career and made naive presumption that one day I would have both. Now that I am in that fortunate position, I have to fit a whole week of being 1400 people’s GP into just 3 days and a whole week of being 2 people’s mum into the rest of the time. It’s easy to feel that you are not giving either audience your full attention.

Much more helpful than a sense of under achievement for me and other GP parents is the notion of collaboration between these two roles.  My experience as a parent gives me valuable insight into the challenges of parenting and provides some practical information too which can make all the difference in the consulting room when building trust and rapport with parents. Understanding how frustrating it is when a 6month  breastfed baby refuses to take a bottle of milk or what devilish tricks or chocolate buttons are needed to persuade a stubborn toddler to take his penicillin helps you understand better the situation being discussed.

My medical knowledge as a GP is useful, of course, when my own children complain of various coughs and colds as I know how to safely manage most things myself. Also useful when reassuring my husband that our son’s momentous tantrums are well within the normal range for a 2-year-old. More importantly, I come home with a sense of gratitude. I hear a whole lot of life in my consultations, talking to up to 60 patients a day and it makes bedtime stories even more precious.

And so the two roles can enable each other to flourish – synergy if you like.

There are times during my working day, when the triage call list extends off my screen, the electronic prescription requests reach treble figures and my coffee is stone cold that I wonder, would I rather be a stay-at-home mum?  One advantage of working part-time, is that you never have too many consecutive days to consider this question. In fact, it was approximately 08.15am when I heard a crash and went into the lounge to find my youngest jumping on the coffee table, my tax return papers all over the floor and peeking out from under them – my laptop. I had my answer.

It is important to recognise the limits and the opportunities being a GP parent offers and learn to say yes when it matters, and more importantly – no when it doesn’t. You don’t need to join the PTA the first term your child starts school but for the same reasons, you don’t have to complete that extra dermatology qualification in your first few years of being a GP. By accepting occasional mediocrity in both your macaroni cheese and your medical knowledge of malaria, you give yourself a more realistic chance of success in finding that star-spangled Lycra fits you and your mum-tum.

 

#Hopedec09 – How to ignite a flame? Fuel, Oxygen and a Spark.

You might think a reference to one of my school chemistry lessons is an odd way to start a blog but bear with me.
It was the first and most prominent theme that came to mind as I travelled back on a packed evening train from Paddington yesterday evening. I had spent the afternoon at an event held in Westminster with over 150 people from the Perinatal Mental Health (PMH) community. They included leaders in this field from a variety of specialties – Health Visitors, Midwifes, Obstetricians, GPs, Psychologists, Psychiatrists – all working in very diverse roles but united by the same objective – to improve care for women, men and their families experiencing PMH problems.
As well as professionals, there was a large number of women, and some men, who have been personally affected and listening to some of their stories told was a maelstrom of emotions. Empathy, concern, guilt, shock and above all, compassion. But a very rich source of fuel for this particular fire to be started.
All those who speak publicly about their own personal tragedy deserve some respect but not all can make such a lasting impression as did Antoinette Sandbach, MP. She has become a passionate advocate for improved perinatal bereavement support, health professional training and hospital facilities after experiencing her own personal tragedy. She spoke with such honesty, such visible pain, that all of us came away knowing there is much work still to be done in this important area.
Cutting edge research on the economic and the biomedical arguments for the prevention, early detection and prompt treatment of PMH illness were persuasive. Dr Alain Gregoire, Prof Vivette Glover and Anna Day spoke with passion, conviction and their experienced words held everyone’s attention. Some memorable points: 10% of childhood behavioural, cognitive development and emotional difficulties may be attributable to perinatal mental health problems although this is not an inevitable consequence for the vast majority of PMH illness. And as if this wasn’t enough science to motivate us all to do more – 70% of our brain’s development happens in the first 2 years of life, the other 30% happen in utero. Tackling PMH issues really is a chance to improve not only the lives of the parent in front of us, but their children as well.
Lindsay Robinson spoke eloquently, emotionally and connected with the audience in a very powerful way. Her delayed disclosure, diagnosis and appropriate treatment for postnatal depression which followed undetected antenatal depression was heart-wrenching to hear. But equally powerful was her courage to share her story in the hope of helping others to have a better experience of early motherhood than she had. Similar motivation had prompted Sanchita Islam to share her narrative which illustrated the huge challenges and complexities of living with a chronic severe mental illness like schizophrenia.
Powerful fuel indeed.
There was also some news of policy progress from Dr Giles Berrisford, Associate National Clinical Director for Perinatal Mental Health. He outlined the current situation: only 15 % of the UK having robust perinatal services but that this postcode lottery is finally being addressed with £360 million investment coming over the next 5 years. As well as supporting the development of many specialist PMH community teams across the country, this money will also support 4 new Mother and Baby Units across England so offering many more beds than are currently available for those women with the most severe type of PMH problems.
However, there is no money pledged yet for a Mother and Baby Unit in Wales and there was a strong Welsh presence yesterday including Mark Williams who is one of the leading PMH voices in Wales raising awareness of how fathers as well as mothers may be affected. The impact and reach of his work is admirable and his story again is one that has, and will, motivate many others to come forward and seek the help they need.
As Beverley Turner outlined – the importance of words cannot be underestimated, women too often become “passengers” in their own journey when it comes to pregnancy, birth and parenting. There needs to be more discussion, more debate, more myth busting – and we all have a role to play in that dialogue.
There is a feeling of momentum in PMH at the moment with more awareness, more investment and an increasingly vocal community on social media breaking down some of the stigma of PMH illness. This together with the collective buzz of optimism and tangible sense of hope as was seen in the audience yesterday must be the oxygen to this flame. Remembering the days of starched white coats and blue Bunsen burners – to ignite a fire with fuel and oxygen, all you need is a spark.
And that bright spark was Mr Raja Gangopadhyay, an obstetrician with a special interest in PMH, who by organising #Hopedec09, has done something very wonderful indeed. He has ignited a fire in the hearts and minds of those within the PMH community to continue in their work to improve the lives of all affected by PMH problems for this generation, and beyond.
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“Mums, Mental health and Welsh cakes”

