MIDWIFERY, WOMEN AND MIDWIFERY, WOMEN AND MENTAL ILLNESSMENTAL ILLNESS

Lyn GardnerLyn Gardner

The Impact of Pregnancy on The Impact of Pregnancy on Mental HealthMental Health

• The NSF for Children, Young People and Maternity The NSF for Children, Young People and Maternity Services in Wales states that ‘childbirth is an Services in Wales states that ‘childbirth is an immense physical, emotional and psychological immense physical, emotional and psychological experience which may place some women at risk experience which may place some women at risk of developing a mental health problem or disorder’ of developing a mental health problem or disorder’ (p. 57).(p. 57).

• It may also exacerbate pre-existing mental health It may also exacerbate pre-existing mental health problems and increase the risk of relapse, leading problems and increase the risk of relapse, leading to possible relationship problems (with partners to possible relationship problems (with partners and children), suicide attempts and self-harm.and children), suicide attempts and self-harm.

• ‘‘Depression during pregnancy may be as Depression during pregnancy may be as prevalent, if not more so, than post-natal prevalent, if not more so, than post-natal depression, which affects around 13% of women’ depression, which affects around 13% of women’ (p.57). (p.57).

DIAGNOSIS OF MENTAL DIAGNOSIS OF MENTAL ILLNESSILLNESS

Psychiatric definitions or diagnosis of mental Psychiatric definitions or diagnosis of mental illness are made using the following illness are made using the following classifications:classifications:

IDC-10 (International Classification of Diseases) IDC-10 (International Classification of Diseases) research based concepts updated by research based concepts updated by international committees on behalf of WHO. international committees on behalf of WHO. Section on Mental and Behavioural Disorders Section on Mental and Behavioural Disorders and divided into 9 groups.and divided into 9 groups.

DSM-IV (Diagnostic and Statistical Manual) DSM-IV (Diagnostic and Statistical Manual) compiled by the American Psychiatric Assoc. compiled by the American Psychiatric Assoc. Numerous revisions over short period of time Numerous revisions over short period of time – created debate and controversy– created debate and controversy

FROM PERSON TO PATIENTFROM PERSON TO PATIENT

• Is a diagnosis helpful? Labelling has a Is a diagnosis helpful? Labelling has a negative effect and any description is negative effect and any description is a ‘linguistic straightjacket’ (James, a ‘linguistic straightjacket’ (James, 1998)1998)

• A label can liberate and represents a A label can liberate and represents a public recognition of personal pain public recognition of personal pain (Figert, 1998)(Figert, 1998)

THE PROCESS OF DIAGNOSISTHE PROCESS OF DIAGNOSIS

• Crowe (2000) argues that the process of Crowe (2000) argues that the process of psychiatric diagnosis is based on positivistic psychiatric diagnosis is based on positivistic understandings of reality which reduce the understandings of reality which reduce the experience of individuals to ‘experience of individuals to ‘a prioria priori categories of normality and abnormality that categories of normality and abnormality that reveal a strong gender, culture and class reveal a strong gender, culture and class bias’. bias’.

• In doing so, the DSM constructs what is to In doing so, the DSM constructs what is to be regarded as abnormal and ‘what society be regarded as abnormal and ‘what society can expect as normal behaviour’can expect as normal behaviour’

Cont.Cont.

Thus, according to Casey & Long Thus, according to Casey & Long (2003) (2003)

‘‘psychiatric diagnoses are not psychiatric diagnoses are not objective, scientific renderings of objective, scientific renderings of truth, but constructions of life truth, but constructions of life experiences inextricably linked to the experiences inextricably linked to the social and political context’social and political context’

NON-COMPLIANCE WITH NON-COMPLIANCE WITH PSYCHIATRIC CLASSIFICATIONS PSYCHIATRIC CLASSIFICATIONS

OF SELFOF SELF

‘…‘…we should never forget how the we should never forget how the bestowal of a psychiatric label can so bestowal of a psychiatric label can so usurp the person’s sense of identity usurp the person’s sense of identity that all subsequent distress (relapse) that all subsequent distress (relapse) is reconstituted as a function of that is reconstituted as a function of that diagnosis’diagnosis’

Barker et al (1999)Barker et al (1999)

