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Health visitor always wants to diagnose postnatal depression

You have suspected for a while that Jo, the health visitor, is rather keen to diagnose postnatal depression, regardless of the Edinburgh postnatal depression scale score (EPDS). She says her own experience of PND gives her a

particular rapport with 'her mothers' and she often implies that other health care professionals have missed vital cues.

A few of the women she refers to you are significantly depressed, but the majority of those you see at their postnatals or with their babies tend to describe tiredness and occasional low mood rather than overt depression.

Sarah, a competent third-time mother, comes to see you and complains that Jo has wrongly labelled and 'stigmatised' her as suffering from depression; she wants the diagnosis removed from her records. She also says other women at her postnatal group share her views and demands you stop Jo making new mothers feel inadequate.

Dr Christine Maple

'We know Jo had depression in the past ­ is it resurfacing?'

This could be rather a difficult situation and one that must be handled sensitively. First and foremost you have a duty to your patient to take her complaint seriously.

I think I would discuss this situation with my partners

to see if any others have a similar feeling about Jo's diagnoses. In particular there may be one GP who has more contact with Jo ­ the GP responsible for child health. I would also tentatively ask her health visitor colleagues if they have any concerns.

I don't think there is any getting away from the fact that you need to discuss this issue with Jo and I would need to gain the consent of Sarah to disclose her feelings. During any meeting I would stress to Jo the importance of documenting the EPDS score and persuade her that she should not make the diagnosis of postnatal depression without the patient seeing a GP, or at least without her discussing the patient with a GP.

I would also hope to be sensitive to Jo's issues too. She has had depression in the past; is there any evidence of this again? Has she identified any problems herself with regards to patient care? Is she stressed and is this colouring her judgment?

Finally, there is the request to change the medical records. I would obviously need to carry out a formal postnatal depression assessment. Assuming I do not feel Sarah is depressed, I would need to consider how best to amend the notes. It may be that it is only documented in the health visiting record. A written amendment to the effect that the diagnosis had not been confirmed by the GP may suffice. If it is documented in the main medical record a dated entry in the written notes to the effect that the diagnosis was unconfirmed should be sufficient. For medicolegal reasons entries should not be deleted or crossed out.

Computerised records are more difficult to amend since, if Read coded, they will appear on audits even if a subsequent entry states the original diagnosis was erroneous. The original entry would need to be amended with an appropriate Read code for 'entry amended' to ensure the record remains accurate.

Dr Chris Hall

'Perhaps the health visitor ''needs to be needed'' too much'

Jo needs to be made aware that just because patients attend you, it doesn't mean they're 'your' patients. As ever, tact is the order of the day, but she sets herself up for a fall with the apparent selfishness of her empathy. Experience of a disease process does not imply ownership of another's ailment. Just who is the patient? Perhaps Jo 'needs to be needed' rather too much.

Although I am not directly her employer, as gatekeeper to further services I must point out to Jo that 'people are talking'. It may be prudent to have a partner or a trust representative sit in on the meeting as things can be said in

the heat of the moment that should be witnessed, if not recorded ­ stress and 'nervous debility' are highly emotive and litigious areas.

How does Jo feel about the comments of others? She may be genuinely surprised; indeed, her apparent over-referral may just indicate a lack of confidence, or may reflect her own PND being missed ­ was it? If this is a confidence or indeed an arrogance issue we should strive to identify an agreed learning need.

It may be helpful to assess several of Jo's patients myself (or along with a colleague) to establish if her diagnostic skills really are in doubt. It should be pointed out to Jo that, irrespective of her feelings, implying to patients her diagnostic acumen is superior to that of her peers is highly unprofessional and inequitable.

If she agrees, it may be a useful (if time-consuming) exercise to talk through a few specific cases where others have disagreed with her. How exactly does she reach her diagnoses?

Turning to Sarah, she should be given a sympathetic but objective ear. If she wishes to complain about specific aspects of Jo's care she should do so in writing to Jo's employer.

While I may be required to contribute to subsequent soundings, I draw the line at acting as the trust's complaints and human resources officer! It would seem foolish to alter medical notes. However, some of Sarah's anger may be diffused by allowing her to add brief comments,

appropriately witnessed.

Dr Jane Bowskill

'I have encountered a few health visitors who contradict GPs'

The problem would seem at first sight to be Jo. Diagnosing and treating depression is a job for the patient's GP,

although support from health visitors and assessment using EPDS is invaluable.

I would reassure Sarah that I believed her and would investigate further, while asking her how she felt at this time, and offering the option of another consultation if things changed. She may have been depressed but now be better, or Jo's assessment may have been inaccurate.

But why is Jo ignoring the scoring system? She may have had postnatal depression herself but it doesn't sound as though she is being at all objective. Her comment about 'knowing her mothers' is odd, too ­ why does she need to own them?

Health visitors are usually not employed by GPs and GPs have little control over their work. I have unfortunately encountered a few over the years who contradict any advice given by GPs, especially on infant feeding and minor illness.

I once had a health visitor attached to my practice who was anti immunisations!

It would be useful to know how long Jo had been employed, and how long there has been a problem. We certainly need a meeting to clarify what is going on. It can be neutrally phrased: practice policy on postnatal depression.

With professionalism and tact it should be possible to work out what Jo is doing, how she is reaching her diagnoses and what she thinks about the EPDS. Depending on Jo's receptiveness, you may then be able to discuss concerns that some patients have raised, including that they have been told they have postnatal depression but disagree.

I would be inclined to leave things there, and arrange to liaise in a couple of months, monitoring the situation meanwhile.

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