The Dr Louise Newson Podcast - 255 - Mental health issues and hormones: introducing Newson Health’s psychiatrist Dr Louisa James

Episode Date: May 7, 2024

This week on the podcast Dr Louise is joined by a new colleague, Dr Louisa James, a psychiatrist who has recently joined the team at Newson Health. Dr Louisa’s personal experience of the menopause prompted her to learn more about the impact of hormones, and incorporate her knowledge in her role as an NHS consultant psychiatrist in a home treatment service. Here she discusses the importance, and power, of asking patients about their hormones during a psychiatric appointment. Finally, Dr Louisa shares her tips for thinking about your hormones alongside your mental health: 1.Consider whether this feels different to any previous episodes of depression you may have experienced or if your symptoms are fluctuating. Some women have suicidal thoughts or are depressed at certain times of the month. Track your symptoms and look at the fluctuations. Your history can affect your menopause. If you’ve had an episode of postnatal depression or PMDD, then you're more likely to experience mental health difficulties in the perimenopause. How do you feel about your life? Lack of joy rather than a sadness, the emotional lability, is often greater with a hormonal mental health problem whereas irritability, rage and impulsiveness can be greater with mental health problems. Dr Louisa James is now offering consultations to existing Newson Health patients. Click here for details.    

Hello, I'm Dr Louise Newsom. I'm a GP and menopause specialist and I'm also the founder of the Newsom Health Menopause and Wellbeing Centre here in Stratford-Pon-Avon. I'm also the founder of the free balance app. Each week on my podcast, join me and my special guests where we discuss all things perimenopause and menopause. We talk about the latest research,

bust myths on menopause symptoms and treatments, and often share moving and always inspirational personal stories. This podcast is brought to you by the News and Health Group, which has clinics across the UK dedicated to providing individualised perimenopause and menopause care for all women. As many of you might know who's listened to my podcast before, the most important area of menopause and hormones in my mind is about mental health and hormones,

which I hadn't realized many years ago when I started to learn a little bit about the menopause. It was all about hot flushes, night sweats, vaginal dryness. And that's still what many people perceive the menopause is when we think about symptoms. But actually seeing the thousands of women and listening to thousands of stories over the last seven, eight years or so that I have, is the mental health component that worries me the most because it's neglected the most. And the more I do, the more I see. And actually, the more I see how mental health. improves with hormones, the more worried I am that we're not doing enough. So I have quite a chaotic

life. I'm always reaching out to people. I'm always sending emails far too late at night saying, are you interested? What do you think? Is this something that you're seeing in your clinical practice? So today I've got with me a consultant psychiatrist, Dr. Louisa James, who answered to one of my crazy emails, probably late at night or over the weekend, and we spoke. And I'm now really delighted because she's been working very closely with us behind the scenes, and now she's actually working with us in our clinic and then use and health clinic to really help work with people who have mental health issues for all sorts of reasons related to their hormones.

So thanks Louisa for joining me today. Pleasure. Thank you for asking me to join you. So you're a fairly local, our clinic, the main clinic, we've got clinical space elsewhere, but our main clinic is in Stratford-upon-Avon, so you're not too far away there. I'm not. And so just tell me about why you became a psychiatrist. I'm always interested because obviously medicine is a passport for so many different

specialties. So why did you decide to become a psychiatrist? Well, it was quite a late decision, really. I mean, I did my medical, my undergraduate medical training in the mid-90s. And I popped out of medical school really at the end, not really knowing what I wanted to do. And thinking, well, I'd like to try a few specialities. And in those days, you could do sort of six months here and there and sort of cobble it

together to become a GP at the end if nothing had taken your fancy. And actually, the first job I did after my general medical and general surgical house jobs was psychiatry, and I absolutely loved it. And it just all kind of fitted together, really. I think I found being a house officer in medicine and surgery really fraught and your time with your patients was really limited. And in psychiatry, it was just completely different. You know, had an hour to sit and talk to people and you really knew about them. And I did have a bit of an interest in my undergraduate years in Birmingham. I think we just did like eight weeks of general psychiatry and mine was actually split. So I did, I was really fortunate in some ways to do half older adult and half general adult

psychiatry. And I worked with, observed a very inspirational psychiatrist at that time. And he just knew everything about his patients. He knew their family. He knew their kids. He knew their parents and their grandparents. And he didn't need to look in the notes. He wasn't sort of fumbling. and I just thought that's really what medicine's about. It's about knowing people. It's about learning from your patients as well as you helping them. And that's kind of where it went really. And it's so important, isn't it?

