 The webinar tonight is Perinatal Mental Health, working better, working together. This webinar is presented by MHPN. The panel tonight are Dr. Morton Rowland, Professor Breanne Barnett, Professor Jeanette Nogrum, and Ms. Stacey Noble. Morton is a GP. Brianna is a psychiatrist. Jeanette is a psychologist, and Stacey is a consumer. I'm your facilitator, Markle Murray. This webinar is hosted by MHPN. It is a Commonwealth-funded project supporting the development of sustainable interdisciplinary collaboration in the local primary mental health sector across Australia. We currently support over 450 local interdisciplinary mental health networks. For more information, go to MHPN.org.au. The learning objectives tonight. At the end of this session, participants will be able to better recognize the early warning signs of perinatal mental health issues, better recognize the core principles of and pathways to effective treatment and management of perinatal mental health issues, better understand the merits, challenges, and opportunities in providing collaborative care to people experiencing perinatal mental health issues. To find out more about your discipline, CPD, recognition, please visit MHPN.org.au. The webinar is comprised of two parts. We will have a facilitated interdisciplinary panel discussion and a question and answer session. Feel it from the audience. So please feel free to put questions up in the message box on the right-hand side and we will keep an eye on those and present them to your panel during the evening. So the grand rules are that I will moderate the panel discussion and field questions from the audience. You can also submit questions for the panel by typing them in the message box. You can also minimize that message box if you're finding it distracting. Use any arrows. And if your specific questions are not addressed or if you want to continue the discussion, feel free to participate in a post-webinar online forum on MHPN online. If you require technical support during the evening, please call 1-800-733-416. Ensure that the sound is on and the volume turned up on your home computers for all participants. This does not apply to the panel. If you're experiencing problems with sound, dial that number. Dial that number, dial that number, dial that number. If you're having bandwidth issues, sound or internet lagging or dropping out, you can minimize this by clicking on the presenters' web cams and pressing the pause button under the video screen. You will still be able to hear the presenters when you pause their web cams. Webinar recording and PowerPoint slides will be posted on MHPN's website within 40 hours of the live activity. Again, for technical support, call 1-800-733-416. Now, we're going to hear from our consumer rep, Stacey Noble. Stacey will present her presentation now. Thank you, Stacey. Thanks, Michael. Hi, everyone, and thank you for joining myself and the other panel members this evening. I hope that you enjoy the session and get a lot out of it. Anti-natal depression, which is, as you're probably all aware, depression during the pregnancy period from conception through to birth and approximately 10% of pregnant women in Australia experience anti-natal depression. And postnatal depression, which is the period from birth following the birth of the baby, has almost 16% of women in Australia experiencing postnatal depression. And I actually fell into both of those categories with my second child, basically suffering anti-natal depression from conception through to postnatal depression, which lasted for approximately three months following the birth of my baby. Perinatal depression does not discriminate. It can, and it does affect women and their families across different cultures, age groups, and from different social, professional, and financial positions. Through my own experience and through my work as a counsellor with the postnatal depression association, I've seen the impact of Perinatal mental health on not only the affected woman, but her partner, other children in the family, family and friends. Quite often a woman will present by saying that she knows that there's something wrong, but she just can't work out what it is. She doesn't feel herself. Likewise, I often hear from the partners of these women that they can't do a thing right. Everything that they try to do is wrong and they really have no knowledge or they don't have the skills to be able to identify that there's actually a problem. What ends up happening is that they put it down to a lack of sleep and it's simply the demands of being a new mum. Quite often this can reach a crisis point and at this point it throws the whole family into turmoil. This is often the family's first point of contact in regards to the woman's decline in health, which quite possibly has been beginning to happen over a long period of time. And at this point, when it does reach a crisis point, there's quite often a need for the woman to be admitted as an inpatient. Many times the partner is struggling with his own transition to parenthood and he often feels quite low himself and then he finds himself in the unlikely position of having to support his wife emotionally and quite often the other children that may be in the family also. Michael. Thanks very much, Stacey. That was a lovely presentation and it's a really good introduction to our work tonight. Morton, I'd like you to start your presentation now if you may. Thanks, Michael. Welcome, everybody. It's great to be here. Morton, may I just ask you just to move the microphone a little bit closer? Thank you. Maybe speak up a little bit. Is that any better? That's much better. Thank you. Great. Thanks, everybody. It's great to be with you. This is a really important issue in mental health. As Stacey said, a very large percentage of women do suffer from perinatal depression and I think it's absolutely important for us to recognize that it actually does start from conception and then you've also got the postnatal perspective which in sort of traditional terms the postnatal depression was the one that most of us were taught about but it's actually much bigger than that. There is a spectrum of severity. Certainly in my years of general practice, I think most mothers will have a degree of anxiety and the pregnancy blues. Most are mild but like any of these problems there is a great spectrum of the severity to the very severe where people are thinking and contemplating of suicide and more particularly harming their children as well. And those are the sort of things that we're aiming to try and prevent obviously. One of the problems with perinatal and postnatal depression is that it often, in my experience, presents a little