Tag Archives: anxiety

These words have been in my head and they needed to come out (a blog post about suicide)

Trigger Alert – this blog contains info re suicide which may be unsettling for some people.

Guest Post: Stevie Jacobs has contributed this guest post to meta4RN.com

StevieJacobsStevie Jacobs is the pen name of a newly-minted Enrolled Nurse. The person behind Stevie is smart, experienced in life and has some awesome insight into the world of the student and new graduate nurse.

You can follow Stevie Jacobs on Twitter: @SJWritesHere

Stevie has contributed to other nurse blogs, including the excellent site Injectable Orange, by Jesse Spurr.

These words have been in my head and they needed to come out
(a blog post about suicide)

I am ‘Pro choice’.

I am a patient advocate.

I am a person advocate.

I support euthanasia.

I am pretty much of the opinion that if you have all the facts, figures and feelings figured out then you can go ahead and do pretty-much whatever you like. Even if it’s ‘bad’ for you. I can provide you with action plans and phone numbers and personal support, however ultimately, the choice my friend, is yours.

So when someone wants to kill themselves/suicide/take their own life (however you want to put it) what does my head feel about that? I’m not talking about obligations as a Health Care Professional, I’m talking about obligations as a human being. I can provide you with an ear to bend, a shoulder to lean on, I can find you professional help if you want, I can tell you that I don’t think you’re in a safe space and I want to get more support. For both of us. I can do all that. What I am stuck with is that if euthanasia is assisted suicide and I’m OK with that (OK meaning I won’t physically stop you nor judge you), does that mean I am ‘OK ‘ with someone’s suicide? Both have the same ending:, the removal of pain through the death of a person. I don’t know how my heart or my head feel about that.

Robin Williams was 63. That’s a long time to be living in pain. Yes, there are medications and therapies and support groups, but what if that starts to feel just all too much? That living is just all too much, a bit like ‘diabetic burnout’, where the person with diabetes basically gets fed up with ‘managing’ their diabetes and becomes unwell. That can happen with all chronic diseases. That can happen with mental health issues. Yes, some people have a depressive episode, it’s self-limiting and then they never have another one. Wonderful. For others, it just keeps on coming back, more painful than before.

To someone who is experiencing suicidal thoughts, suicide I can seem to be a rational method of pain relief. It’s the ultimate pain reliever for the person experiencing the thoughts.

For those left behind it can be devastating.

I can’t make up my mind. Do I have the ‘right’ to stop someone from suicide? I’m on the fence. The boundaries get blurred. I’ve experienced anxiety & depression, I’ve experienced suicidal thoughts & been ‘suicidally depressed’, I’ve had a family member suicide and I’ve known someone I followed on Twitter suicide. Which is a really fucking weird experience, quite frankly. Grief for someone who you ‘know’, but don’t ‘know’. 101 ‘What ifs?’. I could ‘see’ that something wasn’t right, but aside from checking in and offering an ear what else could I do? I’m at peace with those choices now, no longer haunted by ‘what ifs’. I’m sure that is not the same for their family and friends. I realised that what has stayed in my head is a photo of themselves they posted shortly before it happened. It’s their eyes. Their eyes haunt me. I can see something in their eyes I’ve seen time and time again. In my face. In the faces of others. I know those eyes so well. However good your mask is it’s in the eyes.

So, what to do? Who am I to tell anyone what to do? There isn’t really a clear answer. I think it’s really important to keep checking in on people: RU OK? I have RUOKed a few people and I will keep doing it. If it’s a ‘No’, and they express some ideas that worry you, it’s OK to ask “Do you have a plan?” If it’s a ‘Yes’, what then? Especially if you just don’t believe them. That’s trickier ground to navigate. I’m no expert on this. There are links at the end of this from people who are.

RU OK? It’s just a simple question. A simple, lifesaving question. I was on another planet from OK, and someone who barely knew me asked me that question.

It was like a thunderbolt.

It made me stop and think and choose to get help to make living less painful. Choosing to get help is hard. Getting help can be harder. What’s even harder is acknowledging that choosing to live is a conscious effort. It’s an effort. Accepting that medications and therapy and exercise and diet changes and avoiding triggers are now part of your life is an effort.

In time I hope that life will once again become effortless, but it might not.

Finally, after years of effort, I now think I am OK with that.

.

Post Script 1:

I wrote the above post a little while back. Normally when I have said all I have to say on a subject it doesn’t pop back in to my head. This post did. If I am honest, I have only scratched the surface. I have more to say. The way I write usually is like a good vomit on a night out: it all comes out in one go and it’s done and dusted and you’re up and dancing again. The other way I write is a bit more like a gastro bug: on and off with a bit of dry retching when you just can’t get it out. Then you’re done and you feel better.

