Women’s mental health: what must change, with Linda Gask

Content advisory: this podcast contains themes of mental health and suicide

Joining Dr Louise on the podcast this week is Linda Gask, retired psychiatrist and author of new book Out of Her Mind: How We Are Failing Women’s Mental Health and What Must Change.

In her book, Linda draws on the lived experiences of women, alongside expert commentators, recent history, current events, and her own personal and professional experience to look at women’s mental healthcare today.

Dr Louise and Linda discuss the challenges women face in accessing mental health treatment, the importance of understanding the impact of hormones on women’s mental health, and the need for women to be listened to.

Find out more about Linda’s book here.

For more information on Newson Health, click here.

Dr Louise Newson’s first-ever live theatre tour, Hormones and Menopause – The Great Debate, runs until 12 November. For more information and tickets, click here.

Contact the Samaritans for 24-hour, confidential support by calling 116 123 or email jo@samaritans.org.

Transcript

Dr Louise Newson: [00:00:11] Hello. I’m Dr louise Newson. I’m a GP and menopause specialist, and I’m also the founder of the Newson Health Menopause and Wellbeing Centre here in Stratford-upon-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 Newson Health Group, which has clinics across the UK dedicated to providing individualised perimenopause and menopause care for all women. So many of you know, I’m really interested in the brain. I’m very interested in mental health. And it wasn’t until I started to do as much work as I do with hormonal health, I realised the association between hormones and the brain and also just how many women are affected with different mental health conditions and often find it really difficult to get treatment. So I’m very privileged and honoured to have with me today a psychiatrist who actually is from Manchester, which is where I trained, so another coincidence. And so Linda is someone I reached out to on Twitter, I think. So Linda Gask was a consultant psychiatrist, NHS consultant, academic, and has written a book, which is incredible. Everyone needs to have a read, but be quite shocked when you read as well. So really honoured that you’re here on the podcast. So thanks for joining me today, Linda. [00:01:55][104.7]

Linda Gask: [00:01:56] Thanks for asking me. [00:01:57][0.8]

Dr Louise Newson: [00:01:58] So I read something on Twitter about your work and then I saw that you had a book coming out, and I think I just messaged you on Twitter. And then we had a great conversation, didn’t we? [00:02:06][8.9]

Linda Gask: [00:02:07] We did. Yeah. [00:02:08][0.7]

Dr Louise Newson: [00:02:09] So your book that’s just come out is called, it’s quite a long title, but every word is really important. So I’m going to read it out. It’s entitled Out of Her Mind: How We Are Failing Women’s Mental Health and What Must Change. Really powerful. So tell me a bit about why this is so important and what led you to write this book? [00:02:36][27.1]

Linda Gask: [00:02:37] Well, I’ve had my own mental health problems over the years, and I’ve written about those, and I’ve spent most of my career actually caring for women because my particular interest was in common mental health problems, anxiety and depression. And so I’ve very much worked with women and done quite a bit of psychotherapy with women as well. And when I was younger, I was really very determined that we were going to do something to really change things for women’s mental health. It was the 1980s when I started training as a psychiatrist, and now towards the end of my career when I retired, I looked back and I thought, Do you know, things haven’t really changed very much for women in that time. In fact, in some ways they’ve actually gone backwards. And it was quite shocking to start researching this book and realise that young women are going through, I think, worse things than I went through when I was growing up. Women’s mental health remains a kind of hidden problem because the whole kind of narrative about mental health at the moment is about suicide, which is very, very important. But that’s something which is much more common in men. And women get very depressed, suffer and take their own lives. And a lot of their problems are related to relationships and the families and the struggles that we have in life. And yet we don’t get the same attention and concern. I think because we survive. Many women, far more women than men, harm themselves. But very often our problems are just not taken very seriously. We’re viewed as though we’re overreacting or making a big fuss or not asking for help in the right kind of way. And so… [00:04:42][125.3]

Dr Louise Newson: [00:04:43] And that’s gone on for centuries thought, hasn’t it? [00:04:45][1.4]

Linda Gask: [00:04:46] Yes, it has. I mean, you know, this was happening in the 19th century in Vienna when women were presenting with hysteria and no-one was really asking or considering even the things like abuse might be happening to them. But they were. So many women, women have far more problems with anxiety, depression, post-traumatic stress disorder, many more of those kind of problems. And a lot of that is related to the difficulties that we have in our lives right from childhood through having far more exposure to abuse than boys and men. The struggle… women are the people who hold families together. Women are subject to a lot more comments about our appearance. We have to behave in a certain way. Talking to young women, it was quite shocking to find out how much they’re still expected to conform when, you know, in the 70s, when I was growing up, I was determined that we were not going to conform. You know, we were going to be able to do woodwork just like the boys. Okay, we can do the woodwork now, but we still have to wear the right clothes and we still have to look the right way. And it’s even worse because if we don’t do the right things, people on social media are talking about us and bullying us. And those are the kind of problems that young women are still facing. [00:06:10][84.7]