Because I was very lucky. I trained in Manchester. So my psychiatry training was in North Manchester, very, very deprived area. And the hospital was incredibly busy. When I did my hospital, medicine, as a junior doctor, we'd often have 50 emissions. You have to get through. It was really hard work, really hard.

But when we did, you know, did psychiatry, it was in a lovely building away from the hospital, it was quite a new build, and there was this calmness there where it was in the hospital, it was very, very finesse, it was so much going on that your head was just constantly exploding and you're absolutely right. I knew the patient's blood results, I knew their diagnosis or potential diagnosis, I knew when they were going for a scan, but I had no idea what their life at home was like. I really didn't, because I didn't have time, not because I wasn't interested. And suddenly you go to the calmness of psychiatry and then they say oh louise you've got an hour to discuss this patient or to talk and because

I did my junior house jobs there as well a lot of patients would come in after an overdose or whatever so then I'd have the privilege of knowing the psychiatrist because I did my training there and you're sort of going back to this holistic because it is holistic when you've got more time I totally think you learn things from people that impact on their mental but also their physical health as well and their decisions regarding lifestyle absolutely the drugs that they're taking all that and their perceptions because often the more I do in medicine it's about what people perceive and what they want to get out of the consultation but what's led them to their particular condition or illness or mental health

aspect and you can't do that in isolation in 10 minutes can you without knowing any background No, absolutely. And I think what we start with in a psychiatric history, as you know, is we ask people about their family. We ask them about their childhood. It doesn't matter whether they're 20 or 60. We still ask them about what school was like. We asked them about what things were like when they were growing up. We asked them about any trauma. But we also ask them about their hobbies and their interests and their personality. And I think you just build a much broader view of the person that you're sat with and it develops a different. type of relationship and I guess that's really why I ended up stuck in psychiatry because I couldn't imagine going back to those 10 minute consultations really. And it's so important now, even more, I think, because medicine has become very fragmented and also working in silo because everyone's super specialised. But when I started my GP practice, we saw our own patients. So you could build that picture quite well. And it was quite a small practice so you'd often know the relatives and then you'd know, you know, when you see people grow up and you'd understand more about why they

were a certain ways. But then as I left, it was so busy and so different that you often wouldn't be able to piece those pieces together. So one of the many advantages of working where I do is that we do have that time again and a lot of the doctors at work with us say, gosh, I have so much longer with people. So I feel I know my patients now so much better. And even when they come in and, you know, 98% of women we see as new patients in our menopause clinic have psychological symptoms. And often they are really quite distraught and they're ruminating and they're overthinking. They're, you know, obsessing about various things. And I don't know their pre-morbid personality. I've got no idea whether they've always been like that or whether their change in hormones has made things worse.

And often it's the latter. But you've got time. But also when they come back, it's not just the first consultation when they come back, you've still got time to explore, but because you've known them well or you've learned so much about them, it's easier then to unpick what is related to something that's treatable and what is relatable to something that's, you probably can't change people's situations or other aspects of their lives that are affecting their mental health. And that's really important. So we're not medicalising every single symptom, are we? No, and I think it's really important for patients to have that opportunity to give you their narrative to tell you their story because they tell you so much more. I mean, what they might have

been referred for or what they might have booked their GP appointment for might be completely different to what they really, really want to tell you. And I think it's a bit like with menopause, like you don't have that clear blood test that you can say, right, we've done your blood test and you are menopause. And it's a bit like that with depression and psychiatry and all psychosis or any mental illness, really. So as I will say to medical students that come and spend time with me, I don't have a stethoscope anymore. The only thing I have to work on is what my patients tell me. And that's why that relationship is really, really important because I have to work with

what they tell me. Therefore, I have to make sure they feel comfortable to tell me everything. And I will always say it's a really, really privileged position to be in. And I'm lucky I work in a home treatment team. So I don't even have a clinic or an office. I go out in my NHS job. And I see people in their own homes, in their own environments. and they do tell you, you know, you can't ask questions and people will tell you the most personal

