Diagnostics in the OB/GYN Setting
That depression is widely prevalent among women - especially during the reproductive years - is well known. And, as most women visit an obstetrician/gynecologist at some point during those years, this seems to be a logical setting for screening and even treatment. In reality, however, such attention is infrequent. Here, a panel of experts explores the possible reasons and remedies for this failure to address a common illness in women.
Sichel: With so many women using an OB/GYN as their primary care physician, I'd like to ask our panelists where we are in terms of diagnosing depression in women. Dr Ciotti?
Ciotti: OB/GYNs are in the same position as many other primary care providers in that the rate at which we detect depression in our patients does not equal the prevalence of depression in reproductive-aged women. These are the women at greatest risk.
Sichel: Should OB/GYNs be responsible for recognizing depression?
Ciotti: Most OB/GYNs feel great responsibility for both primary and preventive care of women, and detecting depression would be considered a part of that responsibility.
Sichel: Dr Ling?
Ling: At the start of their careers, OB/GYNs typically concentrate on obstetrics, with an emphasis on younger, healthier patients. As these physicians mature, so do their patients. They literally age together, almost as a unit. We see women during the life stages when depressive episodes are most likely to occur-from adolescence and childbirth through menopause and later life. Although older physicians may not have been trained to provide primary care for depression, they have a long-term bond with their patients that gives them unofficial but valid insight. So, many OB/GYNs have already taken a more active role in treating depression.
Sichel: I agree. When a physician gets to know how a patient experiences the world, if she presents with a vague complaint, the physician's 'sixth sense' will let him or her know that something is wrong. Dr Ciotti, how can we teach this 'sixth sense' to residents and others?
Ciotti: Although much of OB/GYN training concerns technical aspects, we must also encourage our residents to look at the whole picture-including psychosocial issues. It would be helpful for OB/GYN attendings and faculty to serve as role models in this area. Although it's essential to build working relationships with psychiatrists, psychologists, and social workers, we must also know the basic skills and impart that knowledge.
Sichel: Dr Burt?
Burt: The OB/GYN residency training program leaves little room for formal training in psychology. Therefore, OB/GYNs are not likely to become aware of psychosocial issues until they work with patients. We psychiatrists can talk with OB/GYNs, join in grand rounds, lecture at the community level, and write for peer-reviewed journals that are directed at both OB/ GYNs and psychiatrists. But formal training will happen only when the established hierarchy recognizes the need.
I've found clinical interfacing about actual cases to be particularly useful. For example, we may see a 38-year-old patient with two or three prior episodes of major depression who has responded very well to antidepressants. Now she wants to have a child but is afraid to stop her medication. I'll contact an OB/GYN, and together we'll work out a plan so that this woman can go safely through pregnancy. We'll develop a dialogue and, as a result, the OB/GYN will continue to treat the patient. There's a real sense of collegial cooperation.
Sichel: Dr Stowe, what's your perspective? Should OB/GYNs care about a patient's psychological health?
Stowe: In academic centers, the knee-jerk response of most residents is to obtain a consult-but the key to successful consultation is liaison. In fact, before my residents in psychiatry seek consultation for hypertension or diabetes, I ask that they attempt management themselves. By the same token, I tell OB/GYN residents that we're happy to help them, but they should make the initial attempt. We try to show them that because they have an established relationship with the patient, they are better positioned to evaluate and manage her depression. By interacting with the psychiatrist, OB/GYNs can learn how to assess and treat most cases of depression.
Burt: When I do grand rounds with OB/GYNs, I ask how many inquire about a patient's psychological history. Invariably, at least 50% of the physicians raise their hands. Then I ask them what they do with that information, and there's a collective pause-because, of course, the information is filed away.
Depression occurs twice as often in women as in men, and it's particularly common in women of childbearing age. Furthermore, a patient with a single episode of depression has a 50% risk of a second episode, and those with two prior episodes have a 75% chance of a third episode. So OB/GYNs must realize that they're at the gateway far more often than are psychiatrists, who see the patients only when they're very ill.