bit late. Often with the person very much feeling guilty, why is this happening to me? It all should be perfect. Well, life isn't always like that and it's important for us to recognize that we need to be very supportive. The approaches that are important are that we need to move people to discuss their problems and certainly listening empathetically, not sympathetically only, but listening and actually hearing what people are saying is really important. Open-ended questions which are important and in actual fact don't increase the time of your consultation markedly. If you look at the research, are really helpful in this case and you'll actually usually get more information with open-ended questions. I think it's really important in this situation that we remember that there's quite often some social isolation occurring here as well. Whether it's because mom and bubba are at home or whether the process, particularly with the first baby, not enough help around and it's important to remember that that's something that you can actually work on to help. I can't emphasize strongly enough that suicide can occur so it is not something to be taken lightly and acknowledging that the person isn't feeling good about themselves and they are having problems is really an important thing and not just to say they're there, it'll be okay. From the general practice perspective, some of the things that can be done by the GP apart from actually listening and recognizing that there's a problem and potentially helping that person to get to the other health professionals within our network to help them specifically but actually to help that person to goal set. Small cues and small wins each day are often really helpful and giving them some tasks that they've agreed are helpful is often a very important thing. Contracts with the patient, particularly in the more severe forms I always find is really helpful. If you're feeling like this, you can contact me or the crisis team in your state or contact your mother or it needs to be worked out with the patient but it's a safety net. I've also found that often almost more important than some of the things that are actually said are the non-verbal cues. How mom actually comes into the room, how they're dressed, how mom and baby are interacting and also how the family unit is acting with the partner or mother-in-law or mother, whoever's coming with mom and Bob. It's important to get that vibe if you can. And I think the other thing that I've learned over the years that's really important here is to remember that the mother and baby are a coupled group and sometimes some of the things that you would perhaps suggest to somebody who has a depression or an anxiety not associated with the perinatal and postnatal period. In other words, leave what's stressing you and go out and have a night with your partner having a dinner or something may not be actually possible with young babies and you have to be realistic in helping mom with your counseling. So I might leave it there and hand over to Mike again. Thank you very much, Morton. That was a very, very good presentation. We're now just going to move on to Breanne Barnett's presentation. She's requested that we, before we put her slides up, she just speaks to the audience first. Thank you, Breanne. Thank you very much and thank you Morton. I think we have to have you cloned immediately. Trevor, now let's just begin. I haven't had the opportunity yet to discuss her story with Stacey, so I'm taking up the position of the psychiatrist who is her first contact when she calls the hospital after Jake's arrival. And because I trust all those hundreds of you out there, implicitly I'm going to tell you how my mind works under these circumstances. But Stacey has contacted our hospital psychiatric mother baby unit. She's been a patient here before after the birth of Madison and she wants help again now. So we arrange for her husband to bring her and Jake to the hospital and leave Madison with Stacey's mother. Here is the story as I might have seen it at the time and I'm pondering about it. Stacey is a 36 year old woman at this stage. She's been married for eight years to Wayne and they have two children, a girl aged three or four, Madison, and a baby boy aged five weeks, Jake. The latter was a planned pregnancy but she felt unwell throughout and his being a boy was a problem. He slept poorly, had severe reflux and has a strong personality. Though I think this is a distressed baby but I'm glad to say he hasn't given up hope of getting the help he needs. Assisted, I hope, by reading the notes from her previous admission, I now want to know from both of them what their current difficulties are. Despite help from Wayne and her mother, Stacey is obviously going under and prolonged sleeplessness is certainly a major health hazard. I need exact details about the insomnia and I need to know about her mood over the course of the day and her anxiety and panic attacks. What is she worried about? Does she have any intrusive thoughts about harm to herself, her partner or the baby? And I want to know about her weight and appetite and so on. Also, it is important to discover whether there are any signs of loss of touch with reality. In other words, is this a psychotic illness? I also want to know about the pregnancy and the delivery and how her health has been physically since then. Her pride for help alone is enough to make me think I'd like her to be in hospital for observation at least over the next short time. So admission of mother and baby are arranged and Wayne will visit daily with medicine as appropriate and the staff are instructed to ensure that mother and baby are fed and tucked into bed with sedation for Stacey if required. Over the following days, I need a lot more information from Stacey and I needed some stage to talk in depth to Wayne and to her mother because they may also need help. For example, is Wayne managing or is he also depressed and anxious? Did his own mother perhaps have similar problems and he found it hard to deal with them? Stacey's mother certainly had similar problems and I need to give her a chance to talk about them. I will also need to make sure little Madison is supported as I do not want in another 20 years to find another anxious, potentially depressed woman in this family. This comprehensive plan will require collaboration and no one person can provide all that's required to help Stacey and her family. I will be pulling in many teeth members. Now could we have the first slide? Thank you. So some of the missing information, what and why, and there are lots and lots of questions that I will need to have answered before I can possibly put together a plan to help