Spotlight On… Mental Health

Mental health continues to be a huge concern in health care, especially with regard to obstetrics and gynaecology issues. This Spotlight is an update on the previous ‘Spotlight on… mental health’ by Mahmood, published just over 4 years ago (TOG 2016;18:89–90). This Spotlight reviews articles published on the subject previously in The Obstetrician & Gynaecologist (TOG) and highlights more recent publications. The latest MBRRACE-UK report1 states that, among 209 women who died during or up to 6 weeks after pregnancy between 2015 and 2017, 20 died as a result of mental health conditions. This figure has increased from the previous triennial report, and surpasses deaths from pre-eclampsia, haemorrhage and sepsis. Maternal suicide continues to be the leading cause of direct deaths occurring between 42 days and 1 year postpartum, and 28% of those who died were known to have pre-existing mental health problems. Sadly, perinatal mental health remains a stigma for both patients and healthcare professionals, leading to reluctance to discuss the subject for fear of opening Pandora’s box. Bambridge et al. (TOG 2017;19:147–53) give excellent guidance for healthcare professionals on how to broach the subject with patients and ‘how to help’ women with their mental health. They also make the important point that there is no evidence that discussing mental health or suicidal ideation leads to an increased risk of self-harm or suicide. Lowes et al. (TOG 2012;14:179–87) remind us that in pregnant women with anorexia, a six-fold increase in perinatal mortality has been reported. The article provides a helpful summary of the types of eating disorders and covers management of anorexia nervosa throughout pregnancy and the puerperium in the form of a useful flowchart. The article by Conlon and Lynch (TOG 2008;10:151–5) makes the point that approximately 10% of pregnant women will experience clinically significant depressive symptoms during pregnancy and that antenatal depression can be difficult to diagnose, as some biological symptoms of depression are common in nondepressed women – for example, sleep disturbance. The immediate postnatal period is one of huge change, and emotional and behavioural changes affect 50–80% of all new mothers between day 3 and day 5 of the postnatal period. Oates (TOG 2008;10:145–50) explains that all types of psychiatric disorder can complicate the postpartum period, arising either de novo or as a recurrence or relapse of a pre-existing condition. The importance of the early recognition of and aggressive treatment for women with postpartum psychosis cannot be stressed enough. Suicide, especially in a new mother, is a profound tragedy, and for each woman who takes her own life, there are numerous near misses. Di Florio et al. (TOG 2013;15:145–50) remind us that all women should be screened antenatally for the known risk factors, because in 50% of all cases of postpartum psychosis, there is no history of psychiatric disorders. Women with bipolar disorder have at least a 25% risk of postpartum psychosis and require close contact and review during the perinatal period, even if they appear well. The Mental Capacity Act 2005 is often a minefield for the obstetrician, and in Nicholas and Nicholas’ review article (TOG 2010;12:29–34), it is expertly unpicked with useful boxes, including how to test for capacity. A multidisciplinary team approach that includes a perinatal psychiatrist is key to ensure that an individualised management plan can be drawn up for each patient in advance. Endometriosis is a challenging chronic condition and is closely associated with irritable bowel syndrome (TOG 2016;18:9–16). The brain–gut interaction with anxiety and hypervigilance may lead to normal physiological activity being perceived as painful, and there may be visceral hypersensitivity in both conditions. This 2016 article was followed by a paper on endometriosis-related pelvic pain by Hoo et al. (TOG 2017;19:131–8), who discuss the effectiveness of, and evidence base for, medical and surgical treatments, plus the usefulness of patient support groups and self-management. These approaches can help patients to develop strategies on breaking the pain cycle and dealing with stress, anxiety and negative body image. The diagnosis and management of premenstrual syndrome (PMS) is comprehensively reviewed in an article by Walsh et al. (TOG 2015;99–104), in which we are reminded to use prospective charting to make the diagnosis and consider the influence of background mental health conditions