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Analysis: Fear from probing in perinatal mental health

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Mental health is on the agenda right now. In recent months there have been a series of reports and announcements revealing both the current state of services in the NHS and plans to try and tackle the challenges.

It started with the mental health taskforce’s critical report at the start of the year, which said mental healthcare was “inadequate”, despite attempts to improve the situation in recent years.

The report was followed by the appointment of a new national mental health director for the NHS – Claire Murdoch, chief executive of Central and North West London NHS Foundation Trust and also a registered mental health nurse.

“What are the real issues for nurses working at the coalface and their ability to improve care on a day-to-day basis?”

And as of July, there is now a plan setting out how to implement the taskforce’s recommendations through funding and workforce changes.

But, while senior NHS figures thrash out the strategy for bringing in the service modifications needed, what are the real issues for nurses working at the coalface and their ability to improve care on a day-to-day basis?

At a perinatal mental health conference last week at London South Bank University, I heard about the complexities of the task at hand.

The audience of mostly health visitors and midwives were given a series of presentations about a range of disorders including psychotic disorders, obsessive compulsive disorder, perinatal anxiety and depression – and crucially how to differentiate them from one another, especially when they might occur at the same time.

“There was an underlying message about the fear surrounding mental health”

However, in addition to the clinical information about screening – or prediction and detection techniques, as one presenter referred to it – there was an underlying message about the fear surrounding mental health.

Fear among mothers of telling healthcare professionals about their mental health problems was one challenge, particularly due to concerns that their child might be taken away or the continuing stigma surrounding mental health.

But it was also suggested that fear affected health visitors and midwives too – a fear of how to confidently assess and advise mothers who may be showing signs of mental health problems, and whether there was enough time to do so.

Such fear meant nursing staff were not always delving deep enough to find out whether mental health conditions might be present if standard screening tools had raised suspicions, according to one of the speakers.

Opportunities to find out more were being missed in particular during routine checks when screening for anxiety and depression, said Dr Agnieska Klimowicz-Sikora, consultant perinatal psychiatrist at Kent and Medway NHS and Social Care Partnership Trust’s Mother and Infant Mental Health Service.

“It is very common that either women are not asked or midwives are scared to ask,” she told the conference.

Why is it happening? Dr Klimowicz-Sikora suggested time pressures were a key factor as well as patient relationships.

“Midwives are busy, you might have another appointment. A woman has told you something but you don’t know much about her and you are busy. If you ask a few more questions you will learn, but it’s time and it’s trust and it’s down to this relationship,” she said.

“I know everyone has busy lives, but time is crucial to effective screening”

Laura O’Hanlan

Another speaker at the conference, Laura O’Hanlan, a clinical nurse specialist at Newham Perinatal Mental Health Team at East London NHS Foundation Trust, noted similar concerns about time pressures and fear.

Midwives and health visitors had to allow enough time to build a relationship during checks, or else there was a risk the mother would conceal information, she said.

“You can’t screen or assess [the mother] if she is going to say: ‘No there is nothing wrong’,” she said.

“So you need to be able to be aware of this and be able to spend time – and I know everyone has busy lives, but time is crucial to effective screening,” said Ms O’Hanlan.

“If a woman is shutting down on you, you won’t be able to get the detail and information of what is going on. Her fear of her baby being removed will stop her communicating with you,” she added.

“There is an issue where sometimes midwives and health visitors shy away from asking mental health questions”

Mike Scanlan

Another speaker later told me: “There is an issue where sometimes midwives and health visitors shy away from asking mental health questions, almost in case they get a positive response.

“Because if they get a positive response, it is about whether they then feel confident the advice they are giving is correct or helpful,” said mental health nurse consultant Dr Mike Scanlan.

He suggested the ways these problems could be tackled. For instance, by introducing a non-stigmatising emotional check for mothers that could be used by a range of workers as a preventative measure, plus standardised training and support for health visitors and midwives in mental health assessment.

So, the solutions would appear to be taking more time, training to build confidence and potentially new prevention and screening tools that reduce the stigma for mothers.

With statistics that show around 50% of women with perinatal mental health problems are not identified or treated, the issue could not be more urgent. Nurses and midwives want the support and are ready to tackle this. Let’s hope the national plans are too.

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