Anxiety and Depressive Disorders in the Female Patient

The diagnosis and treatment of anxiety and depressive disorders in female patients poses several related challenges. First, there is a temptation to treat, or overtreat, symptoms without establishing an accurate diagnosis. Second, there is a tendency to assume that reproductive events and life stages, such as menopause, cause psychopathology in and of themselves. Third, the clinician may overlook general medical etiologies in the evaluation of emotional and behavioral signs and symptoms.

Women are more likely than men to suffer from affective and anxiety disorders,¹ and it is the primary care providers, including obstetrician/gynecologists, who write most of the prescriptions for antianxiety and antidepressant medications.² Obstetrics and gynecology is a specialty that is exploding with new techniques and information and that is full of unpredictable, emergent, life-threatening situations. It is the specialty that focuses on women's sexual organs and reproductive functions, organs and functions associated with profound meanings and intense feelings.

At the same time, obstetrician/gynecologists are under increasing pressure to see more patients per unit time, to move procedures from the inpatient to the outpatient setting, and to discharge inpatients when they are barely able to ambulate, much less articulate their psychological concerns.³ New psychopharmacologic agents are constantly introduced and heavily marketed as improvements upon the older ones. These realities converge to make the prescription of psychotropic medication even more tempting. These medications can relieve suffering and improve function for many patients, but prescription alone is no substitute for the evaluation and communication that are essential to the effective use of these medications.

'Hysteria' was the first mental illness ascribed to a specific bodily organ, the organ after which it was named. Ancient Greek physicians believed that otherwise inexplicable paralyses and deficits in the special senses, such as blindness, were caused by the rovings of an unmoored uterus from its rightful place in the pelvis to the anatomic areas suffering the deficits.⁴ The belief in an association between female sex and reproductive functions and psychiatric illness continues to this day. This belief 'pathologizes' normal female reproductive functions, confuses the diagnostic process, and weakens the position of women in society in general.

Western medical tradition creates an artificial dichotomy between the psychological and the somatic. In fact, there is increasing and incontrovertible evidence of interrelations between emotion and behavior and central nervous system function. The central nervous system, in turn, interacts in multiple and complex ways with the autonomic nervous system, the endocrine system, and so on. Unfortunately, however, the old dichotomy persists in our clinical thinking. When the symptoms of concern are emotional and behavioral, the clinician may not consider general medical causes. Anxiety and depressive symptoms can be caused by thyroid and adrenal abnormalities, anemia, malignancies (both brain and systemic), hyper- and hypoglycemia, and other general medical conditions. Often general medical or gynecological conditions co-exist with mental disorders.⁵

Context

No illness can be treated effectively without an understanding of its context. Women's lives and emotional experiences have been affected by major changes in their expected social roles and in their day-to-day lives. More women are in the paid work force, they are in jobs and professions previously closed to them, and they hold elected and appointed offices. At the same time, however, gender role traditions are deeply rooted. Social structures to support women's new roles have not evolved. Women continue to assume responsibility for household management and for the care of dependent children and other relatives. Child and other dependent care is expensive and difficult to find. Women often find themselves in a double bind as to how to behave in the workplace, expected to be both assertive and passive.

This social context varies considerably by race, ethnic group, sexual orientation, and social class.⁶ Paid employment may be a liberation or a burden. Pregnancy outside of marriage may be shameful or normative. Homosexuality may be a sin or a life-style. The conflict between an individual woman and her own social subgroup can cause anxiety and depression. Psychiatric diagnoses and care may be heavily stigmatized. Mistaken, stereotyped assumptions about a woman's social context can lead to errors in diagnosis and therapeutic failures. It is essential that the clinician obtain accurate information about a woman's life and background.

Sources of Diagnostic Confusion

The terms 'anxiety' and 'depression' are used both in common parlance, to indicate universal, passing mood states, and as the names of categories of bona fide mental illnesses. Anxiety and affective disorders have diagnostic criteria as well delineated and rigorous as any other medical disorder. Psychiatric diagnosis no longer relies on hypotheses about unconscious psychological conflicts. Diagnosis is based on clear, reliable, verifiable signs and symptoms.

When a woman's life context is justifiably anxiety- or sadness-provoking, when she is medically ill, in pain, poverty-stricken, or abused, clinicians may make the mistake of dismissing signs and symptoms of psychiatric disorder as expected responses to her situation.⁷ Psychiatric sequelae or complications of environmental assaults deserve the same attention and treatment as orthopedic sequelae of traffic accidents, and they respond equally well to appropriate interventions.