Stacey and the family. The second slide, the previous hospital admission, what was the diagnosis? And it followed an extended period of sleep deprivation. What exactly did that involve and what else happened over that period of time? Was she repeatedly perhaps at her GP worried about the baby's health or something else of this nature? What was the diagnosis? Postnatal depression is a pretty useless diagnosis. It can cover such a lot of different things. What was the treatment? I suppose we have to say it was helpful because Stacey has applied to the same hospital again. But what's the diagnosis adequate and what's the treatment adequate is what I'm wondering. And of course, where the couple warned to obtain help early in her next pregnancy because an illness serious enough to have the mother in hospital is likely to recur in the next pregnancy. And I would imagine that someone tried to tell them about this and how they could deal with that. Next slide. After discharge, what was offered to Stacey and the family to enhance their resilience? This is a woman who's been anxious and depressed most of her life. We could, if we intervene now, help her to become more resilient in the future. We can offer her ongoing therapy for herself. We can offer couple therapy. We can offer mother-infant relationship work. And all of this, I would expect our mental health nurses or psychologists to take on. I want to know if medication and other treatments were offered and were they acceptable to Stacey? What side effects did she have and what did she find useful? Next slide. Other things that I'm thinking about at this time before I've even seen Stacey is how is it that she wasn't identified and helped during either pregnancy? Given that in the public system at least, we have mandatory sets of psychosocial questions and depression and anxiety screening and so on, all of which goes on anti-natally. How is it that Stacey slipped through the net? How is it that she doesn't seem to be able to tell health professionals when she's not well? Has she always had to solve her own problems? Is it that she needs approval from people and she tries to be a perfectionist and therefore when things are going wrong, she feels bad about herself and feels it's all her fault? But this is a problem that many women have. And I'm wondering the next slide, please. What else is going on here? When Stacey herself was born, was her mother depressed and anxious? Was her mother very ill when her sister was born? Because Stacey's been anxious, she says, since around the age of four, which I would have thought was around the time her sister was arriving. And I need details of what happened in adolescence when she got depressed. And I wonder why her father and sister are not mentioned for any grandparent. She notes that Jake has a very strong personality and I'm wondering whether her sister is a bit like this or perhaps her father. And she says, and this is clearly something that's very important for her, someone's hungry and I'm wondering who's hungry, hungry for what and what do they want from whom? There clearly are a lot of bits of information that I will need to be able to put together a package that will help Stacey and her family. Thank you very much, Brian. That was a very good presentation. And you certainly raised some questions which many of us would have thought about, but some which we wouldn't have. Thank you very much. That was very nice. Now we'll hear from Jeanette Milgram, our psychologist. Thank you very much. And I'm really pleased to be here and with an audience out there and also with my colleagues, Brian and Morton. It's great to be talking in this multi-disciplinary way. And Stacey, thank you so much for sharing your story. I'm a clinical psychologist. I was asked to react to your story with some thoughts from a psychology perspective. And so what I've done is covering some thoughts that come both from my knowledge in the field from my decades of research in the area as well as from my clinical work and how I would be thinking about what's happened to you, Stacey. Of course, as Brian says, it's a very short snippet and there would be many more questions. I too would like to know, but I've done my best with information I have. So as I started reading your story, Stacey, I started thinking, well, it might be helpful to think about what led to disease and depression. And we find that a very useful way of thinking about what triggers depression is a bi-psychosocial model. And our best understanding is that a combination of biological, psychological, social and historical factors combine in an individual often to tip the balance into postnatal depression. And we can understand from Tracy's brief story that there are some vulnerabilities that have been identified as very important predisposing factors. So Stacey talks about her mother's history of anxiety and her own personal history of depression and anxiety. And the big five of risk factors, and it doesn't mean that that's the only one, are previous history of depression. And particularly also, I'm wondering whether there were any hints in pregnancy with Madison even because anti-natal depression and anxiety can predispose women. So when I encourage people to start looking in pregnancy, not just wait till the birth, major life events, lack of support or low partner support, that didn't seem to be an issue in Stacey's story. And previous depression histories, the other of the big five. So there were two of the big five there in the snippet. And so Stacey, what was quite striking was that Stacey did not seem to have received treatment from a psychologist for previous episodes of depression that she had had or anxiety since the age of four, which might have helped to develop coping skills and perhaps deal in future when she noticed these symptoms recurring. I could have the next slide, thanks. Like Brianne, I was quite interested that Stacey did not disclose her anxiety and panic attack after the birth of Madison. But we know that's not at all unusual. That is a very, very common story. And so professionals such as yourselves working in the field need to be very aware of reasons behind this to best support and encourage women in the perinagal period. They imagine more than when women come to your general practice, they may present with other things rather than directly with how they're feeling. And we know that there are many reasons why women find it difficult to disclose, living up to other people's expectations to your stigma and many others. However, when we're talking about risk factors and difficulties, we also, when we work with individuals, take a good look at one of the strengths and protective factors. And from