Mental health services failing to take account of menopause, says watchdog

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

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

A study examining the suicide of a 56-year-old NHS worker found staff working in community mental health teams were 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 of suicide, too many NHS trusts still use the system, leaving people without the right care, investigators concluded.

The report detailed the case of Ms A, who was in contact with mental health services between 2019 and 2020 and who was diagnosed with psychotic depression.

She was also 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.

The report warned that 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.

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

Research has also found that many women suffering depression or a major depressive disorder at the time of menopause “may find relief of these symptoms and even the disorder by using 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 report found that, just a few days before she took her own life, Ms A had been deemed at low risk of suicide.

Investigators warned that checklists are sometimes used for suicide risk assessment by NHS trusts even though 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 A, 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.

The report said: “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.

“While it is logical to focus limited resources on those deemed most at risk, it does not take into account the dynamic nature of risk; for example, if a person deemed low or medium risk is not given appropriate interventions, their risk can increase.

“Clinicians 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 in England 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.

Amber Sargent, HSIB national investigator, said: “Our investigation findings all point to one thing: that it is absolutely crucial that patients at risk of suicide and self-harm are given a holistic assessment, one that moves away from tick boxes.”