Diagnostic Categories and Criteria

The diagnostic categories and criteria used in this chapter are those of the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV), published by the American Psychiatric Association in 1994.⁸ They have been validated by empirical research; a compendium of this research is available. For the most part, DSM-IV codes are compatible with International Classification of Diseases (ICD)-9 codes. Anxiety and transiently depressed mood are universal human experiences, and both are exacerbated by general medical or obstetric/gynecologic illness. Transient symptoms of anxiety and depression often coexist with, are caused by, and cause other psychiatric conditions as well. The clinical evaluation must include screening for past and/or current sexual or physical abuse, and substance use and abuse disorders.⁹

ANXIETY DISORDERS

The category of anxiety disorders includes not only frank anxiety but also a number of disorders previously classified in other categories.

Panic Disorder Without Agoraphobia, Panic Disorder With Agoraphobia, and Agoraphobia Without a History of Panic Disorder

Panic attacks and/or agoraphobia characterize these diagnoses but are not diagnoses in and of themselves. A panic attack is an abrupt, acute episode of intense dread or fear, with at least four of the following concomitants:

  Palpitations, increased heart rate
  Diaphoresis
  Trembling
  Shortness of breath/feeling of smothering
  Choking sensation
  Chest discomfort
  Nausea, gastrointestinal upset
  Dizziness or lightheadedness
  Sense that oneself or one's surroundings are unreal
  Fear of going crazy, losing control
  Fear of dying
  Paresthesias
  Chills, hot flushes

Many of these signs and symptoms mimic cardiac or other general medical disorders; therefore, they bring patients to the emergency room or primary health care provider rather than to a mental health setting.

Agoraphobia consists of anxiety focused on locations or situations from which it is difficult to escape (or to escape without embarrassing oneself) or in which it is difficult to get relief in the event of panic symptoms. Typically dreaded situations include being away from home and alone, being in a crowd, being in a line, being on a bridge, or traveling in a vehicle. The patient either avoids these situations, suffers through them with considerable discomfort, or seeks the reassurance of a companion.

The diagnosis of 'panic disorder without agoraphobia' requires recurrent, unexpected panic attacks followed by persistent concern about recurrence, implications such as heart attacks or 'losing one's mind', and a change in the patient's normal behaviors in response to the attacks.

In 'panic disorder with agoraphobia', the symptoms of agoraphobia are added to those above. 'Agoraphobia without a history of panic disorder' consists of agoraphobic symptoms related to the fear of developing symptoms of panic.

Specific Phobia

A specific phobia is an intense, persistent fear of a specific single object, a category of objects (dogs, spiders), or a situation (flying in an airplane), which is called the phobic stimulus. The fear is out of proportion to any realistic danger posed by the object or situation, and the patient, unless she is a young child, recognizes the irrationality of the fear. Exposure to the phobic stimulus leads immediately to severe anxiety or a panic attack. The patient either avoids exposure or suffers considerable discomfort. Her avoidance or anxiety interferes with her relationships, her ability to perform her responsibilities, or her routine, or it leaves her with persistent distress.

Social Phobia

For a patient with social phobia, anxiety is provoked by social situations in which she will have to be with strangers (cocktail party with spouse's work mates) or have to perform in some way that is scrutinized by others (classroom, public speaking, sports). She is terrified that she will humiliate herself in some way, either in the process of the activity or by manifesting her anxiety. The patient either avoids such situations, compromising her own interests and success and those of loved ones and co-workers, or anticipates and suffers through them with considerable anxiety, even though she recognizes that they pose no realistic threat.

Obsessive–Compulsive Disorder

Obsessions are recurrent thoughts, impulses, or mental images that are experienced as products of the patient's own mind but are unwelcome and intrusive products. These experiences persist despite the patient's attempts to ignore, dismiss, or counter them, and they cause significant anxiety.

Compulsions are repeated acts (mental or physical) that the patient feels compelled to perform to avoid anxiety or some dire consequence to which the acts have no real connection. The acts may be driven by an obsession and may follow a rigid, ritualistic set of rules.

Obsessive–compulsive disorder is characterized by obsessions and/or compulsions that the patient recognizes as excessive or unreasonable and that consume an hour or more of her time per day, cause significant distress, and/or interfere with her ability to maintain her social and familial relationships and carry out her normal responsibilities.

Post-Traumatic Stress Disorder

Now that post-traumatic stress disorder has been recognized and defined, it has been found in an increasing number of clinical situations. Originally studied in veterans of combat and natural disasters, it can also affect other categories of patients: rape victims, people who witness violent crimes, and mothers of children with malignant disorders. Some patients who have been considered to have personality disorders might be suffering primarily, or concomitantly, from post-traumatic stress disorder.

