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Researching suicide in perimenopause and menopause with Dr Pooja Saini
Advisory: we would like to apologise for the sound quality in this episode, which was due to technical issues experienced during recording.
Dr Pooja Saini is a Chartered Psychologist and Reader in suicide and self-harm prevention based at Liverpool John Moores University. Her work has a particular focus in suicide prevention in primary care and developing community-based interventions for high-risk groups.
Since connecting, Louise and Pooja have been discussing the impact of perimenopause and menopause on mood, mental health and suicide and the many research gaps and unanswered questions in this space. In this episode, Pooja explains more about what is known and unknown regarding the effect of hormones on suicidal thoughts and outlines the research plan for a PhD funded by Newson Health Research and Education.
Pooja’s tips for those with suicidal thoughts:
- Early intervention is key; seek help as soon as you feel you are not yourself
- Change your habits to do more of what you really enjoy
- Talk to your loved ones, family and friends. Don’t try and hide or mask it.
If you need support, you can call the Samaritans on 116 123 for free from any phone or email them at email@example.com
Pooja’s Social Channels
Reference for BMJ article discussed:
McCarthy M, Saini P, Nathan R, McIntyre J. Improve coding practices for patients in suicidal crisis. BMJ. 2021 Oct 15;375:n2480. doi: 10.1136/bmj.n2480. PMID: 34654729.
Dr Louise Newson [00:00:09] Hello. I’m Dr Louise Newson and welcome to my podcast. I’m a GP and menopause specialist and I run the Newson Health Menopause and Wellbeing Centre here in Stratford-upon-Avon. I’m also the founder of The Menopause Charity and the menopause support app called balance. On the podcast, I will be joined each week by an exciting guest to help provide evidence, based information and advice about both the perimenopause and the menopause.
Dr Louise Newson [00:00:46] So today on the podcast, I’m absolutely delighted and thrilled actually to introduce to you someone called Dr. Pooja Saini, who I’ve reached out to probably about nine months ago now. And we’ve been talking a lot, actually, and our conversation is only at the beginning. So welcome, Pooja to the podcast today.
Dr Pooja Saini [00:01:05] Thank you and thanks for inviting me here today.
Dr Louise Newson [00:01:08] So I read an article that you had written in the BMJ, the British Medical Journal, and it was about suicide. And I reached out to, I think I probably like most of my email, sent quite late at night and I send in lots of emails all sorts of people wanting to engage in menopause in a bigger way. And I was so excited when you replied. And then we had a conversation, didn’t we? And things have escalated, which is great. So do you mind just explaining what you do and even, you know, what led you to write an article in the first place?
Dr Pooja Saini [00:01:40] Absolutely. So I’m a reader in suicide and self-harm prevention, and I’ve been looking at suicide prevention, particularly within primary care, because a lot of the research that’s been done to date has been in hospital settings and A&E settings, so what we really wanted to look at within my research area was what’s happening in primary care and how can primary care intervene within suicide prevention. And what came to light really is firstly that a lot of people are communicating to their GPs in the year or months prior to death that they might be feeling suicidal and in many cases primary care provided really good care and that they try to manage the patients in that setting, but did need more support from the wider healthcare settings. But they weren’t necessarily finding it and on many occasions they were just having to refer people to A&E because that was the only option available to them. I think another thing that really struck us with that research was how men were actually help seeking. And one thing that was being highlighted in the research was that, you know, men don’t help seek. So we started to think about, you know, interventions that might be provided within community settings for those high risk groups that are hard to reach. And that’s led to some of the development of the work in some community based interventions that I work on to do with suicide and self-harm. Additionally, what we found when I reviewed A&E records, there was a real variation in how A&Es across the North-West, because that’s where I looked, recorded suicide ideation, self-harm, people attempting for suicide attempts. So the article in the BMJ was really focussing on how do we get a system in place where we have really clear coding for people who come in, not just who’ve actually made an attempt or actually self-harmed, but for those people who’ve come in and communicated that they’re in suicidal distress because they seem to be coded as all different types of things, sometimes for depression, sometimes for anxiety, sometimes psychosis other times, social issues. So we’re not really getting, I think, an accurate number of how many people are presenting to A&E in suicidal crisis. So that’s what that article was focussing on, is how can we code more accurately so that can then be fed into our national data?