Ciotti: Residents at large medical centers often have many resources, such as social workers and psychologists. When they graduate, they may not have such resources at their disposal. In practice, all too often, the patient will see the psychologist, psychiatrist, or social worker, and the OB/GYN may not have access to the assessment. Instead, the OB/GYN and mental health provider must work together in the management of the patient.
Burt: When we are consulted about a patient who is planning to become pregnant, who is pregnant, or who is postpartum, we develop a differential diagnosis in order of priority (Figure) and then a treatment plan. Next, we sit shoulder-to-shoulder with the patient and OB/GYN, with no secrets. Rather than making psychiatry into a mystery, we explain to the patient why we are-or are not-recommending an antidepressant and then review her treatment options during pregnancy and/or breast-feeding.
Sichel: It seems that communication needs to occur at all levels-physician-patient, physician-physician, and partner-husband.
Ling: Many OB/GYNs-both new and established-have become very sensitized to the medicolegal implications of prescribing an antidepressant. Also, some psychiatrists feel it's inappropriate for OB/GYNs to do this. How can we overcome these attitudes?
Stowe: It's critical to distinguish between legal concerns and plain fearfulness. As an OB/ GYN, would you treat pneumonia or hypertension? Some would say yes, others, no. I would encourage a similar attitude with respect to depression. Begin treatment and reevaluate in 8 to 12 weeks. If no improvement occurs, make the referral. Conversely, if the patient is severely depressed and talking about suicide, she should probably be referred immediately. Although physicians are often reluctant to ask whether the patient is thinking about harming herself, this question can actually help them ore confident in treating routine depression.
Burt: I've been involved as an expert witness in a case where no one-neither the OB/GYN nor the psychiatrist-asked that question, and the patient left the hospital following delivery and tried to kill herself. So it works both ways. You may be afraid to ask the question, but you should also be afraid not to ask. Always encourage follow-up. Once a patient is feeling better, she may 'forget' that she has seen a physician and will get on with her life. So, if you embark on a treatment program for a depressed patient, invite her to call you a week later. Monitor the patient during the next 8 to 12 weeks, as Dr Stowe suggested.
Stowe: We have to distinguish among specialties in OB/GYN. While I'd have some concern about a pelvic surgeon handing a prescription to a patient, I have no problem with a generalist OB/GYN prescribing for a patient who has been receiving comprehensive care. I always send the referring OB/GYN a one-page treatment plan that begins with general health and behavioral issues like "no caffeine, no chocolate, take a walk every day" and ends with my medical recommendations. I want the OB/GYN to realize that I don't always prescribe medicine. I encourage the physician to look at the whole patient, such as the woman who may be complaining of insomnia and anxiety while she lives on a diet of cola and coffee.
Sichel: As we all know, not all depressed women meet the classic criteria in the American Psychiatric Association's Diagnostic and Statistical Manual-our colleagues in epidemiology have confirmed this. So how can we reliably identify women who are depressed?
Stowe: Begin with what you know. For the OB/GYN, this may be with recurrent urinary tract or yeast infections or chronic pelvic pain, which can all be affected by stress and depression. I like to make treatment decisions based on two parameters: function and distress. If the patient demonstrates impaired function or significant distress, the number of textbook criteria they meet becomes less relevant.
Ling: And 'distress' certainly includes emotional distress.
Stowe: Of course. For example, if a patient has a miscarriage, how long is she allowed to be upset? We don't have any criteria for that. But treatment should be based on function and distress; diagnosis is what we submit to the insurer for reimbursement. The diagnosis of depression can have an adverse impact on a patient's future insurance claims, so it may be better to use terms like adjustment disorder or anxiety disorder. Once you apply the label of major depression, you may affect her ability to obtain life insurance forever.
Sichel: Dr Ling, you've had some problems with the formal diagnosis.
Ling: I agree with Dr Stowe. I was one of the OB/GYNs who served on the panel that produced the Diagnostic and Statistical Manual for Primary Care; the result was not as user-friendly as I would have liked. Rather than adhering to strict definitions, you've got to rely on your clinical acumen and get a feel for what works. Our specialty is very outcome-oriented; once OB/GYNs understand that they can expect an 85% to 90% success rate in treating true depression with the appropriate antidepressant, they may be more inclined to embrace screening and therapy.
