Recognition of depression in obstetric/gynecology practices

Women's Preferred Sources for Primary and Mental Health Care: Implications for Reproductive Health Providers

PURPOSE

To describe women's preferences for reproductive health providers as sources of primary and mental health care.

METHODS

This is secondary data analysis of the Women's Health Care Experiences and Preferences Study, an Internet survey conducted in September 2013 of 1,078 women aged 18 to 55 randomly sampled from a U.S. national probability panel. We estimated women's preferred and usual sources of care (reproductive health providers, generalists, other) for various primary care and mental health care services using weighted statistics and multiple logistic regression.

MAIN FINDINGS

Among women using health care in the past 5 years (n = 981), 88% received primary and/or mental health care, including a routine medical checkup (78%), urgent/acute (48%), chronic disease (27%), depression/anxiety (21%), stress (16%), and intimate partner violence (2%) visits. Of those, reproductive health providers were the source of checkup (14%), urgent/acute (3%), chronic disease (6%), depression/anxiety (6%), stress (11%), and intimate partner violence (3%) services. Preference for specific reproductive health-provided primary/mental health care services ranged from 7% to 20%. Among women having used primary/mental health care services (N = 894), more women (1%-17%) preferred than had received primary/mental health care from reproductive health providers. Nearly one-quarter (22%) identified reproductive health providers as their single most preferred source of care. Contraceptive use was the strongest predictor of preference for reproductive health-provided primary/mental health care (odds ratios range, 2.11-3.30).

CONCLUSIONS

Reproductive health providers are the sole source of health care for a substantial proportion of reproductive-aged women-the same groups at risk for unmet primary and mental health care needs. Findings have implications for reproductive health providers' role in comprehensive women's health care provision and potentially for informing patient-centered, integrated models of care in current health systems.

Psychological well-being of gynecologic and obstetric patients: a validation of the 12-item Well-Being Questionnaire (W-BQ12)

BACKGROUND

Gynecology and obstetrics are areas of medicine associated with emotionally loaded concerns. Both positive and negative aspects of psychological well-being can be assessed with the 12-item Well-Being Questionnaire (W-BQ12). Our study aimed to evaluate the psychometric properties of the W-BQ12 in gynecologic and obstetric patients.

METHODS

A cohort of 228 gynecologic patients, consisting of endocrinologic (n = 102) and obstetric (n = 126) subgroups, responded to a structured interview or to a questionnaire about sociodemographic and medical data, and to a set of psychometric tests: the W-BQ12, the Hospital Anxiety and Depression Scale (HADS), the Beck Depression Inventory (BDI), and the Hamilton Depression Scale (HAMD). Except for the current health problem, all probable confounding factors (psychiatric, oncologic, or other somatic morbidity, postmenopausal status) were excluded.

RESULTS

The W-BQ12 scores correlated significantly and adequately (r = 0.35-0.80) with reference instruments (HADS, BDI, and HAMD). The internal consistency, measured by Cronbach's alpha, was very good for the whole questionnaire (0.86) as well as for the subscales (0.76-0.79). The principal component analysis indicated a clear three-factor structure with eigenvalues >1. Factors 1 ("negative well-being"), 2 ("positive well-being"), and 3 ("energy") explained 22, 21, and 19 % of the variance, respectively.

CONCLUSIONS

The W-BQ12 is suitable for the global assessment of psychological well-being, as well as for differentiation between negative and positive well-being aspects in gynecologic patients.

Validation of the Polish version of the Hospital Anxiety and Depression Scale in three populations of gynecologic patients

INTRODUCTION

We analyzed the psychometric properties of the Polish version of the Hospital Anxiety and Depression Scale (HADS) in gynecologic patients.