on PMS symptoms, and vice versa. Menopause is associated with psychological symptoms and psychosexual problems in many women. A timely article on the latest evidence for hormone replacement therapy (HRT) recommends HRT rather than selective serotonin reuptake inhibitor (SSRI) drugs for menopause-related psychological distress in women who are not depressed (TOG 2015;17:20–8). Two TOG articles reflect on the safe prescribing of HRT and management of side effects, in particular unscheduled bleeding, which causes concern for patients and clinicians (TOG 2015;17:29–38; TOG 2019;21:95–101). Richardson et al. (TOG 2019;21:291–8) provide a useful article drawing attention to the significant number of women who are rendered menopausal by their treatment for gynaecological cancer, as well as the evidence base for offering or withholding HRT. Gynaecological symptoms may lead to sexual problems, and over 20% of women attending gynaecology clinics have psychosexual dysfunction (TOG 2015;17:47–53). Cowan and Frodsham discuss the need for psychosexual medicine training and how gynaecologists can help patients to see their problems more clearly through enhanced consultation skills. The authors cover vaginismus, vulvodynia and non-consummation, as well as persistent vaginal discharge and tokophobia. The impact of vaginal atrophy (genitourinary syndrome of menopause) on the quality of life of many women is profound and underestimated (TOG 2019;21;37–42). Many women find it hard to discuss this and only mention it with direct questioning, so clinicians must be proactive and sympathetic. The stress of women attending for colposcopy is well known to gynaecologists, and recently our attention was drawn to the anxiety that may be associated with human papillomavirus (HPV) screening in the national cervical cytology screening programme. There can be a significant psychological burden of a positive HPV result, and a negative HPV test may not always be reassuring (TOG 2016;18:251–63). An update was published for gynaecologists who form part of the multidisciplinary team who engage with transgender and non-binary patients, either by performing surgery as part of the transition stage or managing pre- or post-transition gynaecological problems (TOG 2019;21:11–20). The paper explains the importance of optimising mental wellbeing alongside physical health. It is crucial to offer counselling and psychotherapy to address the negative aspects of gender dysphoria, to understand the stigma attached to gender nonconformity and to understand the discrimination and prejudice that transgender individuals face, which leads to high rates of self-harm and suicide. Gynaecologists may encounter women with a history of sexual violence in many forms: domestic abuse, sexual assault and rape, female genital mutilation (FGM), conflict-related violence and child sexual exploitation (CSE). TOG articles have covered all of these topics and have helped us to understand the issues and respond in appropriate ways; a sensitive and nonjudgemental approach is essential. Rape victims are more likely to develop symptoms of post-traumatic stress disorder (PTSD) than victims of any other crime, and long-term effects of rape can include depression, anxiety, drug misuse, self-harm and suicide (TOG 2018;20:87–93). Domestic violence is an important public health issue that clinicians should recognise and routinely enquire about. Cox-George et al. (TOG 2017;19:199–203) discuss the need for multidisciplinary training using simulation and whether a module could be extended to the Maternal Obstetric Emergencies Training courses. FGM has severe physical and psychosexual repercussions, regardless of the age at which it occurs. The psychological and psychosexual consequences are not as widely documented as the physical, because social taboos and cultural norms inhibit women from speaking out. Woman may suffer from nightmares, insomnia, PTSD, stress, panic attacks, anxiety, loss of self-esteem, depression and anorgasm (TOG 2017;19:273–8). Conflict-related sexual violence can have a devastating impact, resulting in severe physical injuries, unwanted pregnancy and sexually transmitted infections, and psychological trauma, plus stigma, shame and ostracism (TOG 2016;18:247–50). Gilmore et al. (TOG 2017;19:205–10) give us tips for recognising children who have been subjected to or who are at risk of CSE, and for coping with their sometimes challenging behaviour. An updated online collection of all TOG articles relating to mental health is available at onlinetog.org.