The diagnosis of post-traumatic stress disorder can be made only when it can be determined that the patient was exposed to one or more events that included death or the possibility of death or serious physical injury to herself or others. In addition, the patient must have reacted at the time with feelings of intense fear, horror, or helplessness. After the original trauma, the event is re-experienced over time by intrusive, distressing recollections, distressing dreams, a sense of reliving the experience, painful emotional responses to reminders of the event, and/or physiologic reactions to reminders of the event.

The patient's life is constricted by a numbing of feelings and disinterest in important activities; amnesia regarding aspects of the trauma; efforts to avoid thoughts, feelings, and things related to the traumatic event; feelings of estrangement from other people; and a sense that she will not live out a normal life span.

In addition, the affected patient suffers from two or more of the symptoms of hyperarousal: sleep difficulty, irritable or angry outbursts, decreased concentration, hypervigilance, and an overactive startle response.

The symptoms must persist for at least 1 month to qualify for the diagnosis.

Acute Stress Disorder

Acute stress disorder manifests reactions very similar to those of post-traumatic stress disorder, but the onset is within 4 weeks of the traumatic event and the reactions last 2 days to 4 weeks.

Generalized Anxiety Disorder

Generalized anxiety disorder is characterized by excessive anxiety about a variety of issues that the patient experiences on most days for 6 months or longer. The anxiety manifests as three or more of the following symptoms: restlessness, fatigability, difficulty concentrating, irritability, muscle tension, and sleep difficulties. The patient cannot control the symptoms, which cause significant distress or impairment. The anxiety is not secondary to another psychiatric or general medical condition.

Anxiety Due to a General Medical Condition and Substance-Induced Anxiety Disorder

These categories are self-explanatory.

DEPRESSIVE DISORDERS

Major Depressive Disorder, Single Episode or Recurrent

“From the time I woke up in the morning until the time I went to bed at night, I was unbearably miserable and seemingly incapable of any kind of joy or enthusiasm. Everything—every thought, word, movement—was an effort. Everything that once was sparkling now was flat. I seemed to myself to be dull, boring, inadequate, thick brained, unlit, unresponsive, chill skinned, bloodless, and sparrow drab. I doubted, completely, my ability to do anything well. It seemed as though my mind had slowed down and burned out to the point of being virtually useless. The wretched, convoluted, and pathetically confused mass of gray worked only well enough to torment me with a dreary litany of my inadequacies and shortcomings in character, and to taunt me with the total, the desperate, hopelessness of it all. What is the point of going on like this?”¹⁰ This is a description of a severe major depressive episode by the person who suffered it: a member of the faculty of the UCLA Department of Psychiatry.

A major depressive episode is very straightforward to diagnose. Presentations in specialty mental health and primary care are similar.^{11, 12} The signs and symptoms have been extremely well validated and correlate well with response to treatment. The failure to diagnose and treat depression can lead to suicide in the patient and to adverse cognitive, behavioral, and emotional consequences for her children.^{13, 14} Risk factors for suicide include previous attempts, family history of suicide, loss of social supports, and substance abuse. The diagnosis requires at least five of the following symptoms (and at least one of the first two), representing a change from the patient's previous condition. These symptoms must occur on most days during a 2-week span:

  Depressed mood most of the time
  Decreased interest or pleasure in most activities
  Change in appetite or unintended weight change
  Change in sleep
  Agitation or retardation
  Fatigue/loss of energy
  Feelings of worthlessness or guilt
  Decreased ability to think, concentrate, or make decisions
  Thoughts of death, or suicidal thoughts or behaviors

Depression is a recurring disorder.¹⁵

Dysthymic Disorder

Dysthymic disorder is a lower-grade chronic condition (lasting at least 2 years) that occurs in the absence of a major depressive episode and causes a depressed mood most of the day and on most days along with two of the other symptoms of major depression.

Depressive Disorder Not Otherwise Specified

Although most of the categories of mental disorders allow for variants 'not otherwise specified', this category is especially important because it includes a diagnosis of particular interest to obstetricians/gynecologists: premenstrual dysphoric disorder, which is the working designation for a severe and disabling premenstrual mood syndrome. Postpartum depression is not considered to be a unique disorder; 'with postpartum onset' is a qualifier for whatever psychiatric diagnosis a patient may suffer after childbirth.