the story, I can see that Stacey has obviously achieved a lot. She's a school teacher. She's managed to be productive. She's got a confidence even when she was having difficulties with Madison and her strategies. She has thought help. It obviously was faster after Jake, but that's a terrific strength and has a supportive partner. But despite this, it wasn't until Madison was five months that Stacey felt she needed an admission. And so I guess that we're now working very much with our multidisciplinary colleagues who might see pregnant and postnatal women before they come to a psychologist to engage in screening exercises because many women do not make it very obvious that they're depressed. They may present looking from the outside okay. And so I guess I'm asking the question, where along the line and which professionals did Stacey come into contact with? With screening for depression and anxiety could have helped earlier. And there we usually turn to maternal and child health nurses and GPs who can play such an important role. And I have the next slide, thanks. So who can screen for depression? Anybody can and I guess that we're also moving not just from looking at professionals who come into contact with women around in the perinatal period, but families who become aware of what the symptoms of depression are. And many of you probably heard of the Edinburgh Postnatal Depression Scale which is being used as a very user friendly almost icebreaker 10 question which raises the profile of distress when it's there. And in that context, anyone who gets a hint that there are symptoms of depression and anxiety needs to also consider what else should I be asking? What else do I need to understand about this woman who is telling me that she has some signs of distress? So they're much broader assessment areas that one needs to cover obviously to get the full perspective of Stacey's story as Brian so elegantly covered. And the Beyond Blue Clinical Practice Guidelines provides a very nice guideline on that. And there's also a very nice online training program that we've been involved with in developing on the website for learning how to screen and recognize signs of depression and anxiety and anxiety right on the Beyond Blue website. But I guess that I would expect all professionals working in this area to be very familiar with the symptoms of depression such as DSM4 criteria. So that's right off as Brian was saying, I'd like to know more about how she's been feeling, whether she's had depressed mood, loss of interest, weight appetite, sleep, psychomotor, fatigue, worthless feelings of worthlessness, guilt, indecision and importantly, we always, as Morton said, want to be very aware of the possibility of suicidal ideation and to immediately engage in a risk assessment process if that seems to be the case. Can I have the next slide, thanks? So, even Stacey's experience with Madison, like Brian, I wondered about what what psycho prevented support she was given in her second pregnancy. Was anyone alerted to the fact that she had had a difficult period with Madison and therefore with Jake, she was likely to have some difficulty? Was Stacey's ambivalence over giving birth to a board related to her self-efficacy and anxiety? I'm starting to raise questions that might be relevant to some of the directions that we might engage in if we decide to go down the line of psychological treatment and like Brian, I would have liked to have seen that the initial efforts and the good gains that Stacey no doubt had by being in the mother-baby unit were followed by post-discharge help and Stacey may have found psychological treatment very helpful both to deal with historical problems and also her current issues. So, it would break that Stacey acted quickly in seeking help with Jake and sought another mother-baby unit admission, but what would help her after discharge? And if I could have my last slide. Well, I guess that's what comes to my mind is that the pressure symptoms and underlying anxiety have been long standing for Stacey. And so, that would be a very strong focus, not only to deal with the current episodes, but to look forward and to see how one could help to develop coping skills by perhaps cognitive behavioral strategies if she was wanting to work in that way so that focus psychological strategies are very important and there certainly is a lot of evidence that CBT, cognitive behavioral therapy and interpersonal psychotherapy are very effective for new mothers. I think that as I do in my own work and in my clinic it needs to be have a tailored to new months like you can't have a mother doing relaxation for 20 minutes, three times a day when you've got a toddler and a baby. And so, for instance, what we do is we teach relaxation on the run. How to sort of learn ways that fit in with being a new mother. As Brian said, we need to mobilize the family and partner support that is just so important as well as giving the partner support as Stacey and Brian said that it's a family issue and everybody gets affected. Mother baby issues may also arise. It doesn't with all women, but when it does, it's very distressing for both mothers and babies where the depression has gotten in the road of a joyful interaction. And what's so rewarding is that intervention results in the ability to reconnect and reestablish relationships when depression has occurred, but these need to be targeted in their own right. So these are just some thoughts about where to go and what I thought when I read your story, Stacey. Thank you very much. Thank you very much, Shannette. That was a very, very interesting presentation and it's raised many issues and many of our participants throughout Australia have commented before and during your presentation on many of those same points. But as we're all consumer orientated, I think we should hear again from Stacey. Stacey, would you be willing to add in some perspectives on what you've heard tonight and your experiences as well during your pregnancy and postnatally? Yeah, absolutely, Michael. I just wish that Jeanette and Brian had have been around for me when I was experiencing this because what you two ladies have mentioned this evening would have made such an incredible difference to my whole experience and even just hearing it without being actively involved in your treatment and care. I know that I would have benefited hugely. So to wrap up and basically to look at the care that I received in comparison to the treatments that you ladies would have provided was that I basically had no screening from my GP. My initial consultation with my GP was to confirm my pregnancy and my next consultation with anyone at all was some 12 to 14 weeks later when