Burt: I agree that we don't want to be overly constrained by absolute criteria, but failing to recognize depression as an illness with distinct parameters can also lead to problems. For example, the OB/ GYN may be seeing a patient who had a difficult delivery of premature twins who are still hospitalized. The patient meets the criteria for depression, but the physician thinks that's perfectly normal because she has two very sick babies. However, the mother can barely get out of bed. She has lost weight beyond her pre-pregnancy level. She is dehydrated and dizzy, and she is unable to sleep even though she's exhausted. She cannot organize her daily activities or even her thoughts. She has good reason to be depressed, but that doesn't mean she has no need for treatment. And if you look back, you may find that this patient had prior episodes of depression-predisposing her to this current reaction.
Ciotti: If the patient is not functional and is not coping, then she needs treatment-even though she has good reasons to be depressed. We often tend to explain things away, and that can be a big problem.
Sichel: We have to remember that depression is a brain disorder. Different events can have an impact on the brain's biochemistry that may ultimately require treatment. It's important not to err on the side of nontreatment just because the patient is having a 'logical' reaction.
Stowe: I like to compare depression and other psychiatric disorders with medical illnesses. For example, most physicians would prescribe an antibiotic when a patient has strep throat, even though there's no evidence that the treatment changes the clinical course of strep throat. Because the physician's priority is to alleviate suffering, we routinely do things that are no more safe or unsafe than initiating a trial of an antidepressant. So when you have a possible upside and virtually no downside, we should probably err on the side of treatment. We should also remember that the treatment often confirms the diagnosis later.
Ling: The key is to convince both the physician and the patient that mental issues are part of physical issues. Once you stop marginalizing psychiatric issues-particularly depression-the patient is more willing to accept pharmacotherapy and/or psychotherapy, plus treatment for any concomitant physical condition. If the patient can learn to regard depression like any other illness, the stigma disappears.
Ciotti: It's time to stop viewing depression as a character weakness and to recognize it as a biochemical imbalance.
Burt: I was actually taught in medical school that when depression is due to loss-of health, life, or family members-it's inappropriate to treat it. The view was that it should be 'worked through,' whatever that means. But psychiatry has changed radically since then, and we now know that this was bad advice. However, a large population of physicians still believe it.
Stowe: It's like a fever. Though the body uses it to fight off an infection, we treat the fever because it can do damage if it gets out of control. In terms of stigma, change has to begin at home. The American Medical Association is one of the few organizations that is routinely allowed to ask candidates whether they were ever treated for a mental illness. I've treated many female physicians who've had severe postpartum reactions and recovered completely; now they're applying for their state medical licenses and they answer that question in the affirmative. The next thing you know, I have to verify that they're competent to practice medicine. It's time to realize that a broken bone and high blood pressure and depression are roughly equivalent in terms of a medical treatment model.
Burt: There is a perception that a patient with a history of major depression, can never be normal again. The truth is that many people with whom we work and socialize have experienced major depression, and we never know. It's a normal part of life. In fact, most of us have a family member who-diagnosed or not-has suffered from clinical depression.
Sichel: Dr Burt, you recently participated in a survey that found that 41% of all women have emotional problems, but that fewer than 1 in 10 would talk to their physician first about depression. This definitely suggests that physicians are part of the problem.
Burt: The data speak for themselves. Now we need to learn why this is so (Table). First, women of childbearing age may not even recognize that they're depressed; they just know that they don't feel right. Even if they do recognize what's wrong, they have to overcome the hurdle of broaching the subject with an OB/GYN who may not be prepared to listen. Another factor is the strict limitations placed on physicians' time by managed care organizations. At some level, women seem to know how reluctant physicians are to undertake therapy for depression.
Some of the best advice I ever received was from a senior, who said to me, 'You know the patient is sick when she looks sick.' More diagnoses are missed because we don't bother to look. You can see depression and you can feel it. This is when you need to spend the time.