MATERIAL AND METHODS

A total of 252 patients, consisting of three subgroups - endocrinologic gynecology (n = 67), high-risk pregnancy (n = 124), and outpatient gynecologic clinic (n = 61) - responded to the HADS, the 12-item Well-being Questionnaire (W-BQ12), the Spielberger State-Trait Anxiety Inventory (STAI), the Beck Depression Inventory-II (BDI-II), and the Hamilton Depression Scale (HAMD). Socio-demographic data were obtained by self-report and interviews.

RESULTS

The HADS presented good internal consistency with Cronbach's α at 0.84 and 0.78 for depression and anxiety subscales, respectively, and 0.88 for the whole questionnaire. The principal component analysis with Eigenvalues > 1 revealed a three-factor structure. Factors 1 ("depression"), and 2 ("anxiety"), as well as the separate Factor 3, explained 23.48%, 21.42%, and 12.07% of the variance, respectively. The items with shared loadings were A1, A3, and A6. The HADS scores correlated strongly with other depression and well-being scales, but not with STAI-X1/X2.

CONCLUSIONS

The Polish HADS revealed a three-factor structure, and 3/7 HADS-A items showed ambiguous factor loadings. All other psychometric properties were satisfactory. The HADS seems to be suitable for use in gynecologic patients, preferentially as an indicator for global psychological distress.

Socio-economic determinants and self-reported depressive symptoms during postpartum period

The researchers' aims were to estimate the prevalence of postpartum depressive symptoms in Italy. Cross-sectional data from the survey, "Health and use of health care in Italy" were analyzed. The authors focused on 5,812 women, pregnant some time during five years before the survey. Multiple logistic regression was used to evaluate risk factors independently associated with postpartum depressive symptoms. Evaluation of seasonal trends was also performed.In the total sample, 23.5% (n = 1,365) reported having suffered postpartum depressive symptoms: 20.7% experienced baby blues, and 2.8% postpartum depression. Factors significantly associated with baby blues were, among others, living in northern or central areas (adjusted odds ratio [aOR] 1.88; 95%CI 1.57-2.15 and 1.40; 95%CI 1.20-1.63, respectively), history of depression (aOR 1.34; 95%CI 1.15-1.56), and attendance at antenatal classes (aOR 1.13; 95%CI 1.04-1.22). Factors significantly associated with postpartum depression were: anamnesis of depression (aOR 3.32; 95%CI 2.69-4.09), gaining more than 16 kg of weight during pregnancy (aOR 1.48; 95%CI 1.03-2.12), and undergoing a cesarean section (planned: aOR 1.56; 95%CI 1.05-2.29; unplanned: aOR 1.78; 95%CI 1.16-2.73). Multiparity was a protective factor both for baby blues (aOR 0.80; 95%CI 0.70-0.91), and postpartum depression (aOR 0.71; 95%CI 0.51-0.98). No clear seasonality was observed for postpartum depression, while for baby blues a certain aggregation of events was registered during the central months of the year. The authors' study highlighted variables associated with baby blues and postpartum depression to target screening for women for postpartum depressive symptoms.

Partner support and postpartum depressive symptoms

BACKGROUND

One out of eight women suffers an episode of depression following delivery. We explored the role of expectations of partner support in postpartum depressive symptoms in new mothers attending a regional public hospital in Italy.

METHODS

Seventy women participated in a two-stage (third trimester and 3 months postpartum) prospective study using self-report measures. At stage 1, they completed the Support Expectations Index to measure expectations for partner support and the Dyadic Adjustment Scale to measure conflicts in marital relationship, whereas socio-demographic (i.e. maternal age and education level) and clinical variables (i.e. previous miscarriages and depression episodes) were collected from medical reports. Depressive symptoms were evaluated at stage 2 with the Edinburgh Postnatal Depression Scale using a cut-off >9 and confirmation of marital support expectations was measured with the Expectancy Confirmation Scale. Stepwise logistic regression analysis was used to examine predictors of depressive symptoms at 3 months postpartum.