details, sometimes things that they've never even verbalised before. And that's really powerful. And I think that's something we should never, ever take for granted, you know, that position that we're in, that very privileged position. I totally agree. I mean, it's such an honour and a privilege being a doctor. And certainly when I did home visits as a doctor, you'd learn a whole new dimension about people. But when people tell you things, and it might not be something that's immediately, happening to them, but something that's happened in their past, that they've never told someone before and they don't even think it's relevant or appropriate or necessary to tell. But as soon as they tell you, and the way that they tell you, it obviously has had an impact on their life,

it's such a privilege because also they know that what they tell you is completely confidential. And you can't do that with your friends or relatives because you're never really sure. But we are bound by confidentiality. And it's really, really important that we use that in the a way to really help shape the narrative of what we're doing. And it's very interesting, I think, because I get obviously a lot of pushback of what I do and people are saying, well, how do you know these people are perimenopausal? They're still having periods. They're not having flushes or sweats. You're putting everything down to hormones. And of course I'm not because I'm very holistic in the way that I treat people, but also diagnose people as well. But not everything in

medicine needs to have a blood test or a scan or whatever. And a lot of women we see actually have had a multitude of tests. They've had brain scans for their migraines or memory loss. They've had heart scans for their palpitations. They've had x-rays for their hip and joint pains. Yet they've been told, oh no, Mrs Smith, your results are normal. Therefore, there's nothing wrong with you. It must be all in your head because, you know, there's no cause for your symptoms. Whereas when we talk to them and it's quite apparent that their symptoms have started when their period started changing or they, you know, you've pieced it all together. but people still feel it strange.

Whereas as you say, in psychiatry, you make a diagnosis. And sometimes, like lots of things in medicine, we don't make the right diagnosis first time, but we give what's called a therapeutic trial. So we'll try a trial of medication, review the person, and then if they've made no improvement with that treatment, then we think, again, have we got the diagnosis right? Is there something else we should be doing or asking?

And that's what you do a lot in psychiatry, isn't it? Yeah, and I think it's sometimes difficult for patients because they come to see you and they want a diagnosis or sometimes even worse, they've been to see somebody else and then you will say, well, I think it's this and they say, oh, well, that's interesting because Dr. So I thought it was something completely different. I mean, I think diagnosis is, you know, it's one of those things that people find helpful to understand. But I'll often say to people, unfortunately, you know, human beings are, there are a mixture of lots of different things. There are a of their genetics of what's happened to them, of what's happening to them now, of lifestyle choices they might be making. And it's very difficult sometimes to give an exact diagnosis. And I will say, you know, a diagnosis is important for research and it's important sometimes for professionals to be able to use it as a shorthand language named Mrs Say and says, it's got this. And we all know what that means in terms of a collection of signs and symptoms. But for patients, you know, one person with depression is going to be completely different for

another person and therefore their treatment needs to be completely different as well. It may be the same medication, but in psychiatry we work with biological, psychological and social causes and treatments. And it's, if you only look at one of those things, you're going to miss two-thirds potentially effective treatments. And you might not pick the right one. You might pick something which is less effective. Yeah, and I think that's really important because there are two things that sort of go in my mind. One is that there's no rush for a diagnosis. So I've had mornings and I'm sure others, people listening will do, where I wake up in the morning, I've had restlessly, if I'm anxious or worried about something, if I've filled out a depression questionnaire, I would definitely have severe clinical depression for that time because, you know, I'm not eating, I'm feeling very low, I feel like giving up everything. I really do. There are times. And it's quite scary when you have these thoughts. But when I talk to others, they've been the same, but they don't last very long. I'll literally then go for a walk, do some yoga. talk to my husband

and then later in the day I'm thinking Louise why were you like that? Come on, pull yourself together. So if I'd seen you and told you everything that was going through my mind that morning you could have easily have rushed to go oh Louise you've got clinical depression and have this this and this but then if I'd seen you in the evening for a meal

