Carmine Pariante is professor of biological psychiatry at the Institute of Psychiatry at King’s College London and consultant perinatal psychiatrist at the South London and Maudsley NHS Trust. At the 35th ECNP Congress in Vienna in October he will present a plenary lecture entitled ‘Stress and perinatal mental health – from mechanisms to clinical practice’. Here he talks about his life and work to ECNP press officer Tom Parkhill.
TP: Have you recovered from COVID?
CP: I did! It wasn’t too bad at all; I think I’ve been quite lucky. I only had it for the first time last month, and the symptoms were only for a week. I could feel the effect of inflammation on my brain and my behaviour, which as you know is one of my areas of research – but it wasn’t too bad!
That’s good, sometimes it’s not so good to be so intimately involved in your work! You are Italian – how did you end up working in London?
I trained in psychiatry in Italy, in Cagliari. Then through a fellowship from the University of Cagliari I managed to go to the United States, and I spent almost three years in Atlanta, Georgia, working at Emory University. When I finished that I really wanted to pursue an academic career in a foreign setting. Of course London hosted the Institute of Psychiatry, now the Institute of Psychiatry Psychology and Neuroscience, which is certainly one of the top places in the world to carry on these activities. So it was a natural place to move on my way back from America to Europe. And what started as a few years’ experience has now become almost 30 years.
So you have worked in three countries. What sort of differences do you see in the way that people work?
In Italy I really only trained as a psychiatrist. I was already confronted by the difficulty of trying to deliver good clinical care in a stretched and underfunded public health service. In America I mostly had research experience. It was the first time I was confronted by working in a laboratory. So the focus there was really on trying to understand how you can ask a research question – about the causal mechanisms, and how you can manipulate a system through an experiment as opposed to just observing, which is more of what you do with clinical research.
The UK is a little bit in the middle. There is still a strong emphasis on the NHS, the public health system, which was lacking in the US. We are facing the same problems, but we have lots of people with energy and passion to deliver the best care possible. I always enjoyed maintaining collaborations not only in these three countries, but also across Europe. I have many colleagues in France and Germany, the Netherlands. So the European panorama in terms of research and academia has exploded in the last few years, and the possibility of collaborating with people anywhere in the world has been amazing.
Of course Britain has opted out of many European collaborations via Brexit. Have you seen a change, or is the research community still functioning as before?
We are suffering the consequences of Brexit, unfortunately. We are seeing that fewer PhD students want to come. Also at the top level we have difficulty in recruiting senior European people in leadership positions in academia, which we used to do before Brexit. There is still an unclear situation with European funding. We hope that we will be able to continue to apply for funding, but it’s a difficult ongoing situation. As you can imagine not only as a European but as a scientist I felt that Brexit was a decision which would have a profoundly negative impact on the science, on the international science. It is creating more silos at a moment when we should be working towards breaking down barriers.
Your forthcoming ECNP talk will focus on stress and depression in pregnancy and how this affects mother-infant communication. How did you start to work in this field?
I started as part of the clinical training in psychiatry, which I undertook when I arrived here. I worked in the perinatal psychiatry unit. The head of the unit was Professor Channi Kumar, who unfortunately died a few years later – everyone will remember him as one of the world leaders in the field. The UK has always had a really important tradition in looking after mothers with mental health problems during pregnancy and in the perinatal period. These specialist services were something which was something unheard of in many other countries. In Italy – which of course I know well – only now, in the last few years, there has recognition of the need for specialist services, and these are still only at the out-patient level, whereas in the UK there have long been specialist units where mothers could be admitted with their babies. You want to maintain the physical relationship between the mother and baby, you want to maintain the attachment, and a functioning relationship even in the context of mental health problems.
This clinical experience was certainly inspiring, it made me think about how important that crucial nine months in utero are, or the 12 to 24 months in the early part of life. You build the core of the emotional relationship with the people who care for you, and the people who symbolise your emotional relationship with the world. I was fascinated by the fact that pregnancy, which has always been considered less important in the context of mental health, was considered a key time point where you could identify women at risk. If women were already suffering from depression or anxiety, you could intervene and treat them through psychological or pharmacological interventions. So this was a really important emphasis in pregnancy, which was new to me. I was fascinated by this. Even today the general public does not know about the very high prevalence of mental health problems in pregnancy. When we talk about women in the perinatal period, everybody thinks about post-natal depression. Actually we now know that probably half of women with post-natal depression are women who were already depressed in pregnancy, and didn’t seek help or they didn’t come to the attention of the services. Of course, they do that in the post-partum period. And that was a revelation for me.