Dr Louise Newson: [00:06:12] Which they didn’t have before, did they? [00:06:13][1.4]

Linda Gask: [00:06:17] No,exactly. And I’ve always been a feminist, but there was some aspects of feminism. I think feminism kind of hasn’t moved on in the way it views women’s mental health problems. I don’t think it’s taken sufficient account of biology very much in the way that, you know, your work around menopause. Traditional feminist approaches were around hormones were that, women were hormonal, we were written off for being hormonal. But actually hormones matter and our bodies matter. And it isn’t just… I think too often our suffering is written off and not only by men, but by women, too. So I set about writing the book and interviewing a lot of women who were kind enough to share their stories with me. And I checked out whether they were happy with what I’ve written. And so there’s a lot of real women’s stories in the book. [00:07:14][57.4]

Dr Louise Newson: [00:07:15] Which is so powerful because I think as a healthcare professional, I still see every day that I work as a privilege to have women, men, but mainly women in my work now who come from all walks of life. And they often tell you things that they’ve never told anyone before and they have complete confidence in us. But you hear things that you’ll never hear anywhere else, and it’s quite revealing, but also quite shocking as well. And I was very lucky. I trained in psychiatry in in Manchester and I trained in North Manchester. So in Crumpsall. So it was a very deprived area. But we had this extended case that we had to write. And I remember the lady so well and I’ve still got the project that I wrote up. So she had an eating disorder, she had bulimia, she had really bad teeth. And she came because she had anxiety, she had depression. And so the consultant said she’d be a really good person. And we had like an hour to take a history, which is such a long time compared to hospital medicine. So I could really talk to her but after half an hour, she’d told me about her bulimia, she’s told me about her teeth. She told me that she was anxious and I thought, I don’t know what else to ask. I’ve got an hour. So I said, Is there anything else that’s ever happened to you or anything else you want to talk to me about? She said, Well, there is actually. She said, I was abused as a child by my stepfather and I’ve never told anyone about it since that time. And then it all came out. So then my project was actually about eating disorders and abuse and association. But what taught me then really young as a young medical student was that it’s the unexpected that you get from people. It’s giving them time, making them feel safe. And then what you hear is not what you expect. And I use these techniques quite a lot still in my clinical practice because it’s very easy to get the top line, isn’t it? But it’s what’s underneath and what’s associated. And actually I could just watch her shoulders go down a few inches because she’d shared her story… because I couldn’t treat her. I wasn’t able to prescribe. I was only a medical student. But what I could then do is talk to her. She gave me permission, of course, I could speak to the consultant and her whole treatment was very different. I thought, Gosh, this is incredible that we can make such a difference, that the only thing I regret about that history taking though Linda is that I didn’t ask her about her periods or hormones or whether she had any change in how she felt throughout her menstrual cycle. And I didn’t know to ask then. And I can’t change the past, but I do it a lot now. And you really notice there’s a hormonal change, often with women… [00:09:53][158.4]

Linda Gask: [00:09:56] Yes. I mean, I, I wasn’t taught as a psychiatrist very much about the impact of hormones. I learned, I think, from my patients. I heard what they told me about the impact of their periods on their mood. And I saw, in my practice I saw several women over the years. I didn’t specialise in perinatal problems, but I saw the impacts of hormonal changes at childbirth and the impact that that could have on women’s mental health. And then I saw what happened around the menopause, and I could see and I could hear from listening to my patient’s stories, but I was taught very little, very little. And we were told, I think, that it really it wasn’t important, as you say. And it’s really shocking, though, when you look back to that period, how little education and until relatively recently, how little education psychiatrists have had about hormones. [00:10:59][63.7]

