Mental health services fail to take full account of menopause, report finds

Mental health services do not take full account of the impact of the menopause, which can have serious consequences for women, patient safety investigators have found.

Women are frequently prescribed antidepressants when hormone replacement therapy (HRT) would more appropriate, they said.

A new report into the suicide of 56-year-old NHS manager Frances Wellburn found staff working in community mental health teams are not trained in this area, and menopause is not routinely considered as a contributing factor among women with low mood who need help.

The report noted that midlife is a point when mental health can deteriorate, leading to an increased risk of suicide.

Plus, women can be at increased risk of developing schizophrenia or other psychotic disorders at or around the menopause.

The Healthcare Safety Investigation Branch (HSIB) report further warned that too many people are taking their own lives while being deemed as at low or moderate risk of suicide.

Despite national guidance telling staff not to rank people as being at low, medium or high risk, too many NHS trusts still use the system, leaving people without the right care, investigators concluded.

The report detailed the case of Ms Wellburn, from York, who was in contact with local mental health services between 2019 and 2020.

In a foreword to the study, her sister described her as a “kind, thoughtful, resourceful, funny and caring” woman who “was loved and valued by her family, friends and the people she worked with”.

Ms Wellburn had a history of depression, which had been managed by her GP with medication, and had no contact with mental health services until September 2019 when she had suicidal thoughts and was admitted to hospital.

After being discharged, Ms Wellburn was in regular contact with community mental health services run by Tees, Esk and Wear Valleys NHS Foundation Trust.

However, there was then a long gap in care when the country went into a Covid lockdown, with no contact between Ms Wellburn and the trust between February and May 2020.

Ms Wellburn was admitted to hospital again in May after her mental health deteriorated and was then in contact with community teams until her death in August 2020. Doctors noted she had ongoing psychotic depression.

Investigators noted Ms Wellburn was prescribed an oestrogen hormone just before she died to help her with the menopause, but on the whole it was a “potentially unconsidered” factor among those treating her.

This is despite her sister telling the HSIB team that the impact of the menopause on Ms Wellburn was profound, both physically and mentally.

The report warned mental health services are not taking the full effects of the menopause into account when assessing women, and are not looking at its potential impact on more severe mental health symptoms.

It said experts in menopause care had suggested the symptoms of menopause and perimenopause “are often mistaken for depression, resulting in women being prescribed antidepressants rather than HRT”.

The report added: “Staff also told the investigation that current mental health assessments do not prompt practitioners to consider menopause as part of the holistic assessment of an individual.”

The study also found that, just a few days before she took her own life, Ms Wellburn had been deemed at low risk of suicide.

Investigators warned checklists are sometimes used for suicide risk assessment by NHS trusts even though the National Institute for Health and Care Excellence (Nice) says they should not be used.

The report said evidence suggests they do not accurately predict the risk of suicide 95% of the time “and that suicide deaths in the large ‘low-risk’ group are often missed”.

When it came to Ms Wellburn, while mental health staff realised her suicide risk could increase, her risk status was not reconsidered when more distressing symptoms came to light.

A care plan written in January 2020 was also not updated to reflect relapses in her mental health.

Furthermore, she met the threshold for rapid treatment under the Early Intervention in Psychosis (EIP) NHS programme, but instead it was decided to manage her within the community team.

This is despite trust managers telling the investigation that all patients who are given a “first episode of psychosis” diagnosis should be referred to the EIP.

The report added: “National experts in suicide and self-harm told the investigation that categorising patients as being at high, medium or low risk of suicide can lead to resources being focused on those assessed as high risk.”

Clinicians also told the investigation that “risk categorisation is often used as a justification for not providing care”.

The HSIB made a series of safety recommendations, including calling on Nice to evaluate the available research “relating to the risks associated with menopause on mental health and if appropriate, updates existing guidance”.

The Royal College of Psychiatrists should also form a working group to identify ways in which menopause can be considered during mental health assessments.

The HSIB noted that NHS England has written to all mental health trusts to highlight the importance of taking a person-centred approach and to “move away” from using tools to categorise people’s risk of suicide and self-harm.

In the report, her sister said Ms Wellburn had, in the last 10 months of her life, been “thrown into unknown territory as she experienced a first episode of psychosis”.

She added: “She became convinced that people close to her were trying to harm her and she lost all trust in everything that had previously given her life meaning.

“This frightening world became her reality and she lost the ability to see what was happening to her as an illness she could recover from.

“Even on her worst days my sister would shower, shop and keep her home clean.

“In her last email she inquired when she may be able to return to her ecological volunteering work and that day’s newspaper crossword was left completed.

“She was trying to live normally in a world where her delusions made every moment frightening.

“Our family have shared information about my sister’s experience in the hope that others like her can be better supported to stay safe and recover.”

A spokeswoman for Tees, Esk and Wear Valleys NHS Foundation Trust said it could not comment on the care of individual patients but added: “We fully support the findings and recommendations in the HSIB report into care delivery within community mental health teams.

“We will keep working closely with our partners in the wider health and social care system to make sure improvements are made.”