Professor Louise M Howard

Professor Howard is a professor in women's mental health and consultant perinatal psychiatrist at South London and Maudsley NHS Foundation Trust . She is also President of the International Marcé Society, an NIHR Senior Investigator and holds a post in the section of Women's Mental Health, Institute of Psychiatry, Psychology and Neuroscience, King's College London.

She is one of 25 women to be highlighted as part of a special project that celebrates the stories of 25 amazing women psychiatrists.

Professor Howard's story

I have been privileged to have had an incredibly rewarding and stimulating clinical academic career, and it continues to be an enjoyable journey.

As science progresses, there is always more to learn and what I did not appreciate when first starting out was that research can lead you in unexpected directions and raise as many interesting questions as it answers. For example, when I started working on a PhD in perinatal psychiatry I was interested in the outcomes of pregnancy for women with a history of a psychotic illness, but I soon realised that the standard outcome measures available at that time were not designed for mothers with severe mental illness (SMI). I set out to interview women about outcomes of importance to them, and many told me about the violence and abuse in their recent or current relationships that were not being addressed by mental health services.

So, in addition to developing an instrument for mothers with SMI¹, I started to learn more about domestic violence and abuse (DVA). I reviewed the research literature and found that only 10-30% of cases were being detected by mental health professionals internationally² for many complex reasons³, that little was known about the prevalence of DVA in our patients, how it presents and what we can do about it.

As a result, I went on to develop a research programme on domestic violence. One of our surveys using British Crime Survey methods in our local patient population found that over 25% of women and 1 in 10 men had experienced DVA in the last year (69% and 49% respectively since the age of 16)⁴. Subsequent work included the development of integrated domestic violence advisor interventions⁵. I then found myself being asked to lead research on the NHS response to modern slavery⁶ and other forms of violence, not areas I ever anticipated researching.

Having identified gendered risk factors in my research, I was aware of the gender bias of mental health research ⁶ and tried to change the lack of focus on women’s needs in policy, practice and in research commissioning. Since I had developed expertise in these areas, I was encouraged by colleagues to apply to chair the NICE guideline on Antenatal and Postnatal Mental Health⁷. It was fortuitous timing, as soon after its publication, NHS England invested £365million into the development of new specialist community perinatal mental health services and the building of four new mother and baby units, using our recommendations as a key driver for clinical care pathways. This was also an opportunity for further perinatal mental health research!

It has taken much longer for other areas of my work to be translated into policy and practice – so my main strategies have been extensive knowledge mobilisation (i.e. taking any opportunity to write commissioned and non-commissioned CPD articles, offering to talk at Continuing Professional Development events in Trusts across the UK and at conferences) and approaching key decision-makers to influence training curricula.

I have found that, in general, women at senior levels have been much more receptive to thinking about, for example, DVA and mental health than men - and I really appreciated the support from Wendy Burn and Kate Lovett in facilitating the first RCPsych conference on domestic violence and mental health and helping me understand how to ensure DVA is included in curricula, exams and CPD materials. 

My career highlights have been two fellowships: firstly, a Wellcome Trust Clinical Doctoral Training Fellowship in the middle of my psychiatry training, which I also combined with episodes of maternity leave and part-time working due to childcare responsibilities and illness. I loved the opportunity to decide for myself what I wanted to research and how I wanted to do it.

My second fellowship, almost 20 years later as an NIHR Research Professor, similarly freed up time from other commitments to learn about methodological innovations internationally, and work on research ideas on which I had not had time to focus previously. The funding also helped build my research team, go on overseas research visits (including a fantastic sabbatical in Australia), network at conferences and get to know new international collaborators, many of whom have since become good friends. I cannot recommend more highly the opportunity to take some time out from clinical training, find collaborators you enjoy working with, and study through an externally funded PhD fellowship. Finding a research mentor is essential. I recently helped develop a NIHR mental health incubator, which should help people find research mentors if they do not have any in their organisation⁸.

The less attractive aspect of academia has been the inevitable rejections on the way –multiple rejections of grants and papers I knew were important, but others failed to see at the time! Dogged persistence has been needed. My own experiences of depression, and disability related to increasing neuropathy have, I think over time, also helped me become a more compassionate doctor, a curious clinical academic and someone who knows the importance of trying to get a work-life balance right for herself and her family, accepting that it is not always possible to do this perfectly.

Therefore, my career could not have been possible without:

• my very supportive family, including my husband who worked part-time (as I did) when bringing up our children - they are now two young women, working as a junior doctor and a teaching assistant for special needs children, and are my proudest achievements. My parents have also had a significant influence on me: my father, a Holocaust concentration camp survivor, was himself a slave labourer in coal mines when Romania was under Nazi occupation, and as a second-generation migrant, I wanted my clinical and research work to help reduce the impact of trauma on other victims of violence and their children
• some fantastic mentors, including a senior male mentor in my organisation, Professor Graham Thornicroft, who was so supportive of my flexible working needs, healthcare needs around postnatal depression and chronic neuropathic pain, and encouraging me to always aim higher than I had planned to!
• the research participants who have given so generously of their time and shared their experiences with our research team.

And I am indebted to the researchers in our research group who have worked very hard to produce high-quality research that has impacted on policy and practice, and who have been so supportive of me and so nurturing of each other.

Thank you to everyone!

References

1. Howard L, Hunt K, Slade M, O'Keane V, Senevirante T, Leese M, Thornicroft G. 'Assessing the Needs of Pregnant Women and Mothers with Severe Mental Illness: The Psychometric Properties of the Camberwell Assessment of Need – Mothers (CAN-M)'. International Journal of Methods in Psychiatric Research. 2007 vol. 16, no. 4, pp. 177-185.
2. Howard LM, Trevillion K, Khalifeh H, Woodall A, Agnew-Davies R, Feder G. 'Domestic Violence and Severe Psychiatric Disorders: Prevalence and Interventions'. Psychological Medicine. 2010 vol. 40, no. 6, pp. 881-893.
3. Oram S, Khalifeh H, Howard LM. 'Violence Against Women and Mental Health'. The Lancet Psychiatry. 2016 vol 4, no. 2, pp. 159-170.
4. Khalifeh H, Moran P, Borschmann R, Dean K, Hart C, Hogg J, Osborn D, Johnson S, Howard LM. 'Domestic and Sexual Violence Against Patients with Severe Mental Illness'. Psychological Medicine. 2015 vol. 45, no. 4, pp. 875-886.
5. Trevillion K, Byford S, Cary M, Rose D, Oram S, Feder G, Agnew-Davies R, Howard LM. 'Linking Abuse and Recovery Through Advocacy: An Observational Study'. Epidemiology And Psychiatric Sciences. 2014 vol. 23, no. 1, pp. 99-113. (see also more resources for community teams)
6. Howard LM, Ehrlich AM, Gamlen F, Oram S. ‘Gender Neutral Mental Health Research Is Sex and Gender Biased’. Lancet Psychiatry. 2017 vol. 4, no. 1, pp. 9-11.
7. Howard LM, Megnin-Viggars O, Symington I, Pilling S. Antenatal and Postnatal Mental Health: Summary Of Updated NICE Guidance. BMJ . 2014;349:g7394.
8. Mental Health Research