Anxiety and depression very often coexist; patients with signs and symptoms of one should be carefully queried about the other.^{16, 17}

For many anxiety and depressive disorders treatable on an outpatient basis, psychotherapeutic treatments are as effective as psychopharmacologic treatments. Psychotherapy combined with medication generally yields the best results, especially in patients with moderate to severe anxiety or depressive symptoms.^{18, 19} Most patients require trials of as many as three medications before finding the one that works for them. Ongoing research into pharmacogenetics offers considerable hope that we will be able to match patients to medications in advance. Treatment choice is based on availability, cost, familiarity, and patient preference. Treatment efficacy for these disorders compares favorably with that for major medical and surgical diseases. Two thirds of major depressive episodes respond to an adequate attempt at treatment.²⁰ 

Modalities

PSYCHOTHERAPY

Psychotherapeutic or 'talking' treatments include the following:

  Psychoanalysis
  Psychodynamic psychotherapy
  Supportive psychotherapy: office counseling
  Group therapy
  Couples therapy
  Family therapy
  Manual-based, time-limited treatments

Psychoanalysis and Psychodynamic Psychotherapy

Psychoanalysis is an open-ended, nondirective psychotherapy requiring several sessions a week. Its aim is to uncover disabling unconscious conflicts by analyzing the patient's spontaneous flow of thoughts and feelings and her relation to the psychoanalyst. Because of the length and intensity of psychoanalytic treatment, it is extremely difficult to establish control groups and to control for intervening variables to determine its efficacy. Psychoanalysis is indicated for patients who are so chronically disabled psychologically that they are motivated to make a major investment in treatment, but who are not too disabled to comply with the demands of treatment. It is for patients who are curious about their own psychological workings. Traditional psychoanalysis is associated with established views of women's psychology, but psychoanalytic theory and practice have evolved considerably over the century since they were first developed.

Psychodynamic psychotherapy is based on psychoanalytic theory but is less intense, with sessions taking place usually once or twice a week. Like psychoanalysis, psychodynamic psychotherapy aims to relieve symptoms by uncovering and correcting their root psychological causes.²¹

Supportive Psychotherapy

Supportive psychotherapy aims to shore up a patient's coping abilities rather than uncover the reasons for her current difficulties. It is indicated for patients experiencing a life crisis or ongoing life stress, such as that associated with caring for a relative with a disabling illness.²² There is evidence for the efficacy of supportive psychotherapy.¹⁹

Group Therapy

Group therapy is especially helpful for patients with social dysfunctions, because the group setting allows those dysfunctions to manifest and be addressed directly. Groups may be diagnostically heterogeneous or homogeneous. In either case, they reassure patients that they are not alone in suffering psychiatric symptoms. Group therapy can be psychodynamic or supportive.²³

Couples Therapy and Family Therapy

Couples (or marital) and family therapy is based on the premise that because human beings are inherently social creatures, individual human beings' feelings and behaviors cannot be properly understood or effectively helped outside the context of their intimate relationships. For these therapies, the couple or family system, rather than an individual 'patient', is the focus of the intervention. The theoretic principle is that identifying one person as sick allows the other(s) to deny their problems.

The therapist does not accept at face value the complaints or observations of one family member about another but rather draws out the underlying feelings and explores ways in which the person complaining facilitates the objectionable behavior. Within the comparative neutrality and safety of the therapeutic setting, family members can express feelings and wishes not known by others in the family. The therapist will teach them to communicate their needs and wishes without blame or emotional blackmail, and to negotiate behavioral compromises (“I will spend a week at your parents' if you will stand up for me when they criticize me.”)²⁴

Domestic violence often leads to symptoms or syndromes of anxiety and depression. Marital and family therapy are not appropriate for women who are ongoing victims of domestic violence. In this case, whatever the mutual contributions to the family problem, one or more members of the family has breached the boundaries of legally and morally acceptable behavior, and the woman and her children, if any, are at risk of bodily injury and death. Therapeutic attempts to resolve marital and family problems are appropriate only after safety is assured.²⁵

Manual-Based, Time-Limited Treatments

The main manual-based, brief psychotherapies are cognitive/behavioral treatment and interpersonal treatment. The term manual-based means that the treatment consists of specific content, activities, and sequences laid out in a formal manual. The treatment does not concern itself with problems in the patient's distant history or unconscious mind but rather deals with the specific problem now troubling the patient. The patient and psychotherapist agree at the outset on the behavioral goal of treatment and on the form of treatment.²⁶ For example, cognitive/behavioral treatment for mild depression focuses on the patient's negative thought patterns. A depressed patient has negative thoughts about herself and a pessimistic view of the future: “I am not smart”, “I am going to fail in my job/school/relationship". She experiences life events as corroborations of her negative views: “The reason my friend said she had to work late tonight was to avoid keeping her date with me”. In treatment, the patient is told that these thoughts are symptoms, that they are depressed views of reality. She is taught to notice them and to actively counter and replace them with positive thoughts: “I am smart enough to do what I need to do”, “I am going to succeed”, “My friend likes to spend time with me, but she has been required to work overtime”. As mentioned above, these therapies are as efficacious as pharmacotherapy for mild anxiety and depressive disorders.²⁷

PSYCHOPHARMACOLOGY

Specific psychoactive drugs used for anxiety and depression are discussed in the next section.