Paul told me the ‘meta’ point of meta4RN is ‘talk about what you’re talking about’. So I guess that’s what I’m doing here. Rereading the above, reflecting on it and trying to work out quite what it is that I still feel I want to say.

We need to talk about mental health. We need to talk about suicide. We need to do it in a safe, appropriate and open way, but we do need to talk about it. Talking about it is hard. Talking about it can be terrifying for anyone. Talking about it when you’re a health professional is really damn hard. There are so many ‘what ifs’. What if they ‘lock me up’? What if they don’t? What if they think I’m not fit to practice? What if I lose my job? What if my colleagues find out? What if I have to be treated in the same hospital that I work in? What if…

I want to talk about how it feels to have suicidal thoughts. I want to talk about how it feels to be suicidally depressed. I’m not sure how to do that. I know that there are media guidelines for discussing suicide. As someone who is trying to describe a ‘lived experience’, I decided the best way for me to write was to let it all come out uncensored, and then give it to Paul to edit it using some of those guidelines and make it ‘safe’. I am in a safe enough space now to be brutally honest about how those suicidal thoughts feel, and far away enough from those thoughts to be able to talk about them without feeling ‘triggered’.

I can only speak for myself. For me there is a distinction between having suicidal thoughts and being ‘suicidal’ or ‘suicidally depressed’, as I have referred to it in the past. The thing about ‘suicidal thoughts’ is that the longer you have them the more rational they seem. For me suicidal thoughts are more of a hypothetical notion; it’s not something I am going to carry out. It’s an icy calm IF. IF things don’t get better, IF that was to happen, IF there isn’t another way out, IF the pain becomes unbearable, IF.

I know exactly how I would kill myself. I know exactly how I would spend the jackpot from a lottery win. I know exactly what I would get done if I had free access to plastic surgery. It’s all hypothetical.

It’s hypothetical. Until it’s not. Until I am suicidally depressed. Until I am in pain. Until the self-loathing I carry around with me every day takes over. Until I truly believe that the people in my life would be better off without me. Until I can’t see any way out aside from that way. And that place is not icy calm. It’s a messy, clinging on to something, anything to get through hour after hour, painful, emotional swamp. I feel emotionally swamped. I can’t think in a straight line. I can’t sleep. I can’t eat. The anxiety eats at my stomach. The panic attacks feel like I am dying of a heart attack. The after effects of which last for days. And nothing, nothing stops the pain. That’s how suicidal feels like for me. I know, however, that it is not what it looks like to other people. People see what they want to see. Even people who are trained to see more. I am brilliant at hiding it. I know how to put on my mask and polish up my armour. It is exhausting.

There are cracks in my armour, sometimes the mask slips. My fellow walking wounded can see though them, but for the most part the people I see every day wouldn’t know. I can make people feel so good about themselves. I can make people cry with laughter. Then, the second I am alone, the pain floods over me and I can barely breathe. I keep coming back to pain. It’s about pain. Not control, nor attention seeking, nor escape; in that moment it is about wanting that pain in my heart to stop. To. Stop.

It’s a horrendous place to live to be honest. It’s a half life. I had to choose to live better. To live for me. To get help – medications, counselling, CBT, exercise, diet. It’s a conscious choice. And what helped me make that choice was being asked ‘RU OK?’

.

Post Script 2:

So, turns out it’s not a verbal gastro bug. It’s verbal C.Diff. The words just keep coming out.

I think I need to make it clear that I am talking about a period of over 10 years. I need to make it clear that I am talking about the past. I might write ‘I know’, but I suppose really it is ‘I knew’. Deciding to share this is a decision that has been easy, but it is a decision that I have made because these words have been in my head and they needed to come out. There are more things I could say, about specific attempts, specific feelings. However, I don’t want to share them. I think that’s OK.

I need to make it clear that I support ‘RUOK’ & WHO suicide prevention strategies. I need to make it clear that if you judge me negatively based on what I have written or if it changes your opinion of me, then that’s your thing, not mine. I’m not asking for agreement or understanding, but I do ask for kindness.

I was asked recently what the best thing in my life is right now. Aside from Nursing, the answer is the people in it. I know that my people love me, and accept ‘me’, and that’s enough.

Black Dog Institute Healthy Living Study is a program to help those experiencing suicidal thoughts manage them: http://www.blackdoginstitute.org.au/public/research/participateinourresearch/index.cfm

Black Dog Institute Healthy Living Study is a program to help those experiencing suicidal thoughts manage them: http://www.blackdoginstitute.org.au/public/research/participateinourresearch/index.cfm

End.