you've gone oh you're in good mood Louise so we have to be really careful of not making that diagnosis too quickly but the other thing that I've been reading a lot about is this DSM criteria that psychiatrists use because it's very interesting when you look at the history of it and how various diagnoses have been added and added. And I don't know whether you could just explain briefly what this DSM means. Well, I mean, DSM is a diagnostic criteria. We also have the ICD 10, which has been upgraded to ICD 11. And it starts off really from a research background in

that, you know, when people are conducting research, they need to be clear that everybody's talking about the same thing so that the results are comparable to everybody. And we do use it in clinical practice, but you use it for, you know, databases and coding and, as I said, as a common language. But it's a very discrete collection of signs and symptoms and you have to tick boxes and you have to have so many symptoms from different categories in order to make a diagnosis. And it kind of grows and things get added to it, gets reviewed every so many years. But for patients' perspectives, I don't think it's really that important. I mean, I think it's one of those things that's a little a bit controversial. But I say to patients, what's important is how you feel and not necessarily

what code I'm giving that so that the statisticians or the analysts can say, or we, you know, the home treatment team saw so many people with this F-33 diagnosis or F, you know. But it's important because in sort of our world looking at perimenopause, menopause, even PMS, PMDD, it hasn't got the right criteria, has it, for this? And that's one of the problems when we look at research, and Prof. Korni's talked about it before, who's a psychiatrist for Melbourne, that it's a chicken and egg thing. Because we don't have a DSM criteria code or IC10 for menopoles or perimenopausal, depression, anxiety, then you can't do the research in it because they say it's not a natural condition. But it is a condition because we see it every day in our clinic.

And women tell us all the time. So I don't know how we get over that. I don't know whether you've had any thoughts about that, Louisa, because it's really a struggle when you look at how we do proper research in this area. And I think it's just getting everybody up to speed, isn't it? It's educating professionals. And so when I make a diagnosis, I will often put a little note underneath. So, you know, we think this is hormonally driven or so you can tick the depression criteria. But we will send people back to their GPs. And I think the research aspect is really, really hard because we're so behind other areas.

And part of me thinks, you know, sometimes that may have come from, you know, historical stigma and things like that. But actually, you know, moving forward, I think a lot of that, we are breaking down lots of barriers. And I think this is a really exciting time to be in this area because things are moving so quickly and things are moving forward. But it's perhaps not moving as quickly enough as we want it to, is it? No. Because when you were doing your psychiatry training as a junior doctor and even a more senior doctor, did you have, many education modules about the role of our sex hormones and our brains? Absolutely none. I don't remember anything. And actually, even as a doctor, I know, I've been a

psychiatrist over 20 years now. And it's only really recently been in the last two or three years that I think I've got up to speed. And I know I've listened to other professionals on your podcast and spoken to people at conferences and things. I think we're also the same thing. You know, we look back and we think of those really important cases where we think, think could the outcomes have been different? Could we have changed things if we'd have known what we know now? But then I feel, you know, with the benefit, there's so many things, wouldn't we? We'd change with the benefit of the hindsight, but we need to move forward and make this an area that people are talking about, people are interested in. And that comes from patients, professionals.

Yeah, it's about trying to make the future more positive, isn't it? Yeah, absolutely. I recently had to take my middle daughter for her driving test and where their driving centre was was just on the boundaries of my old GP practice and I hadn't driven there for a little while and we drove past some houses where I used to visit regularly and there were a few people I used to visit very regularly and as we drove past I said oh Sophie I'm now thinking these women that I kept visiting with their awful mental health issues but they also had urinary symptoms one of them had awful burning mouth she kept doing emergency visit requests at four, they were all menopause.

I didn't even think. Not once did I think. I said, I feel awful, Sophie. And she said, don't worry, mummy, because you're changing things now. But hindsight, like you say, is a great thing, but we can't change the past. But what we can do is look at common sense.

And I've been spending a lot of time, my spare time as you do, looking at neurophysiology and neuroanatomy texts from many, many decades ago, like even from the 80s and 90s, I was a medical student in the 80s and 90s, and I never once was told that Easteran progesterone and testosterone are produced in our brain, that they are neurotransmitters, they change the level of other neurotransmitters.