COMBINED TREATMENT

There is considerable evidence demonstrating that the most effective therapeutic approaches for anxiety and depressive disorders combine medication with psychotherapy.²⁸ It is optimal for the two aspects of treatment to be provided by the same practitioner. It is absolutely essential that the providers of the two modalities be mutually informed and that the modalities be carefully coordinated. Medication cannot be prescribed and followed effectively unless the physician is fully aware of changes in the patient's mood and other symptoms, the patient's circumstances, and the patient's level of functioning. The physician must have enough of an understanding and relationship with the patient to be aware if she fails to take the medication or follow the suggested regimen, or is at risk for overdose.

Conversely, the psychotherapist must be aware of medication effects and side effects so as not to confuse them with psychodynamics. Although it is tempting for the primary physician to write the prescription for psychotropic medication, either omitting the psychotherapy or leaving it to a nonmedical mental health professional, separation of pharmacologic and psychotherapeutic approaches requires a significant commitment to communication and coordination.

ELECTROCONVULSIVE TREATMENT

Probably no other relatively benign and useful treatment has been demonized and attacked as much as electroconvulsive treatment (ECT). ECT consists of the delivery of sufficient electrical energy to the brain to cause a seizure. ECT was first delivered without anesthesia (as was surgery at its inception) during a period when no other effective treatments for major psychiatric illnesses were available, and before informed consent (especially for psychiatric patients) had become a focus of professional interest and legal stipulations. ECT was used for a wide variety of disorders and administered repeatedly, sometimes over a long period of time. Movies and other media were flooded with images of suffering individuals strapped down, choking and jerking, losing their memories and their personalities.

ECT, like all other treatments, has evolved. Informed consent is required, anesthesia is used, the patient's airway is protected, muscle relaxants block the external manifestations of the convulsion, and the electrical stimulus is delivered to just one side of the brain rather than bilaterally.²⁹ However, and tragically for some patients, the perception of ECT has not kept pace with the reality. ECT has been banned in at least one state in the United States and in some public mental health systems.

ECT is extremely useful for the treatment of patients whose depressions do not respond to psychopharmacologic agents, or whose confounding medical problems make the use of those agents problematic. It can be safely used in elderly and pregnant patients and works quickly. For severely suicidal patients, or patients whose depressions severely compromise their nutrition, it can be lifesaving. The obstetrician/gynecologist can play a vital intermediary and educational role with frightened patients and families when ECT is proposed.

Matching the Patient to the Modality

Psychiatric illnesses carry an undeserved but powerful social stigma. Psychiatric disorders are thought to result from moral weakness, laziness, or willfulness. The stigma attaches itself to the treatments and their practitioners as well as to the diseases themselves. Sensationalized media reports and lurid liability suits tarnish one modality or the other on a regular basis; psychotherapists are accused of sexual exploitation of patients, psychoactive medications are said to have led to mayhem and murder, and electroconvulsive therapy is blamed for severe memory loss and personality changes.

This kind of publicity, coupled with family lore and personal experience, makes for intense preferences and avoidances by patients. Some people expect and welcome a prescription in response to every doctor visit. Others fear that all psychoactive medications lead to habituation and dependence. Some patients are convinced that psychotherapy entails embarrassing explorations of their sexual fantasies and damning recollections of their parents' behavior; others see 'counseling' as a benign, supportive experience. Some patients are intensely curious about their own feelings and behaviors; others just want to get back to normal as fast as possible.

Mental Health Referral

In addition to choosing a therapeutic modality, patient and physician will have to decide who is to administer the therapy—the primary physician or a mental health specialist. If they choose a mental health specialist, they will have to decide which kind to use: psychiatrist, psychologist, social worker, religious counselor, or family counselor. Again, these choices are based on availability, expertise, time, and comfort. A patient may prefer the convenience and reassurance of treatment by her trusted obstetrician/gynecologist, or she may prefer a mental health professional because of specialty expertise or a desire to keep revelations about her inner and interpersonal life out of the obstetric/gynecologic setting. The obstetrician/gynecologist may enjoy this aspect of patient care or feel uncomfortable and unprepared. 