Short URL:  meta4RN.com/guest02

Many thanks to Stevie Jacobs for sharing this gutsy piece of writing. Your sensitive, constructive feedback is welcomed in the comments section below.

It’s also important to acknowledge that talking and thinking about suicide can be distressing. People in Australia can access support via:

Lifeline – 13 11 14

Suicide Call Back Service – 1300 659 467

MindHealthConnect www.mindhealthconnect.org.au

phone_hotline-40Outside of Australia and not sure where to get support? Google usually displays a red telephone icon and your country’s suicide support phone number when searching for a suicide-related topic.

This guest blog post has a companion piece, which I have imaginatively called “A Blog About A Blog About Suicide” – the link is here: meta4RN.com/mindframe

Paul McNamara, 23rd September 2014

Stay connected, stay strong… before and after baby

Copy of Stay connected, stay strong… before and after baby DVD on YouTube (33 minutes):

From the back cover of the DVD:

StayConnectedPregnancy, birth and parenting can be a very positive time, but sometimes it may not be how you expected it to be. Adjusting to life as a mother can be hard and make women feel down and distressed. In Australia, one in every six women experience depression during this time.

This DVD has been created to support Indigenous women, men and families understand the importance of good social and emotional wellbeing during pregnancy and beyond.

Going to get help might feel like the hardest part, but it is the best thing you can do for yourself, your baby and your family. Getting help early gives the best chance of a strong and healthy future.

YouTube URL: http://youtu.be/CLsjgw8pvOA

.

Why is the Video Online?

The video is online so that it can easily reach the target audiences: Aboriginal and Torres Strait Islanders families, and those who support them. It is a great little video: not only does it have a very clear message that there’s no shame in asking for a bit of support, but it also looks and sounds great. My favourite thing is how the narration by Jasmin Cockatoo-Collins ties the whole thing together: even though a couple of dozen people appear on camera, Jasmin’s voice weaves the whole thing together so it kind of seems like one story. Well done to Jasmin and film-maker Jan Cattoni (Jan’s a nurse who became a film-maker).

Knowing that the video is so good that it should be shared is one thing, getting it shared is another.

Stay connected, stay strong… is available for free in Queensland and for $20 elsewhere, all you need is this PDF order form from the Queensland Centre for Perinatal and Infant Mental Health: http://www.health.qld.gov.au/qcpimh/docs/resource-order-form.pdf

youtube---the-2nd-largest-search-engine-infographicFar North Queensland residents can borrow the DVD from Cairns Libraries: link.

Queensland Health staff can access the DVD through the Queensland Health Libraries Catalogue: link

However, as accessible as all that sounds, the truth of the matter is that YouTube is the world’s largest video-sharing portal and the world’s second largest search engine. A video is not really accessible until it is online.

Now we can share the video using this link: http://youtu.be/CLsjgw8pvOA

Eek!

This is by far the riskiest thing I’ve done with my professional social media portfolio. I am not the copyright holder of this excellent short film: the Queensland Government is. Although I won’t make any money out of hosting the video, I might be subject to legal action. If there is a credible threat of legal action I will take the video down immediately. Another risk is that I might be inadvertently causing offence or distress to some person or organisation. This may mean that I will not be considered for future work in perinatal and infant mental health (perhaps funding for services will return to pre-July 2013 levels one day).

So, why take these risks?.

My agenda is simple: to demonstrate that social media can be leveraged as another channel for health promoting information. It’s something I started when working in perinatal and infant mental health in October 2011, as evidenced by this from my now-mothballed Twitter handle @PiMHnurse (now I use a less job-specific name: @meta4RN).

PIMHnurse

 

My big hope is that hosting Stay connected, stay strong… before and after baby won’t get me in too much trouble, but will serve as a spur for a more legitimate stakeholder to host the video on their YouTube or Vimeo site.

When that happens I will complete this post-script to the blog post:

Important Update DD/MM/YYYY:

Stay connected, stay strong… before and after baby is now hosted by [organisation name] at this web address: [web address]. The link and embedded video you see above are now from that site, and I have deleted the copy I posted on 7th June 2014 here: https://www.youtube.com/meta4RN

My intention in knowingly posting a video that I am not the copyright-holder of was to act as an agent of change. If I have caused harm or distress to any person or organisation I am genuinely sorry. That was not my intention.

End

That’s it. I’m feeling scared now.