Dr Louise Newson [00:04:16] And it’s so important, I did psychiarty many years ago in the Northwest, actually in Manchester, in North Manchester in Crumpsall a very deprived area. And, you know, the stories I heard, you know, will stay with me forever. And then I did work in Styal Prison actually – a female prison – and again a lot of women had quite a lot of psychological and psychiatric disturbances and illnesses and really very troubled a lot of people. And then over the years, I’ve seen all sorts of people in hospital, in general practice, and now actually in my clinic. And I never thought as a medical specialist I would be so interested in suicide because I suppose I didn’t realise that there was so much psychological distress. We all know about anxiety, we know about low mood, we know about some of the times we get very intrusive, negative thoughts. But I didn’t really think or realise that suicide and suicidal thoughts were on the radar of perimenopause and menopause until I started seeing the volume of women I do, and I know I see a skewed population because a lot of the people I see are really an extreme because they can’t get help elsewhere. But the number of women I have now seen who have quite detailed psychiatric backgrounds, they’ve had all sorts of quite heavy duty to medication. I’ve seen various people have had ECT as well and they’re really not improving. And because I know that they’ve got hormonal variation in their symptoms, other symptoms, physical symptoms as well. I’ll often give them HRT because it gives them benefits for other reasons. Saying to them I have no idea whether this is going to help your mental health. I do not want to give you false hope because that’s the worst thing you want to do for people. And then when they come back and they’re literally skipping in the clinic and say, ‘I wish I’d been like this before’ and these very negative thoughts have gone. And, you know, we’ve spoken about this before Pooja, there are cases of suicides that we know have been related to perimenopause and menopause. And, you know, there’s all this talk about, you know, risks of HRT, risk of breast cancer, risk of whatever, but actually your risk of suicide, if you’ve got suicidal ideation, your risk of death is 100%. And there’s nothing else in medicine is there that has such a high mortality. So ways of recognising it and not just recognising, but acting to try and reduce is so key and I know that’s what you spend your pretty much your entire professional life on isn’t it, on work? But how much of your work has been looking at menopause and perimenopausal until now of course?
Dr Pooja Saini [00:06:50] Yes. So I suppose this really is a new area for me and my interest has been sparked by your initial email that came through and it started to make me think because I used to work at the National Confidential Enquiry in Manchester and I regularly review their reports and their data and that age group of 45 to 55 for women, and potentially perimenopausal age group has always been the highest group in women since I’ve been working in this field. And although numbers are decreasing in some groups for young women, and for women in their forties and fifties it’s increasing, which is quite concerning. And obviously there needs to be more research done into why that might be. And I think your initial email got me thinking, got me looking up at some papers myself, and I started to think myself in these two groups. Is there something related to hormones as well in the younger women and perimenopausal women? So since our initial conversations, I’ve had a look at the data a little bit more. It’s very limited in this field and I think a lot more research needs to be done. And I think from your clinic, there’s a lot of learning that we can start within this space.
Dr Louise Newson [00:08:11] Yes. And it is so important I mean, most of what, well not everything I learn a lot from reading a lot of scientific papers, but I certainly learn a lot from patients. And it surprises me so much, stories that they tell me not just of how they’re feeling but also how they improve. I know it’s not placebo, because there’s so many of them actually that have similar stories and it is how we can pick out whether it is the perimenopause, which is the time when we have great changes in hormone levels or whether it is related to the menopause when hormone levels are low, and everyone’s different. And that’s what makes it so difficult. But we do see a lot of people who have so-called reproductive depression. So they’ve had a really stormy time postnatally, they’ve often had PMS and then the perimenopause comes and a lot of these things reoccur. The doing research is key because that’s the only way we can drive things forward, rather than just doing anecdotal medicine. So I’ve sort of put some of our money where my mouth is, and we’re committed to funding a PHD student for three years and so, you’ve recruited Olivia, who’s brilliant. And so tell us more about what that’s going to involve.