ON THE RECEIVING END OF A ON THE RECEIVING END OF A PSYCHIATRIC DIAGNOSISPSYCHIATRIC DIAGNOSIS

• Some service users fight against their Some service users fight against their diagnosis – refuse medication, feel angry, diagnosis – refuse medication, feel angry, challenge treatment – and try to find meaning challenge treatment – and try to find meaning in their diagnosis:in their diagnosis:‘‘prior to developing schizophrenia, the prior to developing schizophrenia, the workings of my mind had been unquestioned. workings of my mind had been unquestioned. Suddenly I was being told that I could not Suddenly I was being told that I could not always trust my own thoughts and always trust my own thoughts and senses….Self had become a traitor and was senses….Self had become a traitor and was working against my own good’working against my own good’(Champ, 1999)(Champ, 1999)

A DIAGNOSIS CAN VALIDATE A DIAGNOSIS CAN VALIDATE EXPERIENCE EXPERIENCE

• Some people actively seek a label or Some people actively seek a label or diagnosis for their distressing or unusual diagnosis for their distressing or unusual thoughts, feelings and behaviour:thoughts, feelings and behaviour:

‘‘not having a label, I think that’s the real not having a label, I think that’s the real problem’ (Peters et al. 1998)problem’ (Peters et al. 1998)

‘‘on a positive note, at least when I did learn on a positive note, at least when I did learn of my diagnosis I was able to begin coming to of my diagnosis I was able to begin coming to terms with my illness…I discovered a terms with my illness…I discovered a common identity and a camaraderie’ common identity and a camaraderie’ (McIntosh, 1996)(McIntosh, 1996)

DIAGNOSIS – GENDER ISSUESDIAGNOSIS – GENDER ISSUES

• Gender relations are implicated in psychiatry at Gender relations are implicated in psychiatry at both the theoretical and practice levels (issues for both the theoretical and practice levels (issues for women include childcare, single-sex women include childcare, single-sex accommodation, sexism, fear of sexual violence)accommodation, sexism, fear of sexual violence)

• Psychiatric epidemiology reveals gender Psychiatric epidemiology reveals gender differences in rates of diagnostic categorydifferences in rates of diagnostic category

• Mothers and pregnant women may feel that the Mothers and pregnant women may feel that the stigmatising effects of their mental illness stigmatising effects of their mental illness prevents them from fully disclosing their feelings prevents them from fully disclosing their feelings to a midwife/health visitor.to a midwife/health visitor.

• They may also fear the intervention of social They may also fear the intervention of social services, or even removal of their child/ren if they services, or even removal of their child/ren if they reveal the true extent of their symptoms.reveal the true extent of their symptoms.

CONTCONT

• Overall the proportion of people living with a diagnosed Overall the proportion of people living with a diagnosed mental illness over a 12 month period is similar for women mental illness over a 12 month period is similar for women (18%) and men (17.4%) (ABS, 1998)(18%) and men (17.4%) (ABS, 1998)

• However, within that aggregated figure, gender differences However, within that aggregated figure, gender differences are maskedare masked

• The rate of depression for women is twice that of menThe rate of depression for women is twice that of men• The rate of anxiety disorders for women is almost twice that The rate of anxiety disorders for women is almost twice that

of menof men• The rate of substance misuse for men is over twice that of The rate of substance misuse for men is over twice that of

womenwomen• During pregnancy symptoms of a pre-existing (but perhaps During pregnancy symptoms of a pre-existing (but perhaps

usually well-managed) mental illness my become usually well-managed) mental illness my become exacerbated, for example anxiety disorders such as OCD. exacerbated, for example anxiety disorders such as OCD.

DEPRESSIONDEPRESSION• Woman-predominant conditions such as Woman-predominant conditions such as

depression and anxiety disorders are likely to depression and anxiety disorders are likely to be under-diagnosed (Busfield,1996 and be under-diagnosed (Busfield,1996 and Horsfall, 2001)Horsfall, 2001)

• Current mental health service provision focuses Current mental health service provision focuses on caring for people with so-called ‘serious’ or on caring for people with so-called ‘serious’ or ‘serious and enduring’ mental illness‘serious and enduring’ mental illness

• Thus women may be left to feel that their Thus women may be left to feel that their distress and the way it manifests itself is distress and the way it manifests itself is ‘illegitimate, unreal, or inconsequential by ‘illegitimate, unreal, or inconsequential by medical practitioners, family members, or medical practitioners, family members, or friends’ (Horsfall, 2001)friends’ (Horsfall, 2001)

DEFINING DEPRESSIONDEFINING DEPRESSION

• Major Depression Major Depression – according to WHO (1992) diagnosis – according to WHO (1992) diagnosis requires 5 or more specific criteria to be present:requires 5 or more specific criteria to be present:

• Depressed mood or loss of interestDepressed mood or loss of interest• Significant weight loss/gainSignificant weight loss/gain• Disturbed sleep patternDisturbed sleep pattern• Psychomotor agitation or retardationPsychomotor agitation or retardation• FatigueFatigue• Feelings of worthlessnessFeelings of worthlessness• Diminished ability to thinkDiminished ability to think• Difficulty in concentratingDifficulty in concentrating• Suicidal thoughtsSuicidal thoughts

DEFINING DEPRESSIONDEFINING DEPRESSION

• Dysthymia Dysthymia – present for at least 2 years – often – present for at least 2 years – often insidious onset. Symptoms overlap major depression insidious onset. Symptoms overlap major depression – also include pessimism, low self-esteem, lack of – also include pessimism, low self-esteem, lack of energy, irritability and decreased productivityenergy, irritability and decreased productivity

• Minor Depression Minor Depression – symptoms as major – symptoms as major depression, but only 2 need to be present for a depression, but only 2 need to be present for a diagnosisdiagnosis

• Intermittent Depression Intermittent Depression – similar to minor – similar to minor depression with symptoms that are not constantdepression with symptoms that are not constant

• Recurrent Brief Depression Recurrent Brief Depression – major depressive – major depressive episodes, usually one or two per month which may episodes, usually one or two per month which may last for a few hours to a few dayslast for a few hours to a few days

SCHIZOPRENIASCHIZOPRENIA

• The diagnostic rates of schizophrenia are The diagnostic rates of schizophrenia are about the same for men and women – but about the same for men and women – but there are gender differencesthere are gender differences

• Men tend to be diagnosed approx 4-6 Men tend to be diagnosed approx 4-6 years earlier than womenyears earlier than women

• Women are more likely to develop late-Women are more likely to develop late-onset schizophreniaonset schizophrenia

• Women are less likely to be given a dual Women are less likely to be given a dual diagnosis (substance misuse and diagnosis (substance misuse and psychosis/schizophrenia)psychosis/schizophrenia)

CONT.CONT.

• Signs and symptoms of schizophrenia differ between men Signs and symptoms of schizophrenia differ between men and womenand women

• The content of delusions is largely culturally determined The content of delusions is largely culturally determined and accordingly tend to run along gender-role lines:and accordingly tend to run along gender-role lines:

• Women – less bizarre, more somatic, may have romantic Women – less bizarre, more somatic, may have romantic preoccupations preoccupations

• Men – more concerned with political conspiracy, undercover Men – more concerned with political conspiracy, undercover activities (see account by Rufus May), more grandiose activities (see account by Rufus May), more grandiose delusions of power, royalty and divinitydelusions of power, royalty and divinity

• Women experience more depressed mood, apathy and Women experience more depressed mood, apathy and paucity of speech than men.paucity of speech than men.

• More men than women diagnosed with schizophrenia More men than women diagnosed with schizophrenia complete suicide – although the ratio is lower than in the complete suicide – although the ratio is lower than in the general population where men outnumber women 4:1 general population where men outnumber women 4:1

BOARDERLINE PERSONALITY BOARDERLINE PERSONALITY DISORDERDISORDER

• Women are more frequently given the diagnosis of BPD – Women are more frequently given the diagnosis of BPD – three-quarters of people living with this diagnosis are three-quarters of people living with this diagnosis are women (Perkins & Repper, 1998)women (Perkins & Repper, 1998)

• Women diagnosed with BPD often perceive their care as Women diagnosed with BPD often perceive their care as punitive and stigmatizing (Nehls, 1998)punitive and stigmatizing (Nehls, 1998)

• Women who self-mutilate are likely to be given a diagnosis Women who self-mutilate are likely to be given a diagnosis of BPDof BPD

• BPD is often seen by the mental health services as difficult BPD is often seen by the mental health services as difficult or untreatable. At best, the coping behaviours employed by or untreatable. At best, the coping behaviours employed by women such as self-mutilation, are addressed (often women such as self-mutilation, are addressed (often inappropriately) but the underlying causes of the distress inappropriately) but the underlying causes of the distress (for example trauma from childhood sexual abuse) is left (for example trauma from childhood sexual abuse) is left unsupported (Babiker & Arnold, 1997) unsupported (Babiker & Arnold, 1997)