Paul McNamara, 8th June 2014

Perinatal Mental Health Workshop Links and Resources

Previously for Perinatal Mental Health Workshops I have trickled-out the links and resources we refer to during the workshop via Twitter and Facebook.  It’s a nice idea, and has worked pretty well (for more information about this experiment in social media enhanced education please see the video below and/or this link: meta4RN.com/workshop).

However, it is pretty labour-intensive to pre-schedule each individual Tweet and Facebook post every time I facilitate a Perinatal Mental Health Workshop, so to save some mucking-around I’ll list the links and resources here.

The headings in red are not mutually exclusive – some links cross boundaries. The list/links will be updated PRN:

Guiding Clinical Practice

guidelines

2014 Cairns Perinatal Mental Health Workshops (follow the link for info about the workshops and for free registration) pmh.eventbrite.com.au

Australia’s Perinatal Mental Health Clinical Practice Guidelines www.beyondblue.org.au

Promoting Perinatal Mental Health Wellness in Aboriginal and Torres Strait Islander Communities (PDF from the book Working Together: Aboriginal and Torres Strait Islander Mental Health and Wellbeing Principles and Practice; chapter 16 by Sue Ferguson-Hill) aboriginal.childhealthresearch.org.au/media/54907/chapter16.pdf

Perinatal Jargon Busting (get your head around the lingo) meta4RN.com/jargon

Using the Edinburgh Postnatal Depression Scale (tips for midwives, child health nurses, Indigenous health workers and other clinicians) meta4RN.com/epd

Edinburgh Postnatal Depression Scale  (this version is online, anonymous, free and self-scoring) justspeakup.com.au/epds

Perinatal and Infant Mental Health Libguide (a very handy for researchers and clinicians) tpch.qld.libguides.com/PIMH

pnd-dadQueensland Centre for Perinatal and Infant Mental Health (QCPIMH have some great resources) www.health.qld.gov.au/qcpimh

Perinatal and Infant Mental Health Nurse eNetwork (an email network hosted by the Australian College of Mental Health Nurses for nurses and midwives interested in perinatal and/or infant mental health) lists.acmhn.org/wws/info/perinatal-infant-mh

ACMHN Perinatal Mental Health Online CPD Program (a 3 module continuing professional development program which is open to Australian College of Mental Health Nurses members [free] and non-member nurses and midwives [$33 including GST]) www.acmhn.org/perinatal-elearning

Nurturing the Nurturers (info about guided reflective practice/clinical supervision as a self-care mechanism for health professionals) meta4RN.com/nurturers

For the Parent(s)

PANDA

Cairns Perinatal Mental Health Support Options google.com/?q=perinatal+cairns

Stay Connected, Stay Strong: Before and After Baby (cool DVD featuring Aboriginal and Torres Strait Islander parents). Borrow: lib.cairnslibrary.com.au Buy: www.health.qld.gov.au/qcpimh YouTube: http://youtu.be/CLsjgw8pvOA

Behind the Mask: The Hidden Struggle of Parenthood (DVD preview) http://youtu.be/FjqOqJLkyFs

PANDA – Post and Antenatal Depression Association (for info and phone support) www.panda.org.au

How is Dad Going? (for fathers affected by perinatal anxiety/depression)  www.howisdadgoing.org.au

Pregnancy, Birth & Baby (24 hour info and support) www.pregnancybirthbaby.org.au

beyondblue (lots of resources, including booklets regarding emotional health in pregnancy and early parenthood, some multilingual booklets) www.beyondblue.org.au

mindthebumpMind the Bump is a free Mindfulness Meditation App to help individuals and couples support their mental and emotional wellbeing in preparation for having a baby and becoming a new parent www.mindthebump.org.au

Black Dog Institute (info and resources re perinatal depression for women and men; presented in a different style to beyond blue’s info) www.blackdoginstitute.org.au

Doc Ready (for those not sure how to start a conversation about mental health with your midwife, nurse or doctor? maybe building a checklist will help) docready.org

MindHealthConnect (good place to find trusted mental health programs, fact sheets, and to access urgent support via the red “Need Help Now?” button on each page) www.mindhealthconnect.org.au

pnd-mum-torres

Puerperal Psychosis

Information on Puerperal Psychosis (2010) by Dr Anne Sven Williams and Sue Ellershaw (be alert, not alarmed: a self-downloading DOC; the target audience for this is women/families affected by puerperal psychosis,  but many of us clinicians have also found it a useful adjunct to our formal education) www.wch.sa.gov.au

Puerperal Psychosis: A Carer’s Survival Guide (PDF by Craig Allatt: Craig’s partner experienced puerperal psychosis) www.wch.sa.gov.au