Over the years I developed a general interest in biological psychiatry, psychopharmacology, and also in psychoneuroendocrinology and the important role of inflammation and hormones in mental health. Of course pregnancy and the post-partum period is a key time when hormones change in the body of the woman, there is hormonal communication between the woman and the developing foetus, and of course there is the developing hormonal system in the baby in the post-partum period. I could specialise in terms of research in a natural area. So when Professor Kumar’s clinical post became available, I applied and that was the beginning of this area of research for me.
It’s interesting that we were talking about silos. I used to work in fertility, and to try to get an oncologist to take note that treating a young girl for cancer might have an effect on her fertility was quite difficult. They were in their silo, and fertility was in a different silo. It strikes me that this might be one of the problems you are talking about: obstetricians and gynaecologists not talking to psychiatrists (and vice versa). Is that correct?
There is always that problem and there is always that tension. Again, because the UK has dedicated mental health services, they are usually embedded within the general hospital or they have close collaboration with the general hospital. We for example have regular meetings with the midwife and we do multidisciplinary meetings with people from the obstetric services, for women who are pregnant and at risk of mental health problems.
Again, that’s the ideal situation, that’s the ideal culture behind it. Yes, it is difficult but the language we use and the concept of risk is different in different specialties. And if it can be so difficult in a context like the British one, where there is a tradition of this communication, then I know this would be more difficult in other countries where this tradition is not as developed. So for example I know from clinical practice, and also from talking to colleagues elsewhere in Europe, that women with mental health problems, as soon as they become pregnant, are immediately asked to stop the antidepressants abruptly, with no preparation, with no assessment of risk/benefit of continuing. This is usually driven by primary care physicians or obstetricians; of course they are worried about the safety of the foetus, I’m not saying that their worries are not important, but that kind of decision should always be taken by a multidisciplinary assessment – because in some women, the risk of stopping medication in pregnancy is higher than the risk of continuing, especially for women who have had severe depression in the past.
It’s good what you say, that this integrated approach can help us break out of these silos. And also that there are things we can learn at European levels, and this may be one of the areas where international organisations can help. Talking about international problems, the Ukraine war is obviously a disaster. I imagine it’s also a disaster for perinatal mental health. Do you have any thoughts on this?
Not directly. Of course we have all been reading horror stories of hospitals being destroyed by bombs, of women and children dying or suffering severely. We have been trying to get in touch with other mental health professionals, or people involved in mental healthcare in Ukraine, just to collect some testimonies. I’m the editor of a mental health blog, Inspire the Mind. We have some blogs and pieces written by people in Ukraine, or people who are in correspondence with doctors or health professionals on the ground in Ukraine. We’re trying to collect testimonies and trying to understand what’s happening. It is important to give voice to people who suffer there.
You have been very positive about communicating science and mental health, through the blog. Is there anything you can say to psychiatrists and scientists who might be interested in communicating their work to the public?
Certainly, I think that it’s a fundamental aspect of being a doctor or a scientist today that you need to be prepared to go in front of a microphone or camera, or to have something written in with your ‘voice’, to describe science or clinical findings in lay terms that the public can understand. I think COVID has demonstrated even more that we need a voice of science – a voice of reason – and we need to do this across all aspects of science. For people who are interested, put yourself out there: write your own blogs, contact existing blogs. Write to me, we are always happy to publish work from scientists or clinicians, or people with lived experience who are interested in writing about mental health.
Inspire the Mind works very closely with people who have never written before; we can mentor them in the skills needed to talk clearly and effectively. It’s interesting that you see really good scientists with extremely sophisticated minds, but as soon as you ask them to put things in a language that everyone can understand, they immediately freeze. There are skills we can develop. Now more and more there are courses run by universities and hospitals on how to interface with journalists, how to communicate in front of a camera. I’d always recommend that people should do these kinds of courses, because we may all end up having to talk to journalists one day about something we have done and it is important we know how to do it.
I couldn’t agree more! And thank you for being here today and talking to us.
PL.06 Stress and perinatal mental health – from mechanisms to clinical practice
Tuesday 18 October 2022
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