My first post for @HuffPostUK!  published 29/11/16

Vacant seats in our surgery waiting room are a lot like my granny’s welsh cakes – a bit too thin and never quite enough of them, especially these days. Once the front doors open at 8.30am there is a constant hustle and bustle past ever patient receptionists – gouty toes throbbing, the widowed sobbing, young children whimpering, sports injuries limping. They scan the room for the few places to sit and once spotted, move with some speed to claim them. Some concentrate on avoiding eye contact, others look for those they know – old friends, new in-laws, next door neighbours. The electronic call system interrupts the chitchat and by the time that person is up and walking down the long corridor to see their GP or Nurse, someone else has slipped onto the warmed up seat. I sometimes wonder what impression this might give someone new to the surgery of what to expect the other side of my consulting room door.

“Is the doctor busy? Yes. Is she running late? Almost certainly. Is she going to be able to help me today? Perhaps she won’t have time.”

Consider this scenario: an anxious new mum, sat in those seats in the corner trying to settle her 6 week old colicky baby. Whilst half the waiting room coo over this new bundle-of-joy, she is feeling confused and holding back the tears. It may have taken significant courage to actually pick up the phone and book this appointment. She may feel like she is a terrible mother, not deserving of such a beautiful baby. She is quite likely to have considered if coming today will lead to social services getting involved. But she’s made it and now she’s sitting in front of me, crying her eyes out, mascara running down her tired face. I have only 10 minutes to help fix her broken world and for a few seconds, I hesitate. I feel a searing pang of guilt for not having had the same experience of motherhood. And then 13 years of training kicks in.

I listen, validate, listen, reassure, listen, offer hope, and listen again.

There are many common misconceptions about Perinatal Mental Health problems (affecting pregnant women and those up to one year after giving birth) and Health Professionals of all specialities can make a real difference by correcting these myths.

“Yes, parenthood is hard but no, not all women experience these symptoms. No, this is absolutely not your fault. No, this doesn’t make you a bad mother. And no, I’m not phoning a social worker.”

By the time I reach the point of discussing treatment options, I am inevitably running late but I need to keep going. Talking therapies may be helpful, referral to our Health Visitor, online Cognitive Behavioural Therapy, local Mother and Baby group details, Third Sector organisations offering on-line supervised peer support and for some, safe medication options. Too much to take on board today, perhaps, so I will signpost her to the RCGP Perinatal Mental Health Toolkit and arrange a follow up consultation in a week or two. I keep listening and help her formulate a plan that she finds acceptable. The recipe for recovery from mental illness is complex, unique to each person and sometimes difficult to find. A bit like the secrets of grandmothers and their welsh cakes. By the time she leaves my room and walks back out into that waiting room, she has something that she doubted I had time for, she has hope.

