Transcript Midwifery, Women and Mental Illness

MIDWIFERY, WOMEN AND
MENTAL ILLNESS
Lyn Gardner
The Impact of Pregnancy on Mental
Health
• The NSF for Children, Young People and Maternity
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Services in Wales states that ‘childbirth is an immense
physical, emotional and psychological experience which
may place some women at risk of developing a mental
health problem or disorder’ (p. 57).
It may also exacerbate pre-existing mental health
problems and increase the risk of relapse, leading to
possible relationship problems (with partners and
children), suicide attempts and self-harm.
‘Depression during pregnancy may be as prevalent, if not
more so, than post-natal depression, which affects
around 13% of women’ (p.57).
DIAGNOSIS OF MENTAL ILLNESS
Psychiatric definitions or diagnosis of mental illness
are made using the following classifications:
IDC-10 (International Classification of Diseases)
research based concepts updated by
international committees on behalf of WHO.
Section on Mental and Behavioural Disorders
and divided into 9 groups.
DSM-IV (Diagnostic and Statistical Manual)
compiled by the American Psychiatric Assoc.
Numerous revisions over short period of time –
created debate and controversy
FROM PERSON TO PATIENT
• Is a diagnosis helpful? Labelling has a
negative effect and any description is a
‘linguistic straightjacket’ (James, 1998)
• A label can liberate and represents a
public recognition of personal pain (Figert,
1998)
THE PROCESS OF DIAGNOSIS
• Crowe (2000) argues that the process of
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psychiatric diagnosis is based on positivistic
understandings of reality which reduce the
experience of individuals to ‘a priori categories
of normality and abnormality that reveal a
strong gender, culture and class bias’.
In doing so, the DSM constructs what is to be
regarded as abnormal and ‘what society can
expect as normal behaviour’
Cont.
Thus, according to Casey & Long (2003)
‘psychiatric diagnoses are not objective,
scientific renderings of truth, but
constructions of life experiences
inextricably linked to the social and
political context’
NON-COMPLIANCE WITH
PSYCHIATRIC CLASSIFICATIONS
OF SELF
‘…we should never forget how the
bestowal of a psychiatric label can so
usurp the person’s sense of identity that
all subsequent distress (relapse) is
reconstituted as a function of that
diagnosis’
Barker et al (1999)
ON THE RECEIVING END OF A
PSYCHIATRIC DIAGNOSIS
• Some service users fight against their diagnosis
– refuse medication, feel angry, challenge
treatment – and try to find meaning in their
diagnosis:
‘prior to developing schizophrenia, the workings
of my mind had been unquestioned. Suddenly I
was being told that I could not always trust my
own thoughts and senses….Self had become a
traitor and was working against my own good’
(Champ, 1999)
A DIAGNOSIS CAN VALIDATE
EXPERIENCE
• Some people actively seek a label or diagnosis
for their distressing or unusual thoughts,
feelings and behaviour:
‘not having a label, I think that’s the real
problem’ (Peters et al. 1998)
‘on a positive note, at least when I did learn of
my diagnosis I was able to begin coming to
terms with my illness…I discovered a common
identity and a camaraderie’ (McIntosh, 1996)
DIAGNOSIS – GENDER ISSUES
• Gender relations are implicated in psychiatry at both the
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theoretical and practice levels (issues for women include
childcare, single-sex accommodation, sexism, fear of
sexual violence)
Psychiatric epidemiology reveals gender differences in
rates of diagnostic category
Mothers and pregnant women may feel that the
stigmatising effects of their mental illness prevents them
from fully disclosing their feelings to a midwife/health
visitor.
They may also fear the intervention of social services, or
even removal of their child/ren if they reveal the true
extent of their symptoms.
CONT
• Overall the proportion of people living with a diagnosed mental
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illness over a 12 month period is similar for women (18%) and men
(17.4%) (ABS, 1998)
However, within that aggregated figure, gender differences are
masked
The rate of depression for women is twice that of men
The rate of anxiety disorders for women is almost twice that of men
The rate of substance misuse for men is over twice that of women
During pregnancy symptoms of a pre-existing (but perhaps usually
well-managed) mental illness my become exacerbated, for example
anxiety disorders such as OCD.
DEPRESSION
• Woman-predominant conditions such as
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depression and anxiety disorders are likely to be
under-diagnosed (Busfield,1996 and Horsfall,
2001)
Current mental health service provision focuses
on caring for people with so-called ‘serious’ or
‘serious and enduring’ mental illness
Thus women may be left to feel that their
distress and the way it manifests itself is
‘illegitimate, unreal, or inconsequential by
medical practitioners, family members, or
friends’ (Horsfall, 2001)
DEFINING DEPRESSION
• Major Depression – according to WHO (1992) diagnosis requires 5
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or more specific criteria to be present:
Depressed mood or loss of interest
Significant weight loss/gain
Disturbed sleep pattern
Psychomotor agitation or retardation
Fatigue
Feelings of worthlessness
Diminished ability to think
Difficulty in concentrating
Suicidal thoughts
DEFINING DEPRESSION
• Dysthymia – present for at least 2 years – often
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insidious onset. Symptoms overlap major depression –
also include pessimism, low self-esteem, lack of energy,
irritability and decreased productivity
Minor Depression – symptoms as major depression,
but only 2 need to be present for a diagnosis
Intermittent Depression – similar to minor
depression with symptoms that are not constant
Recurrent Brief Depression – major depressive
episodes, usually one or two per month which may last
for a few hours to a few days
SCHIZOPRENIA
• The diagnostic rates of schizophrenia are about
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the same for men and women – but there are
gender differences
Men tend to be diagnosed approx 4-6 years
earlier than women
Women are more likely to develop late-onset
schizophrenia
Women are less likely to be given a dual
diagnosis (substance misuse and
psychosis/schizophrenia)
CONT.