Dr Pooja Saini [00:09:19] Yes, it’s a really exciting opportunity for us to have a look at more of an area that’s related to women’s health, which I think is really exciting in the first place. But we’re going to be focussing on having a look at how some of the pharmacological medications that are given to women for hormonal treatments actually affect their psychological outcomes. So that’s one aspect of a PHD. The second aspect will be having a look at actually introducing some measures where we might actually get to do some comparisons with some questionnaires that measure more for hormonal depression and then others that measure for more general depression. That’s the same type of tools that are used currently in primary care, so the PHQ9. And we’ll be using another question, I call the MenoD, which focuses more on menopause. So we’ll be having a look at what are the differences between those questionnaires and also are women scoring differently on them. They will come into the clinic. So that’s the second aspect. And then the third aspect is looking at this group of women who seem to be vulnerable, who have attended, who may have talked about being suicidal and having a look at more in-depth case notes to see what were they communicating when they came in and if they have improved, what has kind of happened along the way that might have helped those improvements. Is it just coming and talking about the issues or is it some type of medication they’ve been on? Is it a combination of the two?
Dr Louise Newson [00:10:57] Yeah, which is going to be revealing because we don’t know the answer. And there’s a lot that we find on paper when we do questionnaires, and then there’s a lot of subtleties that it’s picking up. And it’s often those subtleties are really important when we’re looking at how to really manage women properly. And like I say, there’s a lot of people that feel flat, a lot of people that feel very low in their mood, they have no zest for life, but they’re not the suicidal ones. And it’s how we can pick up those, because sometimes it’s when people go quieter as you know and who do they talk to and how do we involve other people? So how do we help GPs and mental health workers and relatives as well? And that’s what’s going to be really important, isn’t it?
Dr Pooja Saini [00:11:45] Yeah, well, I think another really important aspect of the research is actually speaking to people. So speaking to clinicians who will be offering some of these treatments, speaking to administrative staff who may be speaking to women when they’re booking in, pharmacies, nurses, and also speaking to women themselves about their kind of lived experience and their supporters and carers and their experience of the process. And when women have become unwell and what they’ve seen as well as some of the key elements of them either getting worse or getting better and I think finding out from people themselves their experiences can be really powerful to add to that kind of quantitative data where we can do lots of number crunching. But I think actually speaking to people and hearing about their experiences can be really powerful in adding to that data as well.
Dr Louise Newson [00:12:41] Yes, definitely. And we’re already doing a lot of educational work, we’ve just writing an e-learning module for the Royal College of Psychiatrists, which is just under the final review now. And it’s how we educate people, because I certainly never thought about asking the questions could it be your hormones, what are your periods like? And talking to a psychiatrist that I know quite well, it’s quite difficult sometimes to get that conversation started, but they are finding that when they do, people actually then think and reflect and go, ‘Gosh, I had no idea this maybe could be related, and I actually come to think of it, my symptoms were like this when I started when my ovaries were removed or when my periods started changing’. And it’s just those connections and we do it a lot in medicine don’t we, but it’s having the time to think about it and then taking a step back. And like you say, sometimes it’s others who are commenting and realising more than the person because it’s very difficult for people to be as judgemental when they’re in it the whole time. And it’s very scary. You know the women I see have a lot of insights, which is quite different actually to quite severe clinical depression. People often don’t have insight, they don’t realise what’s going on, but these women are incredibly scared of their thoughts. And I have seen so many women whose family members have hid the carving knives or anything sharp or they’ve been really, really scared of their actions, but they change with the time. And so often it’s early hours of the morning when we know hormone levels are often at their lowest, where they wake up and they are convinced that they are going to do something really bad and harm themselves. And then three o’clock in the afternoon, they’ll say, ‘No, I’ve been having a cup of tea, I’ve been out in the garden with my family or gone for a walk with a friend and I feel fine. I can’t believe I felt like that at three in the morning’ and those changes throughout the day and certainly throughout the month, are quite classic and typical of hormonal variation. But if you’re only looking at a snapshot, we’re going to miss those things aren’t we.
