Sunday 2 March 2014

Call The Midwife... and the psychiatrist

Call The Midwife's saccharine approach to characters and story lines is normally too much even for my taste for birth and baby-focused TV.  So I tuned in tonight for the first time in months, having had advance notice that the episode was going to centre on a character with postpartum psychosis.  I was curious how PP would be portrayed by the BBC in one of its prime time Sunday evening shows.  And I was fascinated to know what treatment may have been like back in the 1950s.

So, what did I learn?

Warning signs and first clues
In this case, the mother did not seem to have any (noticeable) mental health conditions.  It is very common for PP to present itself in women with no "history", although at the same time it is known that women with conditions such as bipolar disorder can be at high risk of psychosis in the perinatal period.

The CTM mother seemed to enjoy a relatively straightforward birth (although the midwives did make a bit of a thing about the baby being born in its membrane).  So birth trauma was not a factor, although it certainly was in mine.  Amongst the doctors I have spoken to, not much is known about how important a trigger this is.

Shortly after the birth, the mother seemed to display some early warning signs of PP.  Noticeably "racing thoughts" and unusually high energy levels.  This quickly escalated to paranoia and then delusions.  The onset of PP varies enormously - I was psychotic within 12 hours of giving birth.  Other women I know did not experience the psychotic symptoms for many weeks or even months.

An important trigger for me, and it seems for the mother portrayed in CTM, was breast feeding.  She was fixated on her milk not coming in, and this led to further fears about the safety of the water and her baby's health in general.  This chimes a lot with my experience.  I desperately tried to feed my baby, with very little real success.  I was convinced something was very wrong, and that he was starving and it was all my fault.  I could write a whole post (or several!) around BF and mental illness...  Suffice to say I was pleased the storyline included this particular aspect.

Family and midwifery care
In CTM, the midwives of Nunatis (sp?) House are always the heroines of the day, and this episode was no exception.  They were on-the-ball and knew to call the doctor very quickly.  They could not have foreseen that she would spit out the sedative and end up in crisis.  Unlike the CTM character, my psychosis developed while I was still in the High Dependency Unit of the hospital, and I was seen very quickly by specialist psychiatrists.  So my experience of mental health care by midwives is limited.  However, a recent survey report by the Royal College of Midwives is disturbing.  It suggests that over half of third-year student midwives feel inadequately prepared to deal appropriately with mental health problems in the women they care for.

The character's husband was understandably reluctant to admit anything was wrong or different about his wife.  It took a crisis point for him to acknowledge she needed to be admitted to a psychiatric hospital.  Similarly, my family were desperate for me and my baby to stay at home, and get better with just a little rest.  I was desperate for this to work.  Even though it was 2012 and not 1952 I was desperate not to bring "shame" on my husband and family, and ruin all of our lives. But I knew with the very last shred of sanity left in my brain that I needed more help than what my family could offer.  It was a hard decision to take together, but we went voluntarily to the Bethlem, thankfully just before a dangerous crisis point was reached.

Mental health crisis

It made for heart wrenching television, but was the "deranged mum clutching baby on river pier" scene really necessary?  The statistics on this are clear - a very small percentage of women (less than 5% or thereabouts) with PP ever harm their babies.  Yes, this threat must be taken extremely seriously.  But one reason women with PP symptoms are so reluctant to come forward and get the help they and their babies need is the fear that people will think they want to harm the baby.  Psycho = Baby Killer, right?  This assumption needs to change, and CTM missed a real opportunity here.  I have come across far more women whose psychosis means instead they are desperate to protect their baby from some imagined threat.

Psychiatric Hospital
Eventually the CTM mother was admitted to a general psychiatric hospital.  To be honest, given this was supposed to be the 1950s, it didn't look too shabby!  It didn't even look all that different from the Royal Bethlem Hospital, which opened on its present site in the 1930s.  The big difference between then and now is the emergence of Mother and Baby Units.  Until relatively recently, mothers were separated from their babies, and left to recover on their own.  I cannot imagine how hard that would have been.  Once my psychosis receded, I was left to pick up the pieces of what had happened and rebuild both my confidence as a mum and my relationship with my son.  This would have been impossible, had he not been right there with me.  Now, I feel a special bond with him - we went through it together, and emerged all the stronger for it.

A note on ECT
I'm not sure when ECT was first used to treat serious psychiatric illnesses, but I guess it was prevalent in the 1950s.  It is still used now, and there are an interesting set of NICE guidelines around it.  The brain is a little-understood organ, and nobody knows exactly how or why ECT works.  Perhaps it is the human equivalent of "have you tried turning it off and back on again?"   I think, as a last resort, it is worth considering.  It was certainly considered as part of my treatment, and if I had it and it worked I would have been grateful for it.

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