Mental health referral should not end or even imply the end of the patient's relationship with the obstetrician/gynecologist. It is important to ask the patient to call or visit after the mental health consultation to report how it went. Optimally, the primary care physician will collaborate with the mental health professional.³⁰ 

Clinical indications may dictate the choice of health care provider. A patient who is psychotic (suffering from hallucinations or delusions), who has failed one or more therapeutic attempts by the obstetrician/gynecologist, who is suicidal, or whose psychic suffering is increasing and life function is decreasing, should be referred expeditiously, at least for consultation, to a mental health professional. Which category of mental health professional is appropriate? This choice depends on availability in addition to clinical factors and patient preference. Psychiatrists are the only mental health professionals who are fully medically trained and qualified. Therefore, a psychiatrist can determine the need for and prescribe medication, can manage patients with concurrent general medical disorders, and can resolve diagnostic questions involving those disorders.

The term 'psychologist' is used, in various parts of the country, by persons with bachelor's, master's, and doctoral-level training both with and without a license for independent practice. The referring physician should determine the level of qualifications of the given practitioner. Clinical psychologists have expertise in psychotherapies and in psychological testing. Psychological testing, in and of itself, is no more accurate in differential diagnosis than is direct clinical evaluation. It can be a helpful adjunct in forensic situations, and neuropsychological testing can be extremely useful when there is a question of brain injury or cognitive impairment. Social workers with a master's degree perform psychotherapy and can be especially helpful in conjoint work with families and community agencies.

The complexities of third-party-payer reimbursement schedules (both governmental and private) and market factors have blurred fee differentials among mental health practitioners. The referring physician cannot assume that one category will be significantly less expensive for a patient than another. Ideally, every obstetrician/gynecologist should have a close working relationship with at least one mental health professional, who would recommend a colleague in another discipline if necessary.

The prospect of suggesting a mental health referral to a patient who has sought care for other reasons may seem daunting. Will the patient feel insulted or rejected? Will she assume that the gynecologist thinks she is crazy, or that her symptoms are unfounded? Will she follow through with the referral, and return to the obstetrician/gynecologist for ongoing medical care? By following a few practical guidelines, the referring physician can address these concerns successfully.

1. Explain the reason for the referral in terms of observable behaviors: “You haven't been eating (sleeping, going out, and so forth).” “You have been crying.” “You look so sad, slumped in your chair.”
   
2. Explain the psychiatric diagnosis being considered, and the reasons it is being considered: “Sometimes clinical depression causes people to lose energy, have trouble sleeping, and to view the world through a dark lens.” “Your palpitations and fear of dying could be caused by panic attacks.”
   
3. Emphasize that the symptoms or disorder in question is a real clinical condition, not due to weakness, manipulation, or laziness; that it is not her fault; and that it can be accurately diagnosed and successfully treated. The DSM-IV itself, or material especially prepared for patients and families,³¹ can be helpful.
   
4. Emphasize that you do not believe that the patient is 'crazy' or that she is making up any of her symptoms, physical or mental.
   
5. Introduce your referring mental health professional as a member of the clinical team, someone you work with frequently and who understands obstetric/gynecologic patients and problems.
   
6. Give the patient as many choices as possible: the discipline, age, gender, and location of the proposed mental health professional. Let her know that the referral/consultation visit does not commit her to any particular course of therapy.
   
7. Reaffirm your ongoing interest in the patient and her welfare. Solidify these assertions by asking the patient to call you after her first meeting with the mental health professional and by making an appointment to see the patient after her first referral appointment.
   
8. Offer to meet with the patient's significant others to explain the referral.³²
   

SUICIDE

Suicide is a serious risk. Most patients who commit suicide have seen a nonpsychiatric physician within a month of the fatal event. Not all depressed or anxious patients are suicidal, and not all suicidal patients have anxiety or depressive disorders. However, there is a significant correlation between these disorders and suicide.³³

There are several barriers to effective evaluation and intervention with suicidal patients.

1. Clinicians fear that bringing up the question of suicide may precipitate overt suicidal behavior that otherwise would not have happened. This is not true; if anything, the opposite is the case.
   
2. Clinicians assume that patients will not give accurate answers to queries about their suicidal ideation and intent. This is also a myth.
   
3. Clinicians fear that patients will be offended by questions about suicide, because suicidality implies serious mental illness, and mental illness is shameful. This is another myth.
   
4. Clinicians assume that 'normal' people, like most of their patients, would not commit suicide. They do not want to seem to overreact.
   
5. Clinicians assume that patients with a history of previous suicide gestures or attempts are not likely to be serious about current suicidal intent.
   
6. Clinicians fail to recognize, or take into account, important risk factors for suicide, including substance abuse and domestic violence.
   