Like, why did no one talk to me about this? And then when I was doing GP training, it was when the SSRIs came out at a lot, because we used to give a lot of diphyapin to people as a junior doctor. And when the SSRIs came in, and obviously everyone said, well, this is great, they have less side effects, they're brilliant and I've certainly prescribed a lot in my time, but it's all about serotonin and we know there's various theories about whether SSRIs work or don't, or there's serotonin and how they boost, but that's a different conversation. But actually I do also, I've also read information and research that any SSRIs work better when you've got estrogen

on board. So whether that's because a woman's younger and producing her own endogenous estrogen, or whether it's in eustodial as part of HRT. Yeah, I didn't know that. I've given lots of SSRIs to postmenopause or women who won't have estrogen in their body. And now there's a huge move to try and deprescribe anti-difrescent to those people that don't want it. So you're absolutely right.

It's like, how do we train and educate people to say, hang on, just have a little thing first. And a lot of women I see on SSRIs are saying, I know I'm not depressed, Dr. Newsom. I feel flat. I feel joyless. I feel really fed up. But I'm not depressed.

And then when I take the antidepressants, like a lady told me a few years ago, she'd crashed her car. And it was only she was driving into her drive. And she'd just misjudged the wall. And she'd done it for years. Like, obviously, her going into a drive, not her wall. And she said she'd just scrape the whole side of her car. It was really awful. She said, I got out and thought, oh, I don't care.

She said, I just, it was like one of those things. But then she thought, that's really scary. Because if I had crashed somebody or done something, would I still? She said, it's that sort of, oh, can't be bothered. thing that the antidepressants have given me. And that's quite scary. I don't know whether you see that at all in some of your patients. Yeah, certainly.

I mean, people do describe a sort of emotional blunting with it. And obviously you get that lack of joy with the menopause as well, don't you? That's sort of, I think perimenopausal and menopausal women that I've seen in my everyday practice that have obviously been referred to me because they have severe problems with their mental health. They will often describe feeling like they've lost themselves, you know, that they just don't feel themselves. anymore. And there are some very subtle differences between the sort of hormonal depression and the

clinical depression that we might see in terms of often patients are fully made up and, you know, they're well presented and their houses are immaculate. And that's slightly different to those patients that might be clinically depressed where they have, you know, not got the motivation to change their clays or put their makeup on. And it's about those telltale signs, I think, are picking up very subtle things. Yeah, absolutely. And it can be quite subtle, as you say, and as you know, we're doing some research for funding a PhD student in suicide prevention, and we're doing a depression screening questionnaire, PhD9, which I used a lot in general practice. Because on paper, like I've said before, sometimes these mornings, you know, these people fulfil the criteria

for actually quite a severe clinical depression. But when I see them, they have good eye contact, They've got insight. They don't want to be feeling like this. But also what they often say is I don't feel like this all the time. Sometimes I feel like this. And then my period comes and I feel fine for a few days. And then it happens again. So it's this insight.

And that's, again, the art of a consultation rather than just doing everything on a tick box. Absolutely. I do like AI is fantastic and very exciting. And there are things that will be amazing for like reading X-rays and scans and things. But it's not going to replace the art. of the consultation because there are those little non-verbal cues that you pick up and when you're more experience you pick up more don't you it's great even the tone of someone's voice when you know them well yes you can immediately say are you okay yeah I said well yes of course I did it the other

day with a friend and she just didn't sound right she was oh well my grandmother died last week but she was 98 and you know it's not she said how have you picked that up I said I just can tell they're just, you're just a bit more distant, you're not quite yourself. And look, I've been a GP for years. I've got this intuition. And it's hard to describe to other people, isn't it, how you've got this sort of sense almost. Yeah, and the better you know the person and the more relaxed they feel with you, the more likely you are to pick those things up. But it's really important to ask the question, isn't it? You know, if patients are coming to me, they're wanting to talk about their mental health, if I don't ask them about their menstrual cycle or whether they're have changed or whether sometimes I'll just ask a generic question, do you think this might

be anything to do with your hormones that they're not going to tell me because I'm a psychiatrist. So they're not going to come to me and say, I mean, some patients do. Some patients will say, actually, I think this is hormone. Do you think this could be my hormones? But one of the big things that we've done in the team that I work in is we talk about menopoles a lot. And therefore, other members of staff will come to me and say, I ask them about their menoples or I ask them about their hormones and that's really where the future is, you know, in terms of just raising awareness. It's just really one simple question and it can make all the difference to patients because they then feel they have permission to tell a psychiatrist about their hormones. Yes. And it's so

important because everything can be quite siloed in medicine, people think, well, I can't tell my cardiologist about my headaches or I can't tell my neurologist about my bladder problems and it's like, I can't tell my psychiatrist about my hormone problems. And often people don't know. We think everyone knows about hormones, but a lot of people don't realize how our hormones can have effect on our mental health as well as our physical health.