Dr Pooja Saini [00:14:44] And I suppose with your clinic, women have obviously already reached out to you and they’re coming to speak to you about some of their issues. But there’ll be many women who are still under the kind of stigma of suicide and the stigma of menopause, who maybe aren’t even openly talking about their issues as well. So I think the stigma that’s associated with both of these topics can really affect how people disclose what’s going on in their lives as well.
Dr Louise Newson [00:15:14] Yeah, and it can affect different people in different communities as well. And we’ve just spoken about this this morning, how we can reach other communities where it’s not so easy to maybe even understand what’s going on. But even if they do to actually talk about it because there’s a lot of stigma about mental health aren’t there in some communities more than others, and then menopause as well. It’s a double whammy, isn’t it?
Dr Pooja Saini [00:15:36] Absolutely. And I think culturally, you know, I’m from a South Asian background and it’s a case of, well, you know, your grandma didn’t have HRT, your mum’s not needed HRT, why would you need it? And it’s a really new conversation that’s happening within, I think, my own generation. So it’s still very new in this kind of cultural background. So I’m only speaking from my own, but I do know that people would be more negative about you thinking about hormonal treatment than positive. So I think there’s a lot of education and knowledge sharing that still needs to be done as well. You’re right.
Dr Louise Newson [00:16:12] Absolutely. And you know, there’s a lot of celebrities out there that talk about the menopause but a lot of them are caucasian and a lot of people see it as a lifestyle medicine. And they still see it as a drug, but they also see it as an optional treatment, which you can take if you want to have bit more energy or be able to exercise better or have better skin or hair. And actually, it’s not about that at all. And this is how we get these conversations changing as well. But certainly the response from people that I have educated who work in mental health, so psychiatrists, psychologists, mental health workers have been really quite phenomenal in the last year, 18 months has been far more positive than I’ve ever known actually. People have often been emailing and reaching out to say, ‘How can we be involved? We’re now looking at our patients, whether they’re inpatients or outpatients and realising that we’re not doing this proper hollistic service because we haven’t thought about hormones.’ And I don’t know if it’s like that with any of your colleagues Pooja. But are you noticing the conversation is changing?
Dr Pooja Saini [00:17:13] Yeah. So I do a lot of work with the local mental health trust here where we’re looking at people with complex mental health needs and you know, people who’ve got unfortunately really long standing relationships with mental health services and may be in and out of inpatient wards as well, rehabilitation wards. And one thing I’ve taken back to the trust I’m working with is, you know, have you ever thought about this for some of the women who are actually coming in? And they did say, which was quite promising that it’s only recent, but they have actually started to look at HRT and menopause in some of the women at the tTrust. But like I say, it’s a really new conversation. So it’s obviously not something that has been thought about or looked at in previous years, but it’s promising to hear that they’re open to a conversation and that it is being brought to some people’s agendas, which I thought was really good. But again, that’s something I might look at further following on from the PhD with some of the local mental health trusts I work with.