7. Clinicians underestimate the ingenuity, determination, and impulsivity of the acutely suicidal patient.³⁴
   

In spite of the taboos against suicide, it is not a difficult subject to discuss with a patient. Fleeting thoughts of suicide are a nearly universal human experience in moments of great anxiety or other emotional or physical pain. Screening for depression should be a part of regular medical care, especially in women, and screening for suicidal thoughts or intentions follows logically in the doctor–patient dialogue:

  Do you sometimes feel sad? Hopeless? Worthless? Unable to enjoy anything?
  Most people have had the experience of thinking, “I wish I were dead.” Have you?
  Have you had that feeling recently, or do you have it now?
  Have you ever tried to hurt yourself in any way?
  Are you thinking of hurting yourself now?
  Has anyone in your family ever committed suicide?
  Do you have a plan for hurting yourself?
  Do you have the means at your disposal?
  Are you able to resist the urge to hurt yourself?
  Are you able to get help if you feel tempted to hurt yourself?

It is not necessary to continue the questioning if the patient denies suicidal ideation. Most often she will say, “It's never been that bad”, or “I couldn't ever do that to my family”, or “My religion forbids suicide”. Given a reasonable doctor–patient rapport, patients will tell the truth about their thoughts and intentions once they are asked, even if they do not volunteer them. A patient with current, serious suicidal ideation should be seen immediately by a psychiatrist. Although she may deny immediate intent, the determination of risk and treatment should be made by a specialist, unless one is not available either in person or by telephone.

If the patient presents with both suicidal intentions and the means to carry them out, she must be physically transported (accompanied at every moment by someone able to protect her) to an emergency department or psychiatric facility. These precautions may seem dramatic or excessive, but it is better to be safe than sorry. Suicidal patients can be remarkably ingenious, fast, and determined. They can leap through hospital windows even as the clinical team makes rounds, hang themselves or take pills in bathrooms where they have been allowed to go alone for reasons of privacy, or harm themselves in the few moments a family member or 'sitter' goes to get a cup of coffee or make a telephone call.

Psychopharmacology is a rapidly developing field. There will be new agents on the market before this chapter is next revised. Each will undoubtedly emerge amid claims of improved efficacy and a lowered side effect profile. Some may be major improvements. At the same time, familiar drugs are almost always less costly and often equally effective.

Particular care must be used when prescribing psychoactive medications to the elderly. They react much more readily and metabolize drugs more slowly than do younger patients. They are likely to be taking multiple medications, often prescribed by a variety of physicians. Changes in sleep patterns, equilibrium, and physical strength make them increasingly vulnerable to falls.

Many treatment failures stem from inadequate dosages or therapeutic trials. Dosage regimens for the same drug may differ according to the therapeutic indication. On the other hand, side effects lead many patients to discontinue treatment.³⁵ A patient who cannot tolerate the side effects or who is clinically unimproved or worse should be referred to a psychiatrist unless the obstetrician/gynecologist has particular interest and expertise in psychoactive medication management. 

Barbiturates

Barbiturates no longer have a place in the treatment of anxiety and depressive disorders.

Sedatives and Hypnotics

Obstetricians/gynecologists often encounter patients whose sleep is acutely or chronically disrupted, by anxiety or depressive disorders or for other reasons. Loss of sleep can engender secondary irritability, fatigue, difficulty concentrating, and psychic pain. A good night's sleep can restore feelings of well-being and clarify the diagnostic picture. However, hypnotic agents can be habituating and psychologically addictive. They also have variable effects on daytime functioning. They are not specific treatments for anxiety or depression. Therefore, hypnotic agents should be prescribed and dispensed for no more than 3–4 days of consecutive use, and the patient must be aware of possible morning 'hangover' symptoms and must be responsible enough to avoid activities that could endanger herself or others if she is not fully alert.³⁶

Anxiolytics

Benzodiazepines (alprazolam, diazepam, lorazepam, oxazepam) are among the most widely prescribed, effective, and safe medications in the world. However, their use can lead to abuse, dependence, and additive effects with alcohol. In elderly or medically ill patients, they can add to confusion and ataxia. Patients may fail to inform clinicians that they are taking large doses of benzodiazepines, precipitating withdrawal syndromes when they are hospitalized or the medication is otherwise discontinued.

