Practice What Your Patient is Thinking

Maternal mental health: Handle with care

BMJ 2017; 359 doi: https://doi.org/10.1136/bmj.j4986 (Published 08 November 2017) Cite this as: BMJ 2017;359:j4986

A mother describes how opportunities were missed to identify her postpartum psychosis

“Have you tried getting out more?” the health visitor asked. I explained again that stairs had been impossible since my emergency caesarean section a month ago. “I manage, and I have osteoarthritis,” she replied. “You really should try.” It felt like a slap. The lack of empathy for my physical pain meant I felt unable to share my more serious worries, such as my suspicion that my baby daughter had been swapped at birth. Nor did I unveil my growing conviction that social workers, dressed as ninjas, were planning to murder me and steal her. That was the first missed opportunity to identify my postpartum psychosis.

What if she thinks I’m crazy?

The next came two weeks later. My mother and husband became concerned by my anxious pacing and rapid speech, which I now know are common symptoms of postpartum psychosis, and made an appointment for me with a GP. The fact that I didn’t make the appointment myself was a clue that I wasn’t coping. Leaving the house had become terrifying, and the thought of letting someone in a position of power into my head was horrifying. What if she thinks I’m crazy? What if she locks me up? What if she takes my baby?

I sat down fearfully in the consulting room and burst into tears. Another clue. The GP at first listened empathetically. I shared my thoughts in stages, holding back those I felt were most shameful or disturbing. Unfortunately, I didn’t get far.

This was because when I mentioned that I’d found my health visitor unhelpful and preferred not to see her, she immediately started explaining the merits of the multidisciplinary team. This created two sides, the clinical team versus me. If she had instead suggested I see a different health visitor, or simply asked why I felt that way, this could have preserved our relationship.

What if she takes my baby?

Instead she said my unwillingness to engage with the health visitor was a “red flag.” With that single phrase my fragile engagement was shattered. I had been scouring her syllables for the faintest hint that she would take my baby, and assumed the term meant I was an unfit mother. I panicked, shut down, and exited the consultation. I went home and spent the next few days sobbing and having palpitations at each knock at the door.

Missed opportunity

The GP had noticed the consultation had gone wrong, and sent me a letter a couple of weeks later saying that she’d noticed I’d cancelled our next appointment. But, with my condition rapidly spiralling, it was already too late.

I needed the change in my demeanour to have been dealt with at the time. It would have been helpful to hear, “you seem upset, have I said something that’s worried you?”

I wish she’d told me I wasn’t alone in being afraid to be honest, and that I could get help without losing my child.

I endured five months of untreated, worsening mental illness. Much of this time remains a blur, but at some point a different health visitor arrived to find me unwell, speaking rapidly, and unable to stop pacing. She reported back to the GP, who quickly arranged for me to be voluntarily admitted to a wonderful mother and baby unit.

When I arrived I was very sick; terrified first that my baby was going to be replaced by a robot, then that we were going to be torn apart by hyenas hiding behind the nurses’ station. But over six weeks, a remarkable team of nurses and an empathetic psychiatrist saved me. Medication, loving support, and charting my recovery, at first with photographs that I and my family took and, later, by keeping a journal, all helped. I only wish I could have had help earlier.

When a mother divulges mental health problems to a GP, it’s a precious opportunity not only to improve the mental health of the patient but also the wellbeing of a whole family.

What you need to know<box-type>1</box-type>

  • If a perinatal patient doesn’t mention their mental health, you could help by saying: “a lot of parents struggle with their mental wellbeing with a new baby—how are you feeling?”

  • Mothers may fear doctors will take their child away. Be mindful of this and be careful about the language you choose.

  • Pay close attention to your patient’s verbal and non-verbal cues. If you think something hasn’t gone down well, apologise and ask about it.

Education into practice<box-type>1</box-type>

  • If a patient criticises a colleague, how might you handle this?

  • The specific phrase “red flag” triggered panic in this patient. When medical terms are used, how can you ensure that the patient understands their context and meaning?

  • If a distressed patient suddenly wants to cut a consultation short, how might you regain their trust at that crucial point and persuade them to stay?

  • On the basis of reading this article do you reflect on your practice differently, or plan to change it?

Useful resources<box-type>1</box-type>

  • Have an up to date knowledge of the perinatal mental health services in your area, from your nearest mother and baby unit, to any specialised community health services. Organisations such as Action on Postpartum Psychosis, Maternal Mental Health Scotland, and Maternal Mental Health Alliance can provide information to clinicians and support to women affected by perinatal mental illness

  • The Royal College of General Practitioners’ Perinatal Mental Health Toolkit offers a wealth of relevant resources for GPs (www.rcgp.org.uk/clinical-and-research/toolkits/perinatal-mental-health-toolkit.aspx)

Competing interests: The author has declared a competing interest, which is held by the journal.

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