Launched by the Royal College of General Practitioners in July this year, the Toolkit is a free, open access collection of over 400 resources to help GPs and other health professionals support women and their families facing perinatal mental health problems, as well as having a section specifically for patients too. Find out more here:

http://www.rcgp.org.uk/clinical-and-research/toolkits/perinatal-mental-health-toolkit.aspx

If you think issues in this blog sound familiar for you, a friend or relative – please do speak to your GP and get the help you need.

https://drcarrieladd.wordpress.com/

@LaddCar

Dr Carrie Ladd is a GP in Oxfordshire and works with the RCGP as a Clinical Fellow in Perinatal Mental Health.  Earlier this year, she received some payment from NHS England to create this Toolkit but receives no ongoing funds to promote it.

Tags: Mums, Mental Health, Perinatal Mental Health, GP

Can Social Media help Maternal Mental Health?

https://www.theguardian.com/science/blog/2016/aug/31/can-social-media-help-maternal-mental-health

Earlier this year I had a piece published in the Guardian on line – Science section – about a theme I have been increasingly interested in over the last year. The benefits and risks for mental health of people when using forums like Facebook and Twitter. This was widely shared on Social Media and I had a large number of positive responses from people all over the world with whom it resonated and made me think there is enough material for a follow up piece…

“Postnatal Depression? That’s the Health Visitor’s job, isn’t it?”

This piece was published in October 2016 on the NB Medical Education website which can be found here:

http://www.nbmedical.com/the-hot-topics-blog/postnatal-depression-that-s-the-health-visitor-s-job-isn-t-it

Having a baby is supposed to be an overwhelmingly positive experience but for up to 1 in 5 women this precious time is clouded by symptoms significant enough to warrant a mental health diagnosis. You may be surprised to learn that fathers can also experience postnatal anxiety and depression with some estimates suggesting 1:10 men may be affected. Mental health problems during the perinatal time (pregnancy and the first year postnatal) have no prejudice – people from every socioeconomic, cultural or educational background can be affected – including GPs.

Up to 50% of cases of PMH cases are thought to be missed. Stigma is a barrier to the disclosure and detection of all mental health problems, but the perinatal time brings a particular challenge.

A severely depressed pregnant woman is such a cultural contradiction that many of us find it hard to accept, whether consciously or subconsciously. There are also time constraints, competing priorities in the GP consultation such as a woman’s physical health, or postnatally, the infant’s. As well, there are often assumptions that someone else has asked, and so GPs may not ask themselves.

Have you heard of Perinatal Post Traumatic Stress Disorder? It affects 3% women who have children with a traumatic birth being a significant risk factor.

How about Postpartum psychosis? A rare but critically important condition we all need to know about including the 4 hour target set by NICE for psychiatry review when a woman presents with active symptoms.

Perinatal OCD is also an important condition affecting 2% of pregnant women and 2.5% of those postnatal – more common than in the general population. The presentation can be similar to OCD in general but often excessive cleaning, concern about health of infant and intrusive thoughts are part of the picture. I would encourage GPs to ask if women have had any “unwelcome dark thoughts” or “unusual repetitive behaviours”– you’ll be surprised how many cases you’ll find.

When considering medication for mental health issues in women who are pregnant and breastfeeding, there is a lot of misinformation. Many women are told to stop their antidepressants in pregnancy, or that they can’t take them whilst breastfeeding. This is a tricky area, and many GPs don’t feel particularly confident in these discussions. As presented in this seasons Hot Topics Course, there is a lack of robust evidence to suggest one SSRI over another, with the exception of paroxetine NOT being recommended in pregnancy. Further information can be found in the Toolkit listed below.

Although not inevitable, there is a growing evidence base that links PMH illness to a wide range of negative consequences for that child. Infants exposed to higher levels of stress hormones antenatally, for example, show neurodevelopmental differences and higher levels of infant mental health problems. Children of mothers with PMH illness have a higher chance of mental health problems themselves, as a young adult and beyond.

