Background
Methods
Years of experience | Practice Type | Gender |
---|---|---|
< 5 years (n = 1) 5–10 years (n = 5) > 25 years (n = 4) | Urban (n = 7) Rural (n = 3) | Female (n = 5) Male (n = 5) |
1. Tell me about your experience of caring for women who experience PMHPsa in primary care? 2. What facilitates you to identify women who may be experiencing psychological distress? 3. What facilitates you to care for women who experience PMHPsa? 4. What referral options are available to you in your practice? 5. Based on your experiences how best can a training programme prepare future GPsb for their role in PMHc? |
Results
Identification of PMHPsa | • Encountering emotional complexity in general practice • Preconditions for disclosure • Approaches to screening and assessment |
Decision making around PMHb | • Contrasting referral options • It’s out of my comfort zone |
Preparation for a role in PMHb | • Luck of the draw GPc training • Continuous professional development opportunities |
Theme 1: Identification of PMHPs
Encountering emotional complexity in general practice
‘In a way it has to be looked at separately, women are more vulnerable, they respond differently to medication, things can fluctuate more rapidly, pregnancy itself can bring on a crisis, the delivery itself can bring on a crisis so there are a number of stages and a number of flash point’s' (P6).
‘Pressure in society, a lot of women are working full time they might have a few kids at home, they have big mortgages, their husband is working a lot of the time and lot of it is maybe triggered by exhaustion or they are just juggling a lot’ (P4).
‘I feel it’s all about a lot of anxiety but it’s packaged up as the child’s problem and it’s hard to disentangle that’ (P2).
‘Two sides of the one kind so when I talk of PND some of that would be more anxiety weighted than depressive symptoms’ (P1).
‘ The fact that she was pregnant didn’t seem to be anything of a deterrent in relation to possibly killing herself which is surprising, I think it was because she was as depressed as she was the world was a bad place and bringing a baby into a bad place was no achievement’ (P9).
‘Certainly, they would be a lot of fleeting suicidal thoughts and even a bit of suicidal ideation but I don’t think I have had anyone that had a formal plan’ (P9).
‘It’s more with time and personal experience of friends and self and what pregnancy means and what having children means I guess that you become more aware of it’ (P2).
Preconditions for disclosure
‘There are certain expectations of them within their ethnic group not to have a psychological issue’ (P7).
‘It’s a place where they can discuss these things and without necessarily being labelled or admitted or put on medication’ (P1).
‘The art of practice is having that gap or space or vacuum in the consultation where you leave silence … and if you are in listening mode…however it depends on how you say it…it depends on the day, depends on how you are feeling yourself, depends on how the practice is going’ (P5).
GPs were conscious that responding to women experiencing psychological distress may result in longer consultations and this may impact on the time available for other patients presenting with various complexities waiting to see their GP. However, participants also acknowledged that they would make this time for the woman if required.‘There is so much emotion around pregnancy and just having time to explore it can be difficult. Hugely time consuming and you can’t really afford as a working-class GP’ (P5).
‘Can I be honest with you sometimes I wonder if you really want to open this can of worms and it’s so much easier just to jolly along and check the BP, check the urine, check this and that and have them out the door and see the next patient’ (P5).
‘There are sometimes and I wouldn’t lie that I would be absolutely hoping that the answer was going to be no problem’ (P7).
Approaches to screening and assessment
‘If it’s obvious or if there is a history you would, if it’s volunteered you would and I will be perfectly honest now would you routinely ask about it, theoretically yes in practice maybe, maybe not’ (P5).
‘Antenatal care is very protocol driven therefore…it is very easy to ignore the psychological aspect’ (P5).
‘We would be quite good in fact in asking and it’s probably because of that little reminder on the screen’ (P4).
‘I would be guilty of focusing a lot on the child, that’s the big excitement in the room’ (P2).
‘A broad set of questions, you are not just looking at the person but you are looking at the complexities around their family, their environment, and their supports’ (P4).
‘Your antenna would be raised by people coming clean with you that there is something going on…a history…the usual kind of joy isn’t there, they’re, quiet’ (P5).
‘Anytime I met her she was pleasant and cheerful as she always was but obviously she could put it on for five or 10 minutes’ (P9).
‘Very long consultations and just trying to understand where they are coming from culturally can be difficult’ (P1).
‘Are we only seeing them when it reached boiling point because we [GPs] couldn’t get on top of the problem before that’ (P6).
‘I think they were actually stifled in being able to speak and talk and get it out because their partner was always sitting beside her’ (P6).
Theme 2: Decision making around PMH
Contrasting referral options
‘We have to send the form; the patient has to ring to say did you get the form and I am now confirming that I am going to go and then they get an appointment, for someone who is very distressed and you are asking them to jump through hoops’ (P9).
‘CBT is often indicated as first line treatment but really it’s not an option for a lot of women. They don’t have the means to access it, they don’t have the motivation to access online CBT so it really rules it out as an option’ (P3).
“We are lucky to have a good support' (P4).
‘Someone with PMH issues really does not belong in the general psychiatric outpatient clinic.’ (P9).
‘There should have been a link across the divide…it’s kind of now you’re in the hospital, now you’re out of hospital, now look after yourself and get back to where you were, it wasn’t as cold as that and it wasn’t intended like that, it’s just the way it happened’ (P9).
It’s out of my comfort zone
‘Dealing with psychotropic medications and pregnancy is out of my comfort zone’ (P10).
Treatment for women experiencing anxiety focused on providing reassurance, acknowledging the woman’s feelings and in some cases included pharmacological interventions. Participants were explicitly committed to working consensually with women and identified the importance of including women in treatment decisions:‘If they are not coming through with time as they might want to and sometimes doing all the right things and still there is this dead feeling’ (P8).
‘Any decision that would be made around medicine, any kind of management would be made in conjunction with the patient’ (P10).
‘A challenge sometimes in consultations of any kind where you are not prescribing and you are trying to explain that you are still giving them a good service’ (P1).
Theme 3: Preparation for a role in PMH
Luck of the draw GP training
‘It can be luck of the draw what you do get exposed to’ (P1).
‘It’s not something I came into medicine having a formula to talk about.’(P2).
Participants also identified the need to prepare trainee GPs for their role in responding to women and their families experiencing psychological distress across cultures in the community setting. Based on their experiences, participants felt that an obstetrics, gynaecology and psychiatric rotation should be compulsory for all trainee GPs which includes a community mental health placement. In addition to support practice and training, participants highlighted that if PMH guidelines were to be developed then it would be best to distil them into one or two pages (P5) with take home messages that are easily remembered (P2) because appointments are short and GPs need timely access to information. Strategies for facilitating PMH education included input from service users and specialist PMH psychiatrists in GP training programmes.‘Beyond just ticking boxes and try and provide holistic care for women which would include psychological assessment’ (P5).
Continuous professional development opportunities
‘You are kind of jack-of-all-trades, you are master of none’ (P5).
Participants suggested that CPD could be delivered in the format of an e-learning module on PMH and sessions on PMH at monthly meetings and in the annual GP conference.‘Those of us in the medical or allied professions can find it harder to admit that we are vulnerable at times’ (P8).