I had my first obstetrician appointment and it was during this period that I was at my absolute worst, suffering nausea, completely isolating myself and basically reaching crisis point where I was contemplating termination and I was also considering what I could do to myself as a way of releasing myself from this situation. I think that had I been screened at that initial GP appointment where there were in fact details and a past history of my experience of being in a mother and baby unit with Madison and also a history of my mental health but this question was never asked. So that period for me was particularly difficult and by the time I actually had my obstetrician appointment I was probably through the worst but and being at that point in time the fact that I had improved slightly meant that that prevented me from them saying anything because I felt that the worst was over despite going on to have a very unwell and extremely emotionally draining remainder of the pregnancy. You know, as I said, having been assessed I think, I really think it should be routine that with any woman who presents to her GP to confirm a pregnancy, to check whether she's pregnant I think that there should be a routine mental health history completed regardless of whether the GP feels that, you know, this might upset the woman or is intrusive. I really think that this intervention and this question needs to be asked very early on in the piece. I truly believe that if I had had intervention at that point as the ladies have said that I would have been able to get through that pregnancy and I think that when my baby was born I would have had a much more beautiful experience and perhaps not experienced the postnatal depression that I did. I think for me when I did reach the point of entering the mother and baby unit I was extremely lucky that I responded well to the medication as you probably have all read from my story. I was actually discharged from the mother and baby unit in perhaps a worse position than I was when I was admitted. My Edinburgh postnatal depression score was in fact higher upon discharge than it was upon admission and so I actually left the hospital in quite an anxious state. I was just fortunate enough that I managed to bump into my psychiatrist who was in fact a registrar at the time so was very dedicated and very interested in what was going on for me and she responded in the only way that she could because my bed had already been filled. She increased my medication and she ordered my husband to take care of his leave and she presented that option to him as basically being non-negotiable. So at that point on that particular day she really made a big difference. I went home, I had my husband with me for that week which got me through possibly the tender stage where I was still waiting for that medication to kick in and I think by the time he'd returned to work within perhaps a week or so the medication had reached its full potential and there really was a 360-degree turnaround and I think that medication actually treated the anxiety and the depression that I in fact lived with my whole life. So I think, you know, in hindsight and in looking back on my situation it was extremely fortunate that I did respond so well to the medication because the follow-up care and the treatment and the options that were provided for me were really non-existent and I think the important thing to note too is that when a mum is extremely unwell it was impossible for me to access any resources or any information that I was provided with. I literally needed the hospital or medical professionals to make those links for me, to make the phone calls for me, to basically to do everything I wasn't capable of being given information and being able to respond to that. So I look at myself as being one of the lucky ones but I really think that there was a huge gap in the care that I received and the possible outcome and the links that my illness could have gone on for. So I always have, you know, fully supported the absolute need for early intervention. That hits crucial. Thank you. Thank you, Stacey. That was, as somebody has commented, that was a very courageous presentation and we, as practitioners, we very much appreciate your input tonight. Thank you. Morton, I believe you have a question for Jeanette around collaboration between GPs and psychologists. Yeah, thanks, Michael. One of the things that I'd like to talk with Jeanette about is what sort of psychological approaches would be of benefit and how can we better collaborate with our psychology and mental health nurse colleagues to help in this situation? Thanks, Morton. I think it's a great question and the very question itself, sort of that openness of thinking, well, how can we all, you know, use the resources that exist in the community, GPs, nurses, psychologists, psychiatrists and bring them together? And I think talking to each other is terribly important. You know, I often experience women who go to the Immuterum Child Health Nurse and their GP who aren't, and they're psychologists and the three aren't necessarily talking to each other. So collaborative keeping each other in the loop, working out collaborative management plans. I think that the GP plays a very important role in being there in a sense of the anchor of the base and being able to do some very good support of strategy and depending on their skill, more than that. And it's a question of using the other professionals as you need, like, oh, I wonder if I need more of an assessment on this or I think that it might be helpful to say, for example, to get some very focused help with behavioral techniques for her anxiety. So it's about making suggestions and keeping the lines of communication open and vice versa. Psychologists really need to give you very brief but constant feedback to their, to general practitioners and nurses so that everyone's in the loop and we are working together to support a woman, Stacey. Thank you very much, Janessa Morton. Stacey, I believe you had a question for Brian around medications. Yes, Brian, I was just wondering more so, I think from my experience, I had attempted to take medication previously but I always had side effects, headaches, you know, all of those sorts of things. So I gave up on medication and it wasn't until I was in the mother and baby unit that I found one that suited me. So I was wondering and through my work with Panda, I also find women that sort of have to change medications because they're either not working or they don't agree with them. So my question is what happens when a woman tries a number of medications or treatments with no success? Is there always an alternative or at some point, is