Dr Louise Newson [00:18:16] Yeah it’s really important and we’ve been reaching out to some local psychiartists and looking at how we can do just an in-house clinics almost and some advice and guidance, because it can be quite difficult just with contracts with the NHS, trying to help people, but how we can use our experience to really help reach other people. And one of my patients emailed me last week actually and she was a lady who was really in crisis when I first saw her and I hadn’t realised thankfully that she had already written her suicide note and planned her death if she wasn’t going to improve, and I helped her and obviously I helped her to the best of my ability, but I was quite relieved because I didn’t realise that at the time because the pressure on me would have been even more immense. But she had had a long psychiatric history and had been sectioned many times before and kept saying to her mental health team, ‘I think it’s my hormones’. And they said ‘No, no of course it’s not’. But she emailed me last week to say that she’d now got a nurse, a menopause nurse working alongside the mental health team, and that was instigated by her because they have been absolutely shocked how much she’s changed from somebody who was housebound with crippling depression and anxiety for four years, to this person who is now independent and happy, she still has some issues, of course she does. But she has transformed beyond belief and she’s also reduced many of her heavy duty medications as well. So that’s a real step in the right direction, actually, to have a menopause nurse. But we know the training is very limited in the menopause. There aren’t enough menopause specialists in the NHS or privately there’s just not enough. So we need to train within so we don’t have to keep referring to other people because once we have some basic training, actually it can be very easy. It can be very quick to diagnose and signpost in the right direction if not treat themselves.
Dr Pooja Saini [00:20:09] Yeah, and I think the same again goes for suicide prevention. Many health professionals aren’t trained in suicide prevention either. And so I think if you’ve got someone who’s had no training in menopause and no training in suicide prevention and you’ve got a woman coming in potentially with both those symptoms, it’s really difficult. So I agree. I think more knowledge, more training for health professionals, for menopause and suicide prevention. And a really key thing I learnt, I think when I came to your clinic last week was about the fact of when women do go and speak to health professionals about people asking about their periods or how they were after they’d had a baby and whether they’d felt quite low, and how that might show some of the symptoms that they may now also be showing and whether it’s hormone related. I thought that was really interesting.
Dr Louise Newson [00:21:02] Yes. And it was only I learnt it from the late Professor John Studd suggesting to ask women, ‘How did you feel when you were pregnant?’ You know, if they’d have been pregnant before, of course. And usually they just sit back and smile and say, ‘Gosh, that was the best time. I felt amazing’. And then how were you after your baby was born? ‘Oh terrible, absolutley terrible and looking back I probably was depressed’ or some of them have had a post-natal depression diagnosis and those women, I’m sort of, you can never be 100% in medicine, but I’m pretty near 100% sure that they will improve with some hormones. And it’s amazing actually to see how they do improve and getting those balance of hormones as well as carrying on with other treatments. But a lot of people with time do find that they can reduce their treatments and a lot of women I see are on quite heavy duty drugs you know drugs like Quetiapine or even Ketamine now we see quite a few that are given resistant depression and they will have side effects. You know a lot of these women have quite slurred speech, they have slow ways of thinking. And it’s very difficult to know is that their depression or is it side effects of their medication? It’s very difficult. They have this chemical cocktail don’t they and it’s very hard. It’s really difficult. And for a lot of these women, that’s it for the next twenty, thirty, forty years however they live. They are told they have to be on these medications, there’s no other treatment. So it’s been very interesting sort of educating the psychiatrist through their own patients actually. So moving forwards we’re doing the PHD but we’re also collecting quite a few people aren’t we who are really interested and some key players in this field because research is great, but it’s got to be translated to make a difference, hasn’t it? So we’re trying to find the right tools so people can quite quickly, whether they’re in a short GP consultation or a longer psychiatric consultation or in A&E or wherever people present, to really try and help to target and recognise whether hormones might be related to their suicidal thoughts, aren’t they?
Dr Pooja Saini [00:23:11] Yep, absolutely. And I think the more evidence we can gather and disseminate that will be really useful for the field.
Dr Louise Newson [00:23:20] And it’s really interesting because a lot of people think about the menopause and we know that the risk of suicide increases by a factor of seven in the women who are in their late forties. But we mustn’t forget younger women as well in this conversation as well. And when we were talking about scoping out the research, it was very clear that we didn’t want a younger age bracket because it’s younger women that can be caught unaware. And I’ve certainly missed women who have been in their twenties, thirties who I know now are perimenopausal or menopausal, and they might be the ones that are more at risk. We don’t know because so little research has been done in this area. So we are really trying to be as inclusive as possible aren’t we so we can really help the biggest number of people.