So having just that simple question, and I've done a loss of training over the last few years to psychiatrists. And actually, I don't want to big you up, Louisa, but psychiatrists are such an amazing group of people who want to know. They've got this professional curiosity. Like us, they want to learn an. improve. So they're not pushing back, actually. And even on the nice draft guidance, as you know, we registered ourselves as a stakeholder so people couldn't put their views. And one of the big things

about the nice guidance was saying CBT, which is a psychological treatment, as you know, instead of HRT for some women in menopause. And we had nearly 700 responses, but a lot from psychiatrists actually saying this shouldn't happen, which is quite interesting because I think maybe 10 years ago, menopause wouldn't have been on their radar. They wouldn't have even known there was a menopause guidance. So it shows, which is great, this momentum is happening. And that's only going to improve people's mental health going forward, isn't it? I think so, yeah, absolutely.

And it's really interesting. And people will come and ask for training sessions. I've done some training sessions for our local GP training scheme around menopause. This week I've had an email from one of our higher trainees saying, you know, they're organising the peer training for, or regional psychiatry trainees, or they'd like to do something on female hormones. As you know, it's been a bit more of a higher priority at the Royal College.

So things are moving really quickly, which is really exciting. And I think it's going to really help the patients. Because at the end of the day, that's why we're all here, isn't it? We're all here for the patients. And the best outcomes for our patients come when we all work together. You know, I, as we were saying, you know, the GPs tend to know patients well. they tend to know the families if they've been a family doctor. And the most rewarding cases I've had recently have been when we have worked really closely

with the GPs in partnership. And that's where we get the best outcomes for our patients. I totally agree. And so selfishly, I'm really excited that we can work with you to help some of our patients who have mental health issues beyond their hormones, but also for those who have been misdiagnosed in the past and been overtreated with inappropriate medication for their hormones. hormones, so, you know, ones on antipsychotics and lithium and so forth. And when they

want to reduce those, it's lovely having your wonderful expertise as well. So I'm really keen to see how our relationship goes. Yeah, it's really exciting. Very excited, Louisa. So thank you for your time today. Pleasure. Before we end, I always ask for three take home tips. So I'm just going to ask three things that you think people should be alerted to the fact that it could be related to their hormones. So there will be people listening to the podcast who will be on antidepressants or they'll be with somebody who's got a friend or a relative who's been diagnosed, but they might be thinking it could be their hormones. So what are the three things that you think they should do to try and think more holistically about mental health and hormones? So I think probably the first thing

is if it feels different to a previous episode of depression or if their symptoms are fluctuating. So I'm thinking of patients that I see who might come to me because they've got suicidal thoughts or they're depressed. And that happens at certain times of the month. Like you say, if they have a period, then those things improve. I mean, so that's, I think, tracking your symptoms really and looking at the fluctuations is important. I think the history is important as we talked about, you know, people's backgrounds. So if patients have had an episode of, so postnatal depressive, or they've suffered with PMDD, then they're more likely to experience mental health difficulties

in the perimenopause. And I think other things are things about the quality. So like we've said, that lack of joy rather than a sadness, the emotional ability, I think, is greater often with a hormonal mental health problem. And that irritability, the rage and the impulsiveness is often greater with mental health problems. So those sorts of things. Yeah, really, really important. And we've got information about mood and hormones on our website. We can put links onto that as well.

So just thinking about it is the most important thing. And talking about it and then trying to get help. So I'm really grateful for your time and really excited to be seeing more of you in the future. So thanks ever so much for today, Louise. Thank you very much, Louise. You can find out more about Newsome Health Group by visiting www.newsonhealth.com. And you can download the free balance app on the App Store or Google Play.