Dr Louise Newson: [00:11:00] Yes. And you might know we wrote a course about mental health and hormones for the Royal College of Psychiatrists. And I was up in Edinburgh recently accepting a certificate because it was the most downloaded course, which was great because it shows this need. But I didn’t know and and I was recently reading my old psychiatry textbook and it actually said there is no link with hormones and mental health. And so that’s what I grew up. I didn’t think about it even as a hospital doctor, as a GP for many years, didn’t think about this association. But also, as for the tour that I’m on at the minute, I’ve done a lot of reading, and I was reading a book by Edward Tilt from 1870, and he talks about this crisis time before menopause, which obviously now we know is more perimenopause, and how those women still can have regular bleeding, he was saying, regular periods, but their mental health can be in real turmoil, really affected, all the barbaric treatments they were often giving to people, including locking up in asylum. But the more I see women, it’s this havoc that occurs in hormones in the perimenopause that often is far worse than in menopause. When hormones are low and just stay low, they plateau, which makes sense, really, doesn’t it? How our brain works and reacts to changes. [00:12:19][78.4]

Linda Gask: [00:12:20] It does. And I think obviously the difficult thing is that there are so many other changes going on in a woman’s life at that time as well. So that the hormonal changes sensitise you to everything else and are not coping in the same way with everything else. And I think it… When I talk about when I mentioned suicide early, I think, you know, the commonest age that women take their own lives in this country is in the late 40s and early 50s. And no one knows why that is. I can only think, I don’t know, but that is a time when women are not only going through major changes in life, but they’re also going through menopause and perimenopause. [00:13:05][45.1]

Dr Louise Newson: [00:13:06] Yeah, I mean, every day in the clinic we see women and speak to women who have suicidal thoughts. And the reason that I know it’s their hormones often Linda is because they’ve been under psychiatrists. I saw someone recently who has been on three different antidepressants, didn’t help, just made to feel numb. She was given quetiapine then she was given lithium, then she was given ECT. They were thinking about giving her ketamine, but she wasn’t any better. And it was her partner that said, Look, you’ve always been a bit down just before your periods. This is really different. Why don’t you go and speak to this, you know, doctor. But then when I spoke to her, she said, you know, she’d planned what she wanted to do. She couldn’t carry on the way she was. She had very dark, very intrusive thoughts. But when I said, did you have them every day? She said no, when my period comes, which is quite scanty, I feel fine. But she also had great insight. And a lot of these women really have a lot of insight, very different to other people that I’ve seen who have been very clinically depressed and very flat. And we’ve, you might know, we’re funding a PhD students looking at suicide prevention with Liverpool John Moores University, and we do a PHQ-9, which is a depression screening questionnaire and all our patients that come, but what we’re finding is about 25% of women who come to our clinic have very negative thoughts, have thoughts of harming themselves, which they wouldn’t tell us. But on the questionnaire, we can see it, but it’s very high proportion, actually higher than you would think in a menopause clinic where people traditionally menopause is about hot flushes, isn’t it? Of course it’s not. It’s more about the brain. [00:14:50][103.8]

Linda Gask: [00:14:51] It’s about mind and body. [00:14:52][1.2]

Dr Louise Newson: [00:14:52] Of course it is. And there’s so many women say, I know it’s related to my hormones, but no one’s listening. And I think we sometimes, I don’t know what you feel but I’m sure you agree is that women aren’t believed and they’re not listened to enough. And as a doctor, I might not have the solutions, but my job is really to listen and understand. And when women say, I think it’s due to my hormones or I think it’s due to some trauma or I think it’s a combination, in my experience, they’re usually right. [00:15:21][29.3]

Linda Gask: [00:15:22] I think your point about women not being listened to and not actually being heard is crucial. Women do not feel listened to by many doctors. And your example as a medical student, I just think you gave someone time, you gave them attention, you listened. And that is very often something that women don’t experience in medical settings. I’ve experienced that myself, you know, and I’m a I’m a doctor, but I’ve experienced that in my own care. When I went at the time that I was going through the menopause and my menopause was late, I was quite severely depressed. And that was one of the reasons why I gave up work early. And at no point did anyone ask about my menopause, except when I went to the gynaecologist. And I didn’t make the connection either because I’d had mood problems all my life. But those mood problems were worse at that point. And then I have physical symptoms as well. And I’ve spent quite a lot of my career trying to help people with unexplained symptoms. And then I found myself with unexplained symptoms and really understood what it was like for women not to be believed. It was really very, very upsetting. And in the end, things resolved. But it gave me a lot of insight into knowing how understanding how people are just not, well women are just not taken seriously. [00:16:52][90.2]