Keeping Baby In Mind

Print

A Monster Ate My Mum (a children’s book looking at postnatal depression through a child’s eyes) amonsteratemymum.wordpress.com

Still Face Experiment (Edward Tronick’s demonstration of how infants respond to changes in interaction from primary caregivers is often cited in infant mental health education) youtu.be/apzXGEbZht0

Baby Cues Video Guide (trying to work-out what newborns are trying to communicate can be tricky; these video guides might help) raisingchildren.net.au

Circle of Security (re attachment theory and affective neuroscience) circleofsecurity.net

Raising Children Network (an Australian resource for parenting, covers newborns to teens) raisingchildren.net.au

wellbeing

That’s all I have on my list for now. Please add your suggestions for valuable links and resources to share at my Perinatal mental Health Workshops in the comments section below.

Paul McNamara, 7th February 2014

Cyclone: Alert, Not Alarmed

Dear Mum and Dad (and anyone else who is interested),

outlookIn a couple of days you may see on the news that a cyclone has spun-up out in the Coral Sea. At the time of writing the cyclone is predicted but not named. The forecast map (see bottom of the page) suggests that Townsville is more likely to cop it than us.

I think it’s a good idea to put you as fully in the picture as I can. We kind of like the way cyclones get named: it seems to give them each a distinct personality. We’ve had a few cross the coast nearby since we moved to Cairns.

katrinaCyclone Katrina mucked around for a couple of weeks, but never got organised enough to cross the coast as a big blow. Katrina did not cause any deaths in Australia, but a man in Vanuatu lost his life in her rough seas, and hundreds of homes in the Solomon Islands were damaged or destroyed. We were OK in Australia.

800px-New_Orleans_ElevationsCyclone Katrina was much more benign than Hurricane Katrina. The other difference is that although Cairns is not a long way above the high tide mark, at least parts of it are not below the high tide mark as New Orleans is. That’s why so many people died because of Hurricane Katrina: it was not the wind, it was the water. That’s true of most cyclone deaths: flooding and drowning is where most danger lies.

CairnsHospital

Cairns Hospital, 165-171 Esplanade

Luckily we do not own a house on the beach front (there’s also the small matter of not having a lazy couple of million dollars lying around). Storm surges that coincide with cyclones can be a bit of a worry, but at least our place is not in a red zone like the local hospital. Feel free to check our address using storm tide surge address search/evacuation maps here or (just in case the council’s website goes offline) here.

justinThere was heaps of flooding after Cyclone Justin: I remember water lying around for days. Justin is responsible for lost lives In Papua New Guinea and a boat at sea. Closer to home an Innisfail boy was electrocuted by power lines bought down by the cyclone, and a lady was caught in a landslide near Townsville. All that rain and the buffeting wind was bad for crops and trees (some of which fell on to homes).

larryAfter Cyclone Larry we did not have power for five days. It’s amazing how often we still automatically reached for the light switch when entering a room. The reflex of a life time of luxury, I guess. Did you know that about 25% of the world’s population does not have electricity? Info about that here. Going a few days without electricity is a nuisance, but we know it will always come back on. We are better-off than many.

steveCyclone Steve made things a bit soggy for a few days too. The Barron Falls were pumping – if we get another cyclone crossing the coast be sure to checkout the webcam here for a view of the falls in full flood – spectacular! All the tourist operators trot out this cliché at this time of year: “You can’t have rainforest without rain!” It is the wet tropics, after all.

yasiCyclone Yasi looked like it was going to give Cairns a shake-up: so much so they even evacuated the hospitals – the biggest hospital evacuation in Australia’s history. Cairns was lucky that Yasi took a slight turn south before crossing the coast: Tully, Cardwell and Mission Beach really copped a belting though. Yasi was a big, powerful cyclone, but did not directly kill anyone. There was one indirect death: a young man suffocated after bringing a generator inside.

header_logoWe are used to preparing for cyclone season. Every year the Cairns City Council issues information about preparing for cyclones – it’s just part of the annual ritual. we have done it 19 times now.

We have enough food to last a few days. We have containers to store water in, if required. We have batteries for the radio, so we can stay informed about what’s going on if the power goes out. We live high above sea level. We take cyclones seriously. We are prepared.

imagesHowever, we don’t take the hyped-up TV coverage seriously. If the TV shows start shipping their main in-studio people up to Cairns for live crosses please switch of the telly. These shows need to create drama and suspense to make the story compelling, but the truth of it that it’s just weather. Weather that we’re used to. Weather that will be nuisance to many and maybe even dangerous to a few. However, the reality is that it will be more dangerous to drive to the airport to pick you up when you next visit than it is to live in a city with strict building regulations. Houses can still sustain major damage of course, but they don’t blow away anymore. Those images of houses completely blown away by Cyclone Tracy are a thing of the past: Tracy changed building codes right across the Australian tropics.

forecastPlease don’t be worried. Please don’t get seduced by the inevitable media hype. I’ll call/text when I can, and give live updates on Twitter using the @WePublicHealth handle if a cyclone comes close to Cairns this week, otherwise i will use my usual @meta4RN handle. The purpose of Tweeting will to be to provide a non-alarmist account of what’s going-on. The mainstream media are not very good at this, so (to borrow a term from Melissa Sweet ) it is up to citizen journalists to do so.