there a time when a woman has to find alternative treatment other than medication? What medication were you on, Stacey? Initially, look, I tried a number. I tried Zoloft, I tried Cypramil, I tried a number of different ones. Arapax, I tried all of them and they all presented with the same side effects. So I dreadful head pressure and that sort of thing. So I just gave up on them because I would give them long enough to work, you know, a good two, three weeks but the side effects were really quite unbearable. And I'm currently on Lexapro, which is the one that I've been on since I had Jake and I've had no problems on that one. There is a newer version of one of the ones you had before, all of which are in the same group but in fact, just because one of them doesn't suit someone, doesn't mean one can't try another one. There are other medications that I might have tried but we need to be thinking here that your diagnosis is not just postnatal depression here, we've got an anxiety disorder so we definitely need something for the anxiety. Most antidepressants are also quite good for anxiety but a lot of women are a little intolerant of that particular group of medications which are called SSRI, selective serotonin reuptake inhibitors because they do provide nausea and headache and so on, especially to begin with and I think often people are not careful enough to start on a very small dose and let the woman get a little bit used to the medication before you increase to the standard dose. Now medication by itself is never enough, that's one of my hobby horses, so that if you offer or insist on medication before the woman trusts you and you have a therapeutic alliance with her, she's going to get side effects and it isn't going to work. I think it's very important to build up the relationship, use medication appropriately if you have to and to remember all the other things you need to put in place. It's not been my experience that people need several iterations of medication. Usually the first one seems to be all right so to some extent I think it's to do with the therapeutic alliance and what the woman is willing to try and I'm very conservative about medication if I can manage without it and just doing psychotherapy then that's what we do. Thank you. Morton, I get the feeling that you want to say something there. Yeah, look I would just like to echo what Brian was just saying there. I think the therapeutic relationship and the relationship between the patient and their doctor is really critical in these areas particularly around mental health. I certainly also had the same sort of experiences in that when you do know the patient well and there is a trust relationship, things certainly go much more smoothly and more I think comfortably for the patient than where you are looking at a more episodic emergency type relationship which can sometimes be very difficult both for the clinician and also for the patient to get the most out of that relationship. So I think it's important for us as clinicians and GPs particularly because we tend to have more of a long-term relationship with our patients to make sure that we do maintain that relationship through thick and thin. That is interesting actually. May I just jump in there? Sure. I'd just like to ask Brian a question. Some of our attendees have touched on this in their questions. It seems to me as if the person who's got the least time with Stacey has got the most contact with her as the GP. Brian, can you think of any way that we can all collaborate better in the care of Stacey? Well I suppose this is one of the things that is again a particular hobby horse of mine. I spend my life trying to get people to collaborate but one of the ways that I do it is by making sure that all the people we see have a GP referral and that I'm in close touch with the GP and it is important to remember as Morton said that long after they've finished seeing me patients will be going back to their general practitioner. A problem we have in some of the areas where I work is that unlike in Britain people don't have to have a GP allocated and stick with that person and they can often hop from GP to GP which means that nobody has the previous history of this person. I don't see that you can do a great deal in five to ten minutes unless you have got that history already at your fingertips and one of the advantages of general practice is that presumably you already know the patient and the family and if you don't then you saved me behind the eight ball but I don't see why in fact if a woman is pregnant the nurse in the practice can't ask her some questions and the way the midwife would do at the hospital and give her an Edinburgh perinatal depression scale to complete. Some of that can be done outside the GP's time and the GP and the nurse can have a look at the results if they wish. It occurred to me listening to Stacey that she'd possibly been a private patient. Yes, that's correct. Yes, and you see that is a hazard at the moment and we're only just beginning to get the system of doing the psychosocial assessment and depression into the private system. There have been rather far behind in this the public system it's happening in most places the private system it's only just beginning. Yes, there is. Mostly with a midwife but others don't. Yes, there is that peculiar dysfunction now, isn't it? Yes, but we are making a little progress. Good. Now Jeanette, I believe you had a question from Morton around about depression and postnatal depression tools for use in practice. Yes, and if I can just lead off from the discussion right now I think that another quite helpful tool that we sometimes when we refer to a woman who from a GP and then we assess her then we will create a little card that we call collaborative networking amongst health professionals where we write down the names of all the professionals and we ask her to bring that along to each professional appointment so everyone knows who everybody else is and there's some communication happening. What I was going to ask you Morton is in terms of GP practice what are the ways in which you find the most helpful way of identifying women with depression and I'm always curious about what is the best support that we can offer to GPs in the identification and screening of women because there are GPs like yourself who are very well versed in this and there are others who may not have as much experience. So I was just wondering about your thoughts about how you think GP's best go about identifying it as a routine exercise. Sure, thanks for the question. I think general practice has lots of challenges shall we say and one is having the right tools at our fingertips at the right