Dr Louise Newson: [00:16:54] Yeah. And I’ve been doing quite a lot in prisons recently and a lot of women have hormonal changes in prisons because they’re older, you know, they’re in for life when they come 40s, 50s. But also lots of younger women who have abused drugs, they might be alcoholics. They… might just be the trauma or whatever but their ovaries have switched off, their periods stopped and they get worsening symptoms. But also lots of them have PMS and PMDD. But what’s interesting is a lot of them have these physical symptoms, so they’re getting dry, itchy skin, they’re getting cystitis, urinary tract infections, palpitations. Because when I speak to some of the medical staff, they say, no, it’s because they’ve had trauma. It’s because they have difficult lives, because they’re in prison. Of course they need antidepressants, antipsychotics, pregabalin, whatever else. But when I say, well, what about hormones? And it’s almost like, oh hormones, a bit of a lifestyle drug, now it’s all in their heads. They don’t need they’re not taking these other drugs. So why would they take hormones? But I think it’s that thing about taking a complete history, because if someone’s got dry, itchy skin without any other reason, that’s come on with their mental health symptoms, for me, it’s like a bit of a ok, you can’t make up something physical. You could try as a doctor if you really don’t believe patients but it’s very hard to make something that is physical. [00:18:14][79.9]

Linda Gask: [00:18:15] I think one of the… you mentioned trauma, and I think that there’s been a real move to say that everything is down to trauma. And in another way, that’s another way that I think women can be gaslit sometimes because they’re told that what they’re experiencing is due to trauma. And they say, well, I don’t know of any trauma, I don’t remember any trauma. And I think there’s sometimes a denial of the reality of the severity of women’s mental health problems, that depression really does exist. And it’s not just unhappiness. And I see that a lot, that there’s an assumption about trauma. I think that both are important. You know, women experience really adverse things happening in their lives, and that triggers off in those of us who are perhaps vulnerable because of our life history or because of earlier experiences, sometimes because of our genes, some of us, that triggers off something much more severe and they need to be listened to and they need to get the best help. And I see that not happening. I see an assumption that half a dozen sessions of talking to someone, talking to a therapist is going to solve those problems. And and it doesn’t know at all. And I also met many women who’d been told that they had personality disorder when actually they were being misdiagnosed. Some of them had had chronic traumatic experiences, but some of them are young women with PMDD, premenstrual dysphoric disorder, which is very severe and not uncommon. Some of them were women who had undiagnosed autism or ADHD because all of the screening tools for them were designed on boys. Because it doesn’t get picked up and some of them have something more serious like bipolar disorder, which just doesn’t get recognised in young women. They’re just assumed to be young women with personality disorder who are just being difficult. And so there’s so many ways that we are not listened to and don’t get a proper assessment, a full history, a proper assessment. And sadly, that happens in psychiatry as well, particularly at the present time. [00:20:41][145.8]

Dr Louise Newson: [00:20:41] Yeah and even since I qualified in 94, so many years ago now, medicine has become more siloed. I think, you know, it’s quite hard to find a traditional clinician who’s trained in all specialities. And that means that we do then focus too much on one organ, which can be very difficult, because then that sometimes means that we’re making maybe the wrong diagnosis, but also we’re focusing just the treatment on that individual organ as well. And often in medicine there are many treatments. So even though I give hormones a lot to women, there’s no point not looking at their diet and their lifestyle and what else is going on. And, you know, I can’t change their job. I can’t change their partner. But changing how we think about things is really important as well. But doing a sort of multi-pronged 360 degree approach and individualising care in my mind it’s really important. But I think that Individualisation has reduced in medicine because we’re very conveyor belt thinking about the guidelines, doing the same one size fits all. And then I think that gives people less of a good service because they’re not treated as individuals and that often leads to not being listened to as well. And then the frustration can make things worse. Also, so many women say to me, I’m just not going back to see that doctor or clinician because I didn’t feel I was listened to. They don’t say I don’t feel that I got the wrong treatment, because as a doctor we can all give wrong treatments and make a wrong diagnosis, but we can be open about this. I’m sorry that didn’t work. Let me think about X, Y, Z, or let me refer you to a doctor or whatever. And I think patients know that we’re human. But when there’s this closed, no that it, I’ve made the diagnosis, you’re not better. Therefore it’s in your head, is awful, isn’t it? [00:22:38][116.6]

Linda Gask: [00:22:38] It is. It is. And a lot of the work I did over the years in my career was seeing people who they had been told there was nothing wrong with them because doctors couldn’t find any reason for their symptoms. And the first thing it was really important to do was to say, I understand that you really are experiencing this and this is real. And okay, maybe we can’t find a cause for it now. But that doesn’t mean that we won’t find a cause. And it also doesn’t mean that it’s all in your head, which is just a terrible thing that has been said to more women than men. And some of the women that I interviewed for the book were suffering from things like fibromyalgia, which can’t be explained in traditional medical terms, but a very real and really limiting people’s lives. And more common in women. [00:23:33][54.8]