What is really needed is all of us to ask every woman at every contact how they are doing and specifically in relation to their mental health. This is not rocket science – perhaps consider a gentle prompt on your computer system to ask the relevant questions during pregnancy and postnatal contacts?

I highly recommend the RCGP PMH Toolkit – over 400 resources, free to access even if you are not a member. It contains many useful links, and lots of Top Tip documents including a piece on medication use in the perinatal time, which is always an area GPs look for guidance:

http://www.rcgp.org.uk/clinical-and-research/toolkits/perinatal-mental-health-toolkit.aspx

Dr Carrie Ladd is a GP; she has spent the last 18 months as a Clinical Fellow supporting the Perinatal Mental Health RCGP Clinical Priority Programme.  @LaddCar

Welcome to the Twittersphere – using social media to promote mental health tools

I have a confession. I have never logged onto Facebook. I don’t even have an account.  Given my propensity to promote the use of digital technology and my partiality to share a tweet or two these days, that may surprise you.  My instinctive resistance to the permanence and penetrance that comes with documenting life online via Social Media is still strong. My concern of invasion of privacy is even stronger now that I have two young children but, I have wholeheartedly fallen for the awesome power of Twitter.
I have been using Twitter for about the same length of time I have been working as RCGP Clinical Fellow in Perinatal Mental Health (PMH). PMH is a Clinical Priority for the RCGP from April 2014 to March 2017 and I feel Twitter has played a crucial role in the success of much of the work I have been involved with and will try to explain why.

The secret power underpinning Twitter’s massive uptake and continued popularity when other Social Media platforms may be losing their shine, in my view, is the invisible mining of intelligence from an individual’s usage data. Every tweet I send, every blog I read, extends a myriad map of my online persona and as a result, Twitter regularly suggests people that may be of interest to me. This then allows me to fairly effortlessly build a network of contacts who share something in common with me be it an interest in PMH or otherwise. This then allows further dialogue and debate, and brings with it the sociability that makes Twitter so enjoyable.

Twitter has introduced me to many impressive people who I may not have come across via conventional platforms and learning from their twitter activity has expanded my understanding of many areas of medicine, and life in general. Twitter also offers me a channel of communication with high profile figures without the usual formality and I feel it has done much to break down the perceived distance between GP leaders in their ivory towers, and grass-root GPs battling on the front line, who in truth are one and the same.

The PMH series on the E-learning for Health platform which the RCGP produced in conjunction with Health Education England has been live for several months and Twitter has helped share the link widely among a global online health community with some of my tweets having over 10,000 impressions.

The RCGP Perinatal Mental Health toolkit was put together by myself and Dr Louise Santhanam and launched on 22nd July 2016. Twitter was pivotal in finding the most diverse and interesting links for this free open access collection of over 300 resources. It also helped recruit GPs passionate about improving PMH into the RCGP Special Interest Group membership who reviewed the Toolkit as did many of the women with lived experience of PMH who I have met on Twitter during this time. These women are highly motivated to share their recovery narrative via blogs, vlogs or articles on Social Media including Twitter and have given me much insight into the challenges of living with PMH illness as well as the barriers they faced in disclosing symptoms to their GP.

Twitter discussion groups are increasingly popular and #MumTalk was one of the first the RCGP hosted, in conjunction with Sport Relief for World Maternal Health Day earlier this year. These forums allow professionals to discuss, debate and learn from each other, without the logistical challenges of childcare, transport or cost. Subsequent RCGP hosted Q&A Twitter sessions such as #mentalhealthGP have been popular and show an appetite for this type of innovative CPD forum.

The risks of using Social Media whether discussing cases of interest or engaging with non-professionals online about health matters are yet to be fully understood but caution is essential. It is easy to find yourself in an uncomfortable situation with traditional patient doctor boundaries less visible online. The RCGP Social Media Highway Code is a useful framework and highlights the principles of maintaining trust, confidentiality and respect are as important online, as they are in the consultation room.

So although some will use Twitter to complain about #scandalousqueuesinwaitrose or boast their culinary skills with #perfecteggsbenedict, I prefer to use Twitter to connect with other healthcare professionals, to share my work and learn from theirs, so fuelling my enthusiasm for life, and for my role in #teamGP.