times. One of the problems is that certainly making sure that we're teaching our GP registrars about using proper screening tools is really important. I freely admit that when I was trained no such thing existed for general practice and it was learning how to do it on the job. That's a little different now and we're certainly more aware of using various scales and the K10 is probably the most commonly used in general practice but not specific for perinatal and certainly many of us are also using the Edinburgh scale who have interests in and seeing lots of women with the perinatal period. The computerized technology that we now have allows us to have some drop-down menus and things like that which has made a big difference and then it's about educating GPs making sure that we're not staying back 10 years ago just as it is. Things change and we have to change with it. I think critically though it's important to make sure that you listen to your patient well and you can certainly do that in a 10 minute and acknowledge that if you have concerns bringing that patient back sooner rather than later certainly not leaving them hanging for 12 weeks until the obstetrician sees them is really important and certainly with most of my young mums and young ladies who are pregnant I make the point that I'm very happy to see them sooner rather than later and my girls in my practice know that they can get in at a priority if they so demand it. So it's about setting up your practice as well as having the right screening tools. Thank you very much, Jeanette Morton. Stacey I believe and you had a question for Jeanette about accessing or benefiting from psychological therapies when you feel that you may be too unwell to do so. Yes, which leads me back to my point when I was in fact admitted to the mother and baby unit in such a severe state that I really felt that I was incapable of engaging in any treatment because I was that unwell. So that was where my question came from that can psychological treatment be beneficial if that biological or that chemical imbalance is too far out of control? Thanks Stacey. There's a lot of questions packed in there about both the severity of how you're feeling and also what is causing it. But I think that we have psychologists who work both in mother-baby units and then on discharge and the sort of support that psychologists could give a mum would be different when she's in her most unwell state and it might be much more as Morton and Brian were talking about that forming support or relationship, engaging in a trusting relationship to try to help with feelings of fear and safety and not actually starting the very focused work that's only perhaps possible once you're feeling a little more in control. Because as I said before we understand and as Brian said that it's not just a biological event. There's things psychologically happening in your family and relationships and how you feel. The best approach is to always consider help at every level. So I think the short answer is that you wouldn't attempt an intensive psychological treatment of trying to teach someone cognitive strategies of how to challenge intrusive thoughts when you're very unwell but you could very much help with some supportive behavioural strategies and forming a relationship so that you would have had a good experience whilst in the inpatient unit of feeling supported and cared for and contained with the particular issues you're facing at that time. Thanks, Jeanette. Brian, would you like to comment on that? Well, I'm not sure that there's a lot I can add actually to what's been said. I think that if you're in the hospital you're sick enough probably to need medication and that the medication should be sorted out and the patient should have adequate rest before any other work is expected of her. And if in fact she hasn't been well enough to engage in any psychological treatments before she's discharged then I wonder why she's being discharged. I would like her to be attached to various services before she leaves the hospital. I want to know that all this has been set up for her and her family either she returns as an outpatient to our service or we've made contact with other services and linked her in and she should certainly not be going home feeling as bad as or even worse than when she was admitted to the hospital. We seem to, and this has come through from some of our attendees, we seem to have left out some important people in the care of antinatal and postnatal patients of obstetricians mid-wide. Would anybody like to comment on their role? I have already commented to some extent in that some obstetricians are very keen on psychosocial assessments and depression screening being done. They don't necessarily do it themselves although some of them do but they expect that when the woman books at the hospital she will be asked these questions and they will be told the result and they will make sure that referrals are made for support for this woman. Another of my mantras is that a well-trained midwife and similarly postnatally a child and family health nurse a well-trained midwife is an intervention. If the woman sees this midwife perhaps on several occasions trusts her and the midwife takes an interest in her that makes a huge change to the women's anxiety level and her confidence in what that midwife might suggest. And if the midwife says, look you had a bad time last time why don't we link you in with a psychiatrist now so that we have a plan that way we can avoid you getting sick again. By this stage hopefully the woman trusts the midwife well enough to say okay I'll see someone that you can recommend my GP. Thank you. Martin would you like to add anything to that? Yeah look I think Grant's absolutely right I think there are just as there are GPs with different interests within within general practice there are also obstetricians with different interests in their practice and I certainly know several obstetricians who if I have a lady who I am concerned about in terms of her mental health history or her mental health at the time I will be recommending who have really good abilities to talk and collaborate with other mental health professionals. There are several just as I'm sure there are GPs who Stacey probably wouldn't recommend you know I think it's important to if you're not getting the response that you want from your health professional to look for another opinion or sort of make that known to your professional so that some of those issues can be worked through. Thanks Morton. Just Jeanette may I just ask you a question many of our practitioners are from rural areas and regional areas where they may not have access to the luxury of a mother and baby