The choice of benzodiazepine is made on the basis of onset of action, half-life, production of active metabolites, lipophilicity, and metabolic pathway.³⁷ Diazepam is rapidly absorbed: this offers fast relief of anxiety but can induce undesirable muscular relaxation and sleepiness. Alprazolam has intermediate lipophilicity and absorption, whereas lorazepam and oxazepam have low lipophilicity and absorption. For all benzodiazepines, dosages should be raised and tapered gradually. Patients should be monitored carefully for clinical response and signs of abuse or dependence. Patients may obtain prescriptions from multiple clinicians.³⁸

Antidepressants

At least two thirds of patients with major depressive episodes can be effectively treated with adequate regimens of antidepressant medication along with some form of psychotherapy.  Treatment protocols such as the Sequenced Treatment Alternatives to Relieve Depression(STAR*D) are available and extremely useful clinical guides.^{39, 40} Formal systems for following symptoms and treatment response are very useful.⁴¹ Telephone-based follow-up by nurses or pharmacists improve adherence to treatment.⁴²

Major depression is a long-lasting and recurrent illness; the natural history of an untreated episode is 6–9 months. Therefore, patients must be encouraged to remain on medication for that length of time to prevent relapse. Without effective treatment, episodes may become more frequent and severe. There is increasing evidence that patients with recurrent episodes should remain on antidepressants indefinitely.⁴³

Selective serotonin reuptake inhibitors (SSRIs) are the first-line medications of choice. Antidepressant agents are also indicated for dysthymia and have been successfully used for post-traumatic stress disorder, chronic pain syndromes (tricyclics), panic disorder, social phobia (monoamine oxidase inhibitors [MAOIs], SSRIs), migraine headaches (MAOIs and TCAs), bulimia, and obsessive-compulsive disorder (SSRIs). There is some evidence that patients with so-called atypical depression (hypersomnia, hyperphagia, hypersensitivity to rejection, mood reactivity to circumstances) preferentially respond to MAOI treatment.⁴⁴

It should be noted that antidepressant medications are also useful for the treatment of some anxiety disorders.^{45, 46}

All forms of antidepressant pharmacotherapy, in large clinical trials, appear to be equally effective in terms of onset of action and relief of signs and symptoms.⁴⁷ Choices among them are generally made on the basis of side effect profile, dosage convenience, and cost.⁴⁸ The major categories of antidepressants are described here.  However, many, even most, patients require trials of more than one medication before finding one that is effective.  There is ongoing research into pharmacogenetics and other means for matching individual patients in advance with the medication most likely to work. 

The TCAs consist of amitriptyline, clomipramine, desipramine, doxepin, and imipramine. The therapeutic dosage range for these medications is 75–300 mg/d, in divided doses, introduced gradually over several days. When used concomitantly with antiarrhythmics or MAOIs (see below), fatal drug–drug interactions can occur. Their major side effects are weight gain, orthostatic hypotension, cardiac arrhythmia, drowsiness, and the anticholinergic effects of urinary and gastrointestinal slowing, blurred vision, and dry mouth. Desipramine has the fewest of these effects. The side effects generally modulate spontaneously over time but cause some patients to discontinue treatment. Patients with insomnia can take the bulk of the dose before bedtime, capitalizing on the soporific side effects. Subtherapeutic doses are not an appropriate approach to concerns about side effects; it is preferable to switch to another category of antidepressant. These agents, which have been in use for several decades, are available in generic, inexpensive forms.

Nortriptyline and protriptyline have lower therapeutic dosage ranges and fewer of the above side effects, but they have similar serious drug–drug interactions.

The heterocyclics consist of amoxapine, bupropion, maprotiline, and trazodone. The first two of these agents, like those above, should not be used concomitantly with MAOIs. Maprotiline and trazodone cause significant drowsiness. Bupropion may lower the seizure threshold.

The SSRIs consist of fluoxetine, paroxetine, and sertraline. These relatively new agents have been heavily marketed and widely discussed in the popular literature. They have few of the side effects of the more traditional medications and offer the convenience of once-a-day dosing. They can cause headache, tremor, anxiety, sexual dysfunction (anorgasmia), and gastrointestinal upset, especially at the outset of treatment. They should not be used with MAOIs.⁴⁹ They are considerably more expensive than the tricyclics.

The MAOIs include isocarboxazid, phenelzine, and tranylcypromine. MAOIs are especially useful for patients with so-called atypical depressions: depressions that are characterized by increased appetite and sleep, rather than the reverse, and that are most common among patients in their late teens and twenties. MAOIs are also useful for panic disorder and atypical pain syndromes. Patients on MAOIs must comply with a specific diet, avoiding foods and beverages high in tyramine or tryptophan, or they run the risk of hypertensive crisis. Extreme caution must be exercised if these medications are used with vasoconstrictors, decongestants, meperidine, or other narcotics. Side effects include sexual dysfunction, orthostatic hypotension, weight gain, and fatigue, but sedation and anticholinergic effects are much less common than with tricyclic antidepressants.⁵⁰