I wish Meghan had come to see me. I would have known just what to do. People see their GPs about mental health problems all the time, it’s something I manage almost every week (and recently most days). I could have easily squeezed her in to my Monday clinic, or even done an initial assessment over the phone.
If someone comes to see me saying they ‘just don’t want to be alive any more’ I take it very seriously indeed. I know what questions to ask and who to refer to. I know how long it takes to go through everything (at least twice the length of a normal consultation.) I know that everyone else that morning will be seen late, but that doesn’t matter, it’s a priority. That’s just how it is.
I could have taken a thorough history, offered her tissues in case crying blurred her mascara and included Harry in the consultation. I am sure he would be there too, both to support her and to give any extra information if she didn’t feel confident speaking about it.
My assessment of Meghan would not just have been about medical things like low mood and anxiety. I would also have been checked how she was getting on with her partner, her family, her work and who she was living with, to get a proper sense of how she was coping. As well, I would have asked about basic things like seeing friends, exercise, sleep and appetite. These are all part of a proper GP assessment, that’s why it takes a certain amount of time.
If someone made the same statement to you, what would you do? I hope everyone reading this would know to call up their GP. You could also go to a&e. You could speak to a private psychiatrist. You could ring 111. You could telephone the Good Samaritans. Or you could look up information on the NHS website. Because the one thing you would know is that a remark like that is serious. I bet you would do something about it the very same day. Unlike Harry who had ‘no idea what to do.’
The fact that Meghan was pregnant when she was feeling like this meant that it should have been taken even more seriously. Symptoms like this should really have set alarm bells jangling, both for her, for Harry and for their GP.
In the last Confidential Enquiries into Maternal Deaths and Morbidity 2015-17, published in 2019, mental health disorders accounted for 10% of maternal deaths during that 3 year period.
Although maternal suicide is only the fifth most common cause of women’s deaths during pregnancy and immediately afterwards, it ‘is the leading cause of death over the first year after pregnancy.’ https://www.npeu.ox.ac.uk/assets/downloads/mbrrace-uk/reports/MBRRACE-UK%20Maternal%20Report%202019%20-%20Lay%20Summary%20v1.0.pdf
The Maternal Death report doesn’t just count deaths, it analyses each person’s notes and works out what care went well, and where mistakes were made. Each patient’s notes are analysed by up to 15 health professionals including midwives, anaesthetists and psychiatrists as well as obstetricians. This is in order to identify potential areas of improvement.
With regard to mental health care in pregnancy the report particularly identifies that ‘disengagement from care should be regarded as a potential indicator of worsening mental state.’ Its hard to know whether Meghan disengaged from care and was at increased risk of a worsening mental state, because it is not clear from the interview whether she ever managed to engage in care in the first place.
Patients like Meghan, who are both pregnant and suffering from mental health symptoms, need urgent assessment and support. They may need counselling, carefully chosen medications to reduce any risks to the baby and attentive follow up and support.
In my area we have a specific perinatal community mental health team. The psychiatrists and counsellors on the team have links to midwives, social workers and nursery nurses. There is even a mother and baby unit where patients and their newborns can be admitted together if needed. The mental health team always writes to us in General Practice to keep us in the loop. When they hand over care (usually by 12 months) we make a note on both the patient’s and the newborn’s notes so that all clinicians are aware. Communication is where health care so often trips up, so careful documentation is key. Most patients recover really well but if there are ongoing worries, we involve the health visitor who can visit patient’s homes and help out with advice, right up until the infant is 5 years old.
If Meghan had perinatal mental health symptoms in her first pregnancy she should be identified as increased risk during her second and picked up earlier. Let’s hope her American obstetrician was watching the interview and will pick up the baton that has somehow been so disastrously dropped the first time round and offer her the care and support she should have had from the start.