Dr Louise Newson: [00:23:33] Yes. And we see a lot of people with fibromyalgia and they do improve with hormones often, but no one’s thought about hormones because…especially testosterone adding in testosterone, because we know also our hormones affect our perception of pain. They affect our pain receptors as well. But it’s that whole thing that it’s not real pain because we don’t know what’s causing it. [00:23:56][22.3]

Linda Gask: [00:23:56] Absolutely. [00:23:56][0.0]

Dr Louise Newson: [00:23:57] I find really upsetting for these people because they are feeling it. [00:24:00][3.2]

Linda Gask: [00:24:01] Yeah. And women are supposed to have a higher pain threshold than men, which I always find amusing. But I was taught that, I think, as a medical student, which… [00:24:09][8.6]

Dr Louise Newson: [00:24:10] If women and men. There’s studies that show that if women and men have the same pain subjected to, then women are more likely to be given antidepressants and men are more likely to be given painkillers, which is just wrong, isn’t it? [00:24:23][13.7]

Linda Gask: [00:24:24] Yes. [00:24:24][0.0]

Dr Louise Newson: [00:24:25] So before we finish, what’s going to change? You’re saying it must change in your book title? So how are things going to change to improve future generations? I’ve got three daughters. I want them to have a good experience. [00:24:35][10.7]

Linda Gask: [00:24:37] Well, the first thing I think is that women, we mustn’t allow ourselves to be written off and not be taken seriously. We’re taught throughout our lives, that we’re supposed to behave and just do as we’re told and just shut up and not complain. And I think that one of the things I’ve tried to help women with in my career is helping them to rediscover that self, that self that doesn’t mind complaining and shouting out and saying, hey, this is just not good enough. I’m just not putting up with that. And some of the women I met in my interviewing were able to do that and kind of rediscovered that power. I think the second thing is that we have to get away from this idea that things are either all mental illness or all caused by trauma. Both matter. Women get depressed, but they’re also oppressed. And if you just treat the depression, you ignore what’s going on in their lives. That doesn’t work. But if you just treat what’s going on in their lives, if they’re severely depressed, they can’t actually get enough energy together to make changes. And too often we’re all in silos. The people who do the helping and the people who do the treating of mental health problems need to talk to each other. And need… I spent a lot of my life trying to connect women with resources in the community that could actually provide them with practical help. And I think the last thing is we need an awful lot more concern about the problems that are common in women are just not getting enough research and enough money spent on them. When you look at the amounts of time doctors get taught about eating disorders, it’s about two hours in our career. And because they’re more common in women, they don’t get the same attention. Similarly with fibromyalgia, you know, it’s a similar kind of problem, More common in women. Less research. Less investment. So I think we have to support each other. I think women have to support each other in this. We have to listen to each other and take each other seriously. But we also have to really try and campaign to get people to listen to us. And I think we, one of the things that we did do in the past was we got grassroots organisations going that were founded by women and got things going for women in the community. And I think we have to go back to doing that. I don’t think we can rely on men to do these things for us. We have to do it. And it’s a whole new generation that we have to take this forward and actually do the kind of thing that you’ve done, Louise, and actually say, I’m going to make a change here, and we have to do that for each other. And the first thing is to take each other seriously. [00:27:33][175.7]

Dr Louise Newson: [00:27:33] Totally agree. I couldn’t agree more. And I think we’re very lucky actually the way things have changed. Technology has changed. The work I do is on behalf of women I hear from every single day, which when I was sitting in that consultation room many years ago, there was no social media, there was no internet. I kept that story to myself in a project. But now I can share anonymously and you hear others saying the same. And that’s where you learn, from experiences and work together. Women work in mysterious ways, which I love. And connecting with women can make a difference. So I do feel most not all the time, but I do feel positive because I think change is happening. I don’t think we can go back anymore. We can just keep going forward. So I’m really grateful for you coming on the podcast and very grateful for you writing such a fantastic work as well. So I look forward to hopefully meeting you in person sometime too. So thanks ever so much, Linda. Thank you. [00:28:29][55.6]

Linda Gask: [00:28:29] Thank you for asking me, and I look forward to that. [00:28:31][1.7]

Dr Louise Newson: [00:28:36] You can find out more about Newson Health Group by visiting www.newsonhealth.co.uk and you can download the free balance app on the App Store or Google Play. [00:28:36][0.0]

ENDS