Table. Research on Depressive Disorders in Women
Several university centers are conducting studies to better understand the nature and treatment of depressive disorders in women. For more information about these studies on premenstrual dysphoric disorder, depression in pregnancy, postpartum depression, perimenopausal depression, and other aspects of depression in women, contact:
Ling: I like to remember a palindrome coined by Dr Raphael Good, an OB/GYN and psychiatrist. He always talked about the usefulness of 'HATAH'-that is, 'How Are Things At Home?' Provide the patient with that door. She may not walk through it now, but she may remember it 3 months later.
Stowe: I would encourage OB/ GYNs to hedge your bets. If you're pressed for time, it may help to place an idiosyncratic symbol in the charts of patients with a personal or family history of an emotional problem. It may also help to note the anniversaries of distressing events, such as the death of a parent or child. These simple measures can help to identify higher-risk groups and higher-risk times. Also, it's important to watch these patients even more carefully as winter approaches.
Ciotti: If you routinely ask, 'How are things at home?' when you see a patient for an annual examination, she'll come to expect this opportunity to open up. It's an excellent quick screen that gives her permission to discuss her feelings.
Burt: Still, some patients would hesitate to speak. Sometimes it's more helpful to say, 'Help me understand what's going on emotionally for you right now.' In a subtle way, this gives the patient a job to do. She can't just say, 'Okay.' She has to tell you something. I have yet to see a patient who does not try to respond.
Stowe: Let me add a caveat to that. I prefer to ask the question while proceeding with the examination just like it's part of the routine. Then, as I continue with the physical assessment, I might ask, 'How are you sleeping?' or 'How are you eating?' and 'What have you been doing lately?' In our chronic pelvic pain model, we routinely ask about sleeping, eating, and leisure time. If the patient misses on any point, that changes the next series of questions. It's important to find out whether the patient is sleeping a lot or just staying in bed, and whether she dreams or wakes up frequently. If she's having unrestful sleep, I usually assume a psychiatric cause.
Ling: During an annual visit, the physician can ask whether any family members have become ill during the past year. New onset of depression in the family is important, as are circumstances that may affect the woman's lifestyle-like caring for a mother following coronary bypass surgery or for a father who has cancer. An incidental family history helps to identify risk factors for medical problems and circumstances that could trigger depression.
Sichel: You touch on two important issues. First, you can ask a patient about her life and indicate that you're interested in her without using the term depression, thus taking the stigma away. The other issue is the art of being there for a patient.
Burt: We've talked a great deal about stigma and avoiding the word depression, but I've had a somewhat different experience. A significant number of patients want the physician to acknowledge their depression and feel relieved if the issue is addressed. This is our chance to educate the patient about depression-about its prevalence in women and the times of increased vulnerability. Then we can suggest to the patient that we'll work together to figure out how to deal with it. This implies a collaborative relationship, which is very reassuring for the patient.
Sichel: That's an excellent point. Some patients respond to a subtle approach, whereas others want a more direct approach.
Stowe: How many OB/GYNs keep information about depression, bipolar disorder, postpartum depression, and other psychiatric disorders in their waiting rooms? When the physician is short on time, giving the patient this information can demonstrate your interest and help to open a dialogue.
Ling: It's helpful to notice which pamphlet the patient has picked up in the examination room. If she has selected one about depression, then you can steer the discussion that way. Another twist on the issue of using the word depression is that if a patient describes some of the classic symptoms to me, I may say, 'Well, what does that sound like to you?' It is incredible how many will respond with, 'I think I'm depressed.' It's as if the patients just want you to say it; they just want it validated.
Stowe: In my experience, when a woman presents with a complaint of PMS but is crying and upset during the follicular phase, the physician should probably refrain from emphasizing the distinction between PMS and depression until she's calmer. If you reject the patient's label for the disorder, you may lose her to follow-up. The follow-up appointment is the time when the patient can be educated about the differences between PMS and major depression.
Ciotti: Sometimes it's easier to come in and say, 'I think I have PMS,' than to say, 'I'm depressed.'