Well, citizen journalists and the Bureau of Meteorology, that is: www.bom.gov.au

Speak soon.

love, Paul

27th January 2014

Perinatal Mental Health: A Good News Story

diabetes, for instance

diabetes, for instance

Most health messages are such a downer, surely there are many people who will either switch-off from the message, or become unduly alarmed. Compare health marketing to commercial marketing and it’s no wonder obesity is rising. Put frankly, Coca-Cola and McDonalds have better ads: they’re full of fun and optimism:

Things Go Better With Coke!  

McDonalds – I’m Lovin’ It! 

Don’t get me wrong: depression is a bugger of a thing, and perinatal mood disorders are especially poorly timed. Looking after a pregnancy/baby is tricky enough without tossing in anxiety and/or depression.

However, at the risk of sounding all Pollyanna about it, there are some good news stories we can talk about when discussing perinatal mental health. Here’s a small list of things I’d like mentioned in every antenatal class/similar forum for parents-to-be/new parents:

IMG_0328[1] 6 in 7 new mothers and 19 in 20 new fathers will not experience perinatal depression. Are there any other gambles that give you better odds?

[2] Symptoms are usually easy to recognise. There’s even a free online anonymous self-scoring tool available: justspeakup.com.au/epds

[3] If somebody is not sure how to start a conversation about mental health with their midwife, doctor or child health nurse, there’s a handy online tool to help build a checklist of things to mention: docready.org

[4] Information and resources are easy to find. In Australia the “big five” are:

[5] Support is easy to find too:

[6] There are a range of treatment options: it’s not a matter of  “one size fits all”.

[7] If required, there are some medications that can be used in pregnancy and/or breastfeeding.

[8] Recovery rates for postnatal depression are very good.

[9] Some places have access to specialist perinatal mental health clinicians.

[10] Mental health clinicians are not interested in stealing the baby. In fact, mental health clinicians seem quite pleased with themselves when they get to see parents and infants connecting and communicating with each other.

[11] If attachment between parent and baby does not happen as easily as expected (this happens a fair bit with anxiety and/or depression), there are video guides to help, for example: Baby Cues Also, in some towns and cities (especially those with a perinatal and infant mental health nurse), there are clinical staff who can help with this communication/attachment/bonding stuff too.

What’s This About Exactly?

During the week a couple of new mums declined referral to see a nurse (me) from the consultation liaison psychiatry service because they had preconceptions about how negative the experience would be. It’s not absolutely necessary for every parent to see a mental health specialist, of course, but I think we (that’s “we the health professionals”) should start fishing-around for ways to better describe the good news stories about perinatal mental health.

diabetes, that is

diabetes, that is

If Coca-Cola and McDonalds can convey a sense of fun and optimism out of the products they sell, surely we can convey a sense of fun and optimism out of the services we provide. We have something that’s much better than the offerings of either Coca-Cola or McDonalds, so let’s reorientate the language and recalibrate expectations by using positive language.

Maybe when perinatal and infant mental health (PIMH) services in Queensland are re-established, we can re-launch with an upbeat attitude and slogan:

 PIMH for a healthy head-start!

End

What are your ideas for upbeat slogans and messages? Please add them in the comments section below.

Paul McNamara, 25th January 2014

The Myth of the National Perinatal Depression Initiative

og13232011Back in June 2011  I was employed as a perinatal mental health nurse, and was working in partnership with midwives, child health nurses, GPs, Indigenous health workers, allied health staff and obstetricians to provide and develop easy, smooth pathways to mental health care for pregnant women and new mums who needed a bit of extra support.

At the time I was invited to submit this article to O&G Magazine regarding perinatal mental health.