Maternity Services Fail Women Maternity Services Fail Women with Severe Mental Illnesswith Severe Mental Illness

• Pregnant and new mothers with a mental illness Pregnant and new mothers with a mental illness are a ‘forgotten multitude as far as care is are a ‘forgotten multitude as far as care is concerned’ (Royal College of Psychiatrists, 2002)concerned’ (Royal College of Psychiatrists, 2002)

• Women with psychoses are more likely to have Women with psychoses are more likely to have unplanned pregnancies, attend antenatal clinics unplanned pregnancies, attend antenatal clinics late in their pregnancy, more likely to experience late in their pregnancy, more likely to experience complications of pregnancy (nausea, heartburn, complications of pregnancy (nausea, heartburn, pre-eclampsia, difficult labour and delivery) (RCP, pre-eclampsia, difficult labour and delivery) (RCP, 2002).2002).

• In addition some women with mental health In addition some women with mental health problems may also be experiencing relationship, problems may also be experiencing relationship, social and housing problems.social and housing problems.

MedicationMedication

Pregnant mentally ill women may also stop taking Pregnant mentally ill women may also stop taking their psychiatric medication- ‘the moment that their psychiatric medication- ‘the moment that blue line appears they stop smoking, they stop blue line appears they stop smoking, they stop drinking, they stop eating soft cheese and they drinking, they stop eating soft cheese and they stop taking their medicine. This is very dangerous stop taking their medicine. This is very dangerous for women with serious mental disorders’ for women with serious mental disorders’

(Dr Margaret Oates, 2002, RCP meeting to discuss (Dr Margaret Oates, 2002, RCP meeting to discuss findings of the fifth report of the Confidential findings of the fifth report of the Confidential Enquiry into Maternal Deaths in the UK 1997-Enquiry into Maternal Deaths in the UK 1997-1999).1999).

For discussion of use of Lithium during pregnancy For discussion of use of Lithium during pregnancy see Young, K. (2004) Manic Depression and see Young, K. (2004) Manic Depression and Pregnancy, The Practising Midwife, 7, 7:15-18.Pregnancy, The Practising Midwife, 7, 7:15-18.

MAD WOMEN ARE LESS MAD WOMEN ARE LESS TROUBLE TO SOCIETYTROUBLE TO SOCIETY

• Gendered expressions and forms of pain Gendered expressions and forms of pain internalization that are not overtly disruptive internalization that are not overtly disruptive or dangerous for society are less likely to or dangerous for society are less likely to receive social, political, policy or medical receive social, political, policy or medical treatment priority (Perkins & Repper, 1998)treatment priority (Perkins & Repper, 1998)

• Women may not then be diagnosed so Women may not then be diagnosed so readily as men, leaving them without readily as men, leaving them without treatment, support and validation of their treatment, support and validation of their distressdistress

VOICES FROM THE SERVICE VOICES FROM THE SERVICE USER/SURVIVORUSER/SURVIVOR

• Increasingly mental health practitioners Increasingly mental health practitioners (most particularly nurses) are turning (most particularly nurses) are turning to listen to the subjective accounts of to listen to the subjective accounts of those who experience mental illnessthose who experience mental illness

• By listening to service users By listening to service users articulations of their experiences, articulations of their experiences, mental health practitioners can work mental health practitioners can work collaboratively and co-operatively collaboratively and co-operatively

CONT.CONT.

‘‘sharing our stories finally gave us the sharing our stories finally gave us the courage to believe that we are not courage to believe that we are not mad: we are angry…our distress and mad: we are angry…our distress and anger is often a reasonable and anger is often a reasonable and comprehensible response to real life comprehensible response to real life situations which have robbed us of situations which have robbed us of our power and taught us helplessness’our power and taught us helplessness’

(Wallcraft, 1996)(Wallcraft, 1996)

EXPERIENCING ILLNESSEXPERIENCING ILLNESS

• By developing a phenomenology of the By developing a phenomenology of the experience of mental illness, we can experience of mental illness, we can better understand and respond to itbetter understand and respond to it

• Making sense of mental illness ‘involves Making sense of mental illness ‘involves reflection both of the individual reflection both of the individual experiences and of social consequences experiences and of social consequences and cultural constructions of the issue’ and cultural constructions of the issue’ (Kangas, 2001)(Kangas, 2001)