• Signs and symptoms of schizophrenia differ between men and
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women
The content of delusions is largely culturally determined and
accordingly tend to run along gender-role lines:
Women – less bizarre, more somatic, may have romantic
preoccupations
Men – more concerned with political conspiracy, undercover
activities (see account by Rufus May), more grandiose delusions of
power, royalty and divinity
Women experience more depressed mood, apathy and paucity of
speech than men.
More men than women diagnosed with schizophrenia complete
suicide – although the ratio is lower than in the general population
where men outnumber women 4:1
BOARDERLINE PERSONALITY
DISORDER
• Women are more frequently given the diagnosis of BPD – three-
quarters of people living with this diagnosis are women (Perkins &
Repper, 1998)
• Women diagnosed with BPD often perceive their care as punitive
and stigmatizing (Nehls, 1998)
• Women who self-mutilate are likely to be given a diagnosis of BPD
• BPD is often seen by the mental health services as difficult or
untreatable. At best, the coping behaviours employed by women
such as self-mutilation, are addressed (often inappropriately) but
the underlying causes of the distress (for example trauma from
childhood sexual abuse) is left unsupported (Babiker & Arnold,
1997)
Maternity Services Fail Women with
Severe Mental Illness
• Pregnant and new mothers with a mental illness are a
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‘forgotten multitude as far as care is concerned’ (Royal
College of Psychiatrists, 2002)
Women with psychoses are more likely to have
unplanned pregnancies, attend antenatal clinics late in
their pregnancy, more likely to experience complications
of pregnancy (nausea, heartburn, pre-eclampsia, difficult
labour and delivery) (RCP, 2002).
In addition some women with mental health problems
may also be experiencing relationship, social and
housing problems.
Medication
Pregnant mentally ill women may also stop taking their
psychiatric medication- ‘the moment that blue line
appears they stop smoking, they stop drinking, they stop
eating soft cheese and they stop taking their medicine.
This is very dangerous for women with serious mental
disorders’
(Dr Margaret Oates, 2002, RCP meeting to discuss findings
of the fifth report of the Confidential Enquiry into
Maternal Deaths in the UK 1997-1999).
For discussion of use of Lithium during pregnancy see
Young, K. (2004) Manic Depression and Pregnancy, The
Practising Midwife, 7, 7:15-18.
MAD WOMEN ARE LESS TROUBLE
TO SOCIETY
• Gendered expressions and forms of pain
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internalization that are not overtly disruptive or
dangerous for society are less likely to receive
social, political, policy or medical treatment
priority (Perkins & Repper, 1998)
Women may not then be diagnosed so readily as
men, leaving them without treatment, support
and validation of their distress
VOICES FROM THE SERVICE
USER/SURVIVOR
• Increasingly mental health practitioners
(most particularly nurses) are turning to
listen to the subjective accounts of those
who experience mental illness
• By listening to service users articulations
of their experiences, mental health
practitioners can work collaboratively and
co-operatively
CONT.
‘sharing our stories finally gave us the
courage to believe that we are not mad:
we are angry…our distress and anger is
often a reasonable and comprehensible
response to real life situations which have
robbed us of our power and taught us
helplessness’
(Wallcraft, 1996)
EXPERIENCING ILLNESS
• By developing a phenomenology of the
experience of mental illness, we can better
understand and respond to it
• Making sense of mental illness ‘involves
reflection both of the individual
experiences and of social consequences
and cultural constructions of the issue’
(Kangas, 2001)
FINDING A COHERANT NARRATIVE
OF EXPERIENCE
‘I think the best professionals involved in
my care have walked alongside me,
opening themselves to the mystery that is
schizophrenia’
(Champ, 1999)
The Role of the Midwife
(adapted from Price, 2004)
• Validate the women’s experience of
mental illness:
• Acknowledge that women may have preexisting mental illness
• Listen to women’s stories and views
• Help women identify their changing
needs in light of their pregnancy
Cont.
• Act as an advocate for the woman:
• Empathise with her experience
• Help to negotiate access to appropriate
services
• Support her to represent herself
• Intervene assertively where appropriate
Cont.
• Identify and address professional development needs
• Develop and enhance maternity services:
• The Confidential Enquiry into maternal deaths
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recommended that each maternity service should
have a perinatal mental health service, but there
are currently only approx 12-15 in the UK.
Collaboration with other services – primary care,
GPs, CMHTs, CAMHS, health visitors and other agencies
such as housing, social services and non-statutory
agencies.
REFERENCES/READING
Babiker, G. & Arnold, L. (1997) The Language of Injury: Comprehending Self-Mutilation.
Leicester: BPS.
Barker, P. et al (1999) From the Ashes of Experience: Reflections on Madness, Survival and
Growth. London: Whurr.
Busfield, J. (1996) Men, Women and Madness: Understanding Gender and Mental Disorder.
Basingstoke: Macmillan.
Casey, B. & Long, A. (2003) Meanings of Madness, Journal of Psychiatric and Mental Health
Nursing, 10:89-99.
Horsfall, J. (2001) Gender and Mental Illness, Issues in Mental Health Nursing, 22:421-438.
Nehls, N. (1998) Borderline Personality Disorder, Issues in Mental Health Nursing 19:97-112
Perkins, R. & Repper, J. (1998) Dilemmas in Community Mental Health Practice. Abingdon:
Radcliffe Medical Press.
Price, S. (2004) Midwifery Care and Mental Health, The Practising Midwife, 7,7:12-14.
Showalter, E. (1987) The Female Malady: Women, Madness and English Culture. London:
Virago.
Ussher, J. (1991) Women’s Madness: Misogyny or Mental Illness? London: Harvester
Wheatsheaf.
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