unit. Do you have any take home messages for the practitioners attending tonight just sort of you know quick five or a quick ten or a quick six. Jeanette? Yes I could just add something in the previous question because we haven't talked enough about nurses. I think nurses are very privileged in Australia to have a very good maternal and child health nurse as we call them Victoria or similar in other states system and midwives also play a pivotal role and we certainly have found that not only are they important in contact with new mothers but we've trained nurses and found nurses to be able to provide poor mild to moderate personnel depression very effective care. So you know I think that there's another resource there in our primary care network and when we talk about the problems of rural areas of the extent if we've got a national perinatal depression initiative that wants to try and up the screening so all women are screened we need to find ways of reaching women without many resources. So that's your question about the rural and around about way I think that we have to use our primary care professionals that exist and train them up but also be aware of when it gets beyond their level of expertise we would refer to one of their colleagues so if there's a good knowledge of that I think we can use a broader range of professionals and we're certainly exploring other mediums for intervention as well as for example we are developing an online training program supported by telephone counseling. Good that's good and do you have any comments at all on that Stacey what you're hearing over the last five or ten minutes any comments? Yeah look I think particularly for rural women in the area that I work in which is in fact telephone counseling helpline what we're commonly presented with the fact that there appears to be a lack of resources or these women are unable to link in with appropriate resources so for these women we actually find that online support services are extremely useful and with a service such as Panda2 we're hopefully able to provide a link to these women with a database that we can provide so look I think overall basically what I'm hearing here is that there is what I would consider to be a limited network of professionals in this area when you look at the number of women that become pregnant versus the number of professionals dealing specifically or with a specific interest in perinatal depression you can certainly see where the gap is so the obvious question that I pose is how do women access the people such as Brian and such as Jeanette when people with such expertise and such a specific interest in this area are limited thank you now we're just unfortunately time always runs by too quickly when you're engaged Brian we allowed you not to ask any questions in this segment but I'm going to ask you to ask one of your fellow panelists one question that occurred to you during this webinar if you were allowed to make one change to our health system to assist women with perinatal depression and I insist perinatal anxiety what would that change be because from my point of view we no sooner train up lots of midwives who are excellent lots of child and family health nurses who are excellent and the numbers are cut back and they can't do all the things they're mandated to do and it seems to me that if these professionals are well trained they're a wonderful resource we need more of them Morton would you like to address that yeah look I mean I think that certainly from a general practice perspective I think it's about education reminding GPs of the importance of this area as we've said before this is only part of what a GP does so it's important to keep that in the front of their mind and that's probably the main thing that I'd suggest education and keeping them informed Jeanette I can give you 38 seconds to speak no I'd agree with everything that's been and I'd also like to say that families and supportive communities and social networks we haven't talked a lot about that but that's very very important and has been shown to reduce severity and reduce the time of suffering so I'd say yes let's train up as many people as we can and be creative in developing and researching a broader range of services that can be done more remotely and never forget that a group of women getting together is a wonderful resource excellent I'm glad somebody said that I think women getting together and I think people talking at their problems in their own settings is very useful therapy unfortunately we are coming to the end of this webinar nearly a thousand people apply to participate in the webinar and we have had 250 people log in I'd like to thank all of the attendees for logging in and I trust that you will continue to access the MHPN website for further conversation around this topic we didn't get a chance to talk about all of the therapists who can be engaged in this area particularly with mental health nurses and we probably didn't cover sufficiently with maternal and child nurses and I apologize for that I am a GP and I have learned a lot tonight I think it's a very important area it's probably our only biological function is to reproduce so we need to make sure that those who do the most work the mothers all our mothers and all our daughters get good care during this time and I would hope that this webinar will raise the issues that we've discussed tonight more broadly throughout Australia and throughout all the marvelous therapists who have attended tonight I feel very humbled Stacey having listened to your story and I cannot tell you how much we all appreciate how bravely you articulated that I'm going to leave the last word to you I normally have the last word Stacey because you can have the last word tonight I think again I push for early intervention and the opportunity to be given for women to be given permission to say that something's not right and to be listened to and heard I think there still is a stigma about women's mental health and particularly when it's such an experience that is anticipated and projected as meant to be a wonderful joyous time so I think that perhaps by just being given permission to say everything's not as good as what it should be I think would allow for that early intervention and so much work could be done to prevent the experience that I went through and on behalf of everybody I would like to thank all of our panelists I'd like to thank Brian and Morton and Jeanette and last but certainly not least Stacey for her articulation tonight I wish you all well and I trust that we will see you all again at some stage on one of our webinars from MHPN thank you all have a safe trip home good night everybody thank you