FINDING A COHERANT FINDING A COHERANT NARRATIVE OF EXPERIENCENARRATIVE OF EXPERIENCE

‘‘I think the best professionals I think the best professionals involved in my care have walked involved in my care have walked alongside me, opening themselves to alongside me, opening themselves to the mystery that is schizophrenia’the mystery that is schizophrenia’

(Champ, 1999) (Champ, 1999)

The Role of the MidwifeThe Role of the Midwife(adapted from Price, 2004)(adapted from Price, 2004)

• Validate the women’s experienceValidate the women’s experience of mental illness: of mental illness:

• Acknowledge that women may have Acknowledge that women may have pre-existing mental illnesspre-existing mental illness

• Listen to women’s stories and Listen to women’s stories and viewsviews

• Help women Help women identify their changing identify their changing needsneeds in light of their pregnancy in light of their pregnancy

Cont.Cont.

• Act as an Act as an advocateadvocate for the woman: for the woman:

• EmpathiseEmpathise with her experience with her experience

• Help to negotiate Help to negotiate access to access to appropriate servicesappropriate services

• Support her to Support her to represent herselfrepresent herself

• Intervene assertively where Intervene assertively where appropriateappropriate

Cont.Cont.

• Identify and address Identify and address professional developmentprofessional development needsneeds

• Develop and Develop and enhance maternity servicesenhance maternity services::• The Confidential Enquiry into maternal deaths The Confidential Enquiry into maternal deaths

recommended that recommended that each maternity service each maternity service should have a perinatal mental health should have a perinatal mental health serviceservice, but there are currently only approx 12-, but there are currently only approx 12-15 in the UK.15 in the UK.

• Collaboration with other servicesCollaboration with other services – primary – primary care, GPs, CMHTs, CAMHS, health visitors and care, GPs, CMHTs, CAMHS, health visitors and other agencies such as housing, social services other agencies such as housing, social services and non-statutory agencies.and non-statutory agencies.

REFERENCES/READINGREFERENCES/READING

Babiker, G. & Arnold, L. (1997) Babiker, G. & Arnold, L. (1997) The Language of Injury: Comprehending Self-The Language of Injury: Comprehending Self-Mutilation. Mutilation. Leicester: BPS.Leicester: BPS.

Barker, P. et al (1999) Barker, P. et al (1999) From the Ashes of Experience: Reflections on Madness, From the Ashes of Experience: Reflections on Madness, Survival and Growth.Survival and Growth. London: Whurr. London: Whurr.

Busfield, J. (1996) Busfield, J. (1996) Men, Women and Madness: Understanding Gender and Mental Men, Women and Madness: Understanding Gender and Mental Disorder. Disorder. Basingstoke: Macmillan.Basingstoke: Macmillan.

Casey, B. & Long, A. (2003) Meanings of Madness, Casey, B. & Long, A. (2003) Meanings of Madness, Journal of Psychiatric and Mental Journal of Psychiatric and Mental Health Nursing,Health Nursing, 10:89-99. 10:89-99.

Horsfall, J. (2001) Gender and Mental Illness, Horsfall, J. (2001) Gender and Mental Illness, Issues in Mental Health Nursing,Issues in Mental Health Nursing, 22:421-438.22:421-438.

Nehls, N. (1998) Borderline Personality Disorder, Nehls, N. (1998) Borderline Personality Disorder, Issues in Mental Health NursingIssues in Mental Health Nursing 19:97-11219:97-112

Perkins, R. & Repper, J. (1998) Perkins, R. & Repper, J. (1998) Dilemmas in Community Mental Health Practice. Dilemmas in Community Mental Health Practice. Abingdon: Radcliffe Medical Press.Abingdon: Radcliffe Medical Press.

Price, S. (2004) Midwifery Care and Mental Health, Price, S. (2004) Midwifery Care and Mental Health, The Practising Midwife,The Practising Midwife, 7,7:12-14. 7,7:12-14.Showalter, E. (1987) Showalter, E. (1987) The Female Malady: Women, Madness and English Culture.The Female Malady: Women, Madness and English Culture.

London: Virago.London: Virago.Ussher, J. (1991) Ussher, J. (1991) Women’s Madness: Misogyny or Mental Illness? Women’s Madness: Misogyny or Mental Illness? London: London:

Harvester Wheatsheaf.Harvester Wheatsheaf.• NB AVAILABLE AS A POWERPOINT LECTURE :NB AVAILABLE AS A POWERPOINT LECTURE :

http;//shswebspace.swan.ac.uk/HNGardnerLD/http;//shswebspace.swan.ac.uk/HNGardnerLD/