Dr Pooja Saini [00:24:07] Absolutely. And, you know, I was really surprised to hear that women as young as fourteen, sixteen could be going through menopause, and that could be quite a load to take on at that age when you probably just got used to having periods to undergo such a major change. So again, psychologically, that could be really negative for some people and negative for their thoughts as well, as well as the hormonal changes too.
Dr Louise Newson [00:24:35] And it is interesting, once I’ve conquered perimenopause and menopause and I will look at PMS as well, because it’s very interesting when you see this drop just before periods. And even my oldest daughter’s only nineteen, and a lot of her friends really notice it. They have very dark, dark days just for the day or two before their periods. And, you know, that might be really significant when we look at suicide in general and suicide risk, because these women, these girls even are not perimenopausal, but they have hormonal variations, but they do have the intelligence and the strength and the power to sometimes act on how they’re feeling. And this really scares me, actually, because especially if it is related to hormones and a hormone dip before their periods, then it’s easily treated by not even replacing just topping up the missing hormones. But it’s also the people can recognise this as well, isn’t it? Because a lot of people, if they know it’s related, they can be quite reassured that it’s not going to last for long. But what’s really, really important that has just not been thought about before, I think, so much.
Dr Pooja Saini [00:25:44] No, and I think another thing from our discussions that’s now come to light is when we look at these women who data is already collected on, who’ve died by suicide, is actually to start looking more closely at some of the differentiation between the women in those age groups where there maybe more significant hormonal changes and other women. Just to see, you know, are they using more violent methods. Is it happening more suddenly? Have they had longstanding relationships with mental health services? And I think we need to start to distinguish some of that information now, because some of the anecdotal evidence suggests that women who may be perimenopausal, may be using more violent methods, may be more impulsive, may be deteriorating much quicker than other women. And if we have the knowledge that that might be the case, then that might be really useful for clinicians, you know, when you need to have early signs of kind of suicidal behaviours.
Dr Louise Newson [00:26:47] Yeah, so there’s a huge amount of work that we need to do. This is just the beginning, but I think it’s really useful and I hope people have found it useful. I know it’s not an uplifting topic to talk about, but it is really, really important and we’re determined to make a difference in this area. So I’m hoping, Pooja, you’ll be able to come back and we can report about some of the findings and what we’re doing to take this conversation forward. But I’m very grateful for your time already and look forward to seeing what happens going forward. So thanks ever so much for your time. But before we finish, I just want, I always end with three take home tips and I’d be really grateful actually if you could give three tips to people who are worried about relatives or even worried about themselves who have had some dark thoughts, is there anything that you would suggest or what help could they get to know for now?
Dr Pooja Saini [00:27:39] My biggest tip is early intervention, so I think seeking help. As soon as you feel that you’re recognising you’re not yourself, changing some of your wellbeing habits to doing things that you really enjoy, I think can be really powerful sometimes. So if there’s a certain hobby you enjoy, going back and doing that. But yeah, and speaking to people, you know, speaking to your family, speaking to your loved ones about how you’re feeling and not hiding it or masking it. And I think women unfortunately, we’re very good at hiding and masking our feelings. So yep, I think just speaking out.
Dr Louise Newson [00:28:15] Very important and not doing any of this alone is really key.
Dr Pooja Saini [00:28:19] Absolutely.
Dr Louise Newson [00:28:20] And there are people to help. And if it’s not the first person that you speak to, then go to someone else and actually don’t be ashamed of how you’re feeling as well, because it’s a lot more common than people think as well actually, isn’t it? Just to have.
Dr Pooja Saini [00:28:34] Definitely.
Dr Louise Newson [00:28:34] And a problem shared is a problem halved as well. But absolutely no one should be suffering. Certainly no one who’s listening to this. So thank you so much for your time today and hopefully welcome you back in the not too distant future.
Dr Pooja Saini [00:28:48] Thank you for having me.
Dr Louise Newson [00:28:51] For more information about the perimenopause and menopause, please visit my website balance-menopause.com. Or you can download the free balance app which is available to download from the App Store or from Google Play.