One of the closing paragraphs of the article was this:

It would be fair to say that availability of specialist perinatal mental health service in Australia has been patchy. In some health districts, perinatal mental health services have evolved without specific funding, often emerging as a component of consultation liaison mental health. However, until recently there hasn’t been a coordinated approach to perinatal mental health at a national level. This should be addressed, in part at least, by Federal, State and Territory Governments using National Perinatal Depression Initiative funding to seed specific services and models of service delivery at various urban and regional centres. In Queensland, for example, there will a dozen or so ‘perinatal mental health clinical nurse consultants’ seeded in a number of strategic locations around the state, with the hope/intent of developing sustainable referral pathways and contributing to workforce training and development in this area.

Boy, did I get that wrong.

There were a dozen or so perinatal mental health clinical nurse consultants in Queensland Health up until June 2013. Now there are three: two on the northern side of Brisbane and one in Toowoomba. Apparently (if the grapevine is correct) there are funded perinatal mental health positions in Townsville and Gold Coast too, it’s just that they’re both empty at the moment. That leaves two out of sixteen Queensland Hospital and Health Services currently with access to a perinatal mental health nurse.

This is just as I feared back in March 2013 (see: The National Perinatal Depression Initiative and a Canary in a Coal Mine?).

2% of Australia's population lives in the yellow area. Source:  @Amazing_Maps

2% of Australia’s population lives in the yellow area. Source: @Amazing_Maps

For the many health districts that have lost the specialist perinatal mental health nurse, the only alternative is to ask the woman to use phone support or see their GP instead.

But there are problems with both the phone support and the GP option.

Look, I have nothing but admiration for GPs – they’re at the frontline of primary health care and tend to be a very versatile bunch. But, let’s face it: most GPs are as busy as a one-armed Sydney taxi-driver with an ice-cream and an itch. It’s a big ask for the GP and the pregnant woman/new mum to make the time and head space available for ventilating, understanding and re-packaging strong emotions.

When I’m meeting with somebody who is experiencing symptoms of depression, anxiety or other mental health difficulties, it usually takes me an hour or so to feel that I have provided an outlet for the distress, and gained an understanding of what strategies and services we should use to support the person.

Maybe I have just have slow ears.

Maybe GPs can hear, understand and sensitively respond to those complex stories of loss, grief, trauma and unmet expectations quicker than I can.

Or maybe, just maybe, the families that have lost easy access to a specialist perinatal mental health nurse have lost easy access to support.

PANDAIn a cruel double-whammy, at the same time perinatal mental health nurse positions in Queensland were disappearing, the national perinatal mental health telephone support line was also becoming less accessible. Since midway through 2013 PANDA’s National Perinatal Depression Helpline has had to cut-back on available hours to 10:00am to 5:00pm Monday to Friday. This time last year it was 9:00am to 9:00pm Monday to Friday. Earlier this year the Million Mums in May campaign was hoping to get funding for PANDA to offer a 24 hour, 7 day-per-week service.

When perinatal mental health services on the ground are being cut in various places around the country, wouldn’t that be a good time to expand and promote the accessibility of the national helpline? Unfortunately, the opposite has occurred.

It is not all doom and gloom: if parents live within cooee of a St John of God Raphael Centre or near of the long-established state-run perinatal mental health services (usually in capital cities), access to support is still pretty good.

However, coverage is patchy: Australia’s “National” Perinatal Depression Initiative is anything but national. The “national” part is a myth.

Access to specialist perinatal mental health services in Australia is a postcode lottery and, as with all lotteries, there are a lot of losing tickets.

End

As always, your feedback and comments are welcome below.

As there have been no formal announcements/media releases about perinatal mental health services contracting, I have had to rely on first-hand knowledge and, to a lesser extent, hearsay via “the grapevine”.

If there any factual errors as at November 2013 please let me know. Naturally, i would like to make any necessary correction(s) as soon as practical.

Paul McNamara, 28th November 2013

Breast is best. Bottles are good enough.

Food Standards Australia New Zealand (FSANZ) call for submissions; should infant formula have a risk warning?

Food Standards Australia New Zealand (FSANZ) have released a consultation paper on the regulation of infant formula products in the Food Standards Code. You can access the complete documentation and instructions on submission via this link. Below is one section of consultation paper:

6.7 ‘Breast is best’ warning statement

Subclause 14(3) of Standard 2.9.1 requires the label on a package of infant formula product to contain the warning statement: ‘Breast milk is best for babies. Before you decide to use this product, consult your doctor or health worker for advice’. This statement is often referred to as the ‘breast is best’ statement. This requirement aligns with the recommendations in Article 4a of the WHO Code and Article 4.2 in both the New Zealand CoPMIF and the Australian MAIF agreement (see section 2.1.3). The WHO Code also recommends a statement advising consumers to seek advice from their healthcare professional prior to deciding to use an infant formula product.

