MIDWIFERY, WOMEN AND MENTAL ILLNESS

1. MIDWIFERY, WOMEN AND MENTAL ILLNESS Lyn Gardner

2. The Impact of Pregnancy on Mental Health • The NSF for Children, Young People and Maternity 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).

3. 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

4. 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)

5. THE PROCESS OF DIAGNOSIS • Crowe (2000) argues that the process of 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’

6. 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’

7. 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)

8. 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)

9. 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)

10. DIAGNOSIS – GENDER ISSUES • Gender relations are implicated in psychiatry at both the 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.

11. CONT • Overall the proportion of people living with a diagnosed mental 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.

12. DEPRESSION • Woman-predominant conditions such as 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)

13. DEFINING DEPRESSION • Major Depression – according to WHO (1992) diagnosis requires 5 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

14. DEFINING DEPRESSION • Dysthymia – present for at least 2 years – often 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

15. SCHIZOPRENIA • The diagnostic rates of schizophrenia are about 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)

16. CONT. • Signs and symptoms of schizophrenia differ between men and 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

17. 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)

18. Maternity Services Fail Women with Severe Mental Illness • Pregnant and new mothers with a mental illness are a ‘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.

19. 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.

20. MAD WOMEN ARE LESS TROUBLE TO SOCIETY • Gendered expressions and forms of pain 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

21. 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

22. 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)

23. 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)

24. 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)

25. The Role of the Midwife(adapted from Price, 2004) • Validate the women’s experience of mental illness: • Acknowledge that women may have pre-existing mental illness • Listen to women’s stories and views • Help women identify their changing needs in light of their pregnancy

26. 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

27. Cont. • Identify and address professional development needs • Develop and enhance maternity services: • The Confidential Enquiry into maternal deaths 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.

28. 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. • NB AVAILABLE AS A POWERPOINT LECTURE : http;//shswebspace.swan.ac.uk/HNGardnerLD/