Burt: It's easier to believe you have an illness with cycles.
Ling: That's one unexpected benefit of a PMS clinic; it gives a more socially acceptable entry point for patients with depression. In our experience, many of these patients prove to be clinically depressed and choose to continue receiving treatment in a PMS setting.
Ciotti: So how would you initiate therapy in patients who feel they have PMS?
Stowe: The therapy for depression and PMS is essentially the same: no caffeine, no chocolate, daily vitamins, limited naps, and good sleep habits. I start with the lowest dose of medication, usually a selective serotonin reuptake inhibitor (SSRI), and tell her to take it 30 minutes after breakfast to slow its absorption and dampen any initial activation response. When I see the patient again in 2 weeks, I ask whether she's complying with the treatment plan. Then, even if she's complaining of PMS and hasn't had another full cycle yet, I ask how she's doing overall. It's amazing how many patients already notice improvement, suggesting that they were probably depressed.
If the patient has no side effects and is not responding, then she is probably not taking a high enough dose. I have no upper limit; SSRIs are very safe with regard to overdose and toxicity. What's important is getting a patient's depressive symptoms to remit.
Sichel: To wrap up, I'd like to know what each of you would like physicians to take back to their practices.
Ciotti: I think that posing the right questions every time the patient comes in is essential. You can't just rely on your ability to spot the severely depressed woman. Some patients are on their 'best behavior' in the physician's office. Unless you ask the screening questions of everyone, you're going to miss a number of depressed patients. Recognition is so important; we can't treat what we don't recognize.
Ling: As OB/GYNs, we spend an incredible amount of time chasing diseases that occur far less often than depression does. Maybe we need to reorder our priorities, acknowledge that depression is real, and make a commitment to treat the patient or refer her to someone else. But don't deny the problem; and if you feel comfortable in trying a first-line SSRI or a tricyclic antidepressant, so much the better.
Burt: Educate yourselves so that you can screen for the major emotional conditions that affect women, and then educate your patients. Be alert to risk factors in the personal and family history. Know your patients well enough to recognize changes. Acknowledge your patients' complaints, both physical and emotional; listen carefully. Try to become comfortable with one or two antidepressants so that you can initiate treatment. Finally, know when to make a referral so you won't feel frightened about confronting more serious conditions.
Stowe: As one of my superiors said, 'The brain is complex, and a trial of treatment will always be better than a trial of diagnosis.' In the SSRIs, we have broad-spectrum antidepressants that can be used to treat disorders from major depression to panic disorder, obsessive-compulsive disorder, and bulimia. Become familiar with these agents. If you need to go beyond these medications, then ask for help-but know your consulting therapist. Bad psychotherapy can do a great deal of damage.
Sichel: Again, we're a long way from screening for and treating depression in the same manner as hypertension or even cancer. And yet depression can cause just as much impairment and suffering as any other medical disease. Given the high-risk nature of the OB/ GYN's patient population and the long-term relationship that can extend through the childbearing years and into menopause, the OB/GYN is the ideal first line of defense-if he or she will just accept the challenge. TFP
Deborah A. Sichel, MD, is Staff Psychiatrist at Newton Wellesley Hospital in Newton, MA, Instructor in Psychiatry at Harvard Medical School, and Clinical Associate Professor in Psychiatry at Massachusetts General Hospital.
Vivien K. Burt, MD, PhD, is Associate Professor of Psychiatry at the University of California at Los Angeles (UCLA) School of Medicine and Founder and Director of the UCLA Neuropsychiatric Institute and Hospital's Women's Life Center.
Mary Carol Ciotti, MD, is Associate Professor in the Department of Obstetrics, Gynecology, and Reproductive Biology, Michigan State University, East Lansing.
Frank W. Ling, MD, is UT Medical Group Professor and Chair in the Department of Obstetrics and Gynecology, University of Tennessee, Memphis.
Zachary Stowe, MD, is Director of the Pregnancy and Postpartum Mood Disorders Program in the Department of Psychiatry and Behavioral Sciences at Emory University in Atlanta, GA.
Roundtable interview republished with permission by the Female Patient.