Some stakeholders have suggested that the ‘breast is best’ warning statement be amended to a risk-based statement about the risks to infant health of not breastfeeding. These stakeholders state that such a statement would reflect a body of evidence showing that compared to formula feeding, breastfeeding is associated with lower incidence of infection and some chronic diseases, and evidence for improved cognitive development in the breastfed infant.

There should not be a risk-based statement about the risks to infant health of not breastfeeding.

First, please let me attempt to establish my credentials to comment. I have hospital-acquired certificates in both general nursing and mental health nursing, I hold a Bachelor of Nursing, a Master of Mental Health Nursing, and a Certificate in Infant Mental Health. I am a Fellow of the Australian College of Mental Health Nurses. I have been working with pregnant women and new mothers since July 2000, initially on a mental health consultation liaison team, since August 2010 I’ve been in a position that is exclusively to do with perinatal mental health. In these roles I have triaged, spoken-with and supported many hundreds of pregnant women and new mothers (we get about 300 referrals every year).

I don’t have expert knowledge in nutrition, I have never breastfed a baby, and I have no relationship with the Infant Nutrition Council (an industry group representing the manufacturers and marketers of infant formula in Australia and New Zealand).

What I have been privileged with is a front-row seat to pregnant women and new mothers discussing, experiencing, managing and recovering-from the two most prevalent mental health conditions: anxiety and depression. This privileged position has provided more insights into being a Mum than I, as a childless bloke, ever expected to have. On a future post I’ll discuss my position and present the biopsychosocial model of perinatal mood disorders in a bit more detail, but for now I’ll highlight just some of the information relevant to the suggestion that there should be a risk-based statement about not breastfeeding on infant formula packaging.

Austin M-P, Highet N and the Guidelines Expert Advisory Committee (2011) Clinical practice guidelines for depression and related disorders – anxiety, bipolar disorder and puerperal psychosis – in the perinatal period. A guideline for primary care health professionals. Melbourne: beyondblue: the national depression initiative.

The 2011 Australian perinatal mental health clinical practice guidelines state that, “While estimates vary, research suggests that depression, anxiety or both are experienced by at least one in ten women during pregnancy and one in six women in the year following birth.”

1 in 10 antenatally. 1 in 6 postpartum. It’s a big deal.

Not one of the women that I have seen in my clinical role has ever told me that bottle-feeding is the healthiest or easiest thing they can do for their baby. None. Zero. Nada. Zip.

In clinical practice, often women report that one of their biggest disappointments in motherhood has been attempting to breastfeed their baby but being unable to sustain it. Unmet expectations about an ideal pregnancy/birth/parenting experience are very common amongst women who experience anxiety or depression.

We (we the health system, that is) don’t help. As one new Mum said, “I get it: I’ve been to the classes, seen the posters, read the brochures. The message is loud and clear: GOOD MOTHERS BREASTFEED. That makes me a bad mother.”

There are other insights that have come from clinical practice;

  • Depression robs you of resilience and dampens your capacity for pain tolerance, so much so that a cracked nipple, mastitis, or baby that chomps can become intolerable.
  • Depression robs you of the skill of being assertive, so that you don’t feel empowered to have a balanced discussion and feel like you’re being heard if the clinician/health system is relentless in reinforcing the single message that breast is best.
  • Depression robs you of sleep and the luxury of feeling refreshed – if I can offload some of the demands on my time I will feel better; hopefully.
  • Depression makes you feel inadequate, ineffective and stupid – that’s why I can’t breastfeed, no matter how hard I try.
  • Depression and anxiety make me so negative, so prone to thinking the worst, that I just don’t feel safe breastfeeding. It doesn’t matter how good breastfeeding is, I feel as if spending time alone holding this baby is a risk that is not worth taking right now.
  • Depression robs you of joy; I don’t hate my baby, but I can’t stand being around him/her as much as I have been.
  • Depression robs you of power. I don’t have a voice. It is ridiculous that every time I bottle-feed the language and attitude of others makes me feel invalidated. I am making informed decisions about what works best for me/my family right now.

So, with this information in mind, how should we respond to suggestions to concentrate on the risks of not breastfeeding? Perhaps we need a tool to support our decision-making; here’s one I prepared earlier:

We (the health system, the community) need to be respectful of what happens within families – they’re a bit like icebergs sometimes, and we don’t always see what’s going-on below the surface. Obviously infant nutrition is important; infants also benefit from having parents who feel supported in making informed decisions, parents who don’t feel that they have to hide from the health system/their peers, and parents that have their emotional and mental health taken into consideration.

Breast is best, but when breast-feeding doesn’t work-out bottles (like parents) are good enough.

Paul McNamara, 29 September 2012