RESULTS AND DISCUSSION

As many as 55.7% (n = 39) of new mothers presented postpartum depressive symptoms, which were predicted by low expectancy confirmation concerning partner support [odds ratio (OR) 3.02; 95% confidence interval (CI) 1.25-8.10]. Therefore, clinicians should consider the possible role of partner support when treating women with postnatal depressive symptoms.

Prevalence and incidence of postnatal depression: what can systematic reviews tell us?

BACKGROUND

Postnatal depression (PND) has a significant impact on maternal mental health. Systematic reviews provide a useful tool to summarise research, however little is known about the quantity and quality of existing systematic reviews of prevalence and incidence of PND.

OBJECTIVE

The objective of this paper is to provide a systematic overview of existing systematic reviews of prevalence and incidence of PND in the first 12 postnatal months.

METHOD

Medline, Embase, Cinahl, PsychInfo and the Cochrane Library were searched for systematic reviews of prevalence and incidence of PND which met the Database of Abstracts of Reviews of Effects (DARE) criteria. Characteristics of selected reviews, completeness of reporting results and methodological quality were evaluated.

RESULTS

Five reviews were selected for appraisal. Only one systematic review was identified; four reviews were non-systematic. Only two reviews provided a quantitative summary estimate of prevalence of PND. Completeness of reporting results using published guidelines was not undertaken by any review. The methodological quality of four reviews revealed limitations.

CONCLUSIONS

Limited generalisable evidence exists in the form of high-quality systematic reviews to inform current knowledge of the prevalence and incidence of PND. The implication of this represents an important limitation for health services planning and service delivery.

Predictors of Maternal Depression Management among Primary Care Physicians

Purpose. The present surveillance study examined predictors of the management of maternal depression in primary care settings. Methods. A total of 217 physicians completed a 60-item survey assessing demographics, physicians' attitudes, beliefs, efficacy, current practices, and perceived barriers regarding the management of maternal depression. Structural equation modeling was used to estimate a model that examined the relationships among physicians' knowledge, beliefs, self-efficacy, perceived barriers, past training toward and current management practices for maternal depression. Results. In a model predicting physician depression management practices, a good overall fit was observed (χ(2) = 136.63, CFI = .97, TLI = .95, RMSEA = .05), with physician comfort with, confidence in, and perceived responsibility for managing maternal depression all having prominent positive associations. Conclusions. These findings will guide the development of future multifaceted intervention strategies to enhance physician skills in managing maternal depression in primary care settings.

Psychiatric morbidity in gynecological and otorhinolaryngological outpatients: a comparative study

OBJECTIVE

Assessment of the point prevalence of psychiatric disorders in a gynecological outpatient population compared to a control group consisting of otorhinolaryngological outpatients.

METHODS

During an 11-month period of time, 150 unselected, consecutive gynecologic outpatients and 150 matched controls (otorhinolaryngological outpatients) were enrolled in the study. Patients were screened for psychiatric disorders using the Patient Health Questionnaire (PHQ). Sociodemographic data, psychiatric and medical history including inpatient treatments and outpatient contacts, and utilisation of the health care system were assessed.

RESULTS

Within the gynecological group, 45.3% fulfilled the diagnostic criteria for at least one psychiatric diagnosis according to the PHQ, compared to 27.3% of the otorhinolaryngological control group (P=.002). With respect to distinct diagnoses, gynecological patients suffered significantly more often from somatoform disorders (P=.001) and depressive disorders (P=.003) than controls. Less than half of subjects of either group with any psychiatric diagnosis had ongoing psychiatric or psychotherapeutic treatment.

CONCLUSIONS

We found a significant group difference in the number of psychiatric diagnoses between gynecological and otorhinolaryngological female outpatients. Psychiatric disorders may be frequent and unrecognised in women presenting in an outpatient setting, especially in those seeking medical care for gynecological problems. The PHQ may be a useful tool to detect psychiatric disorders even in busy clinical settings.

Primary care physicians' beliefs and practices toward maternal depression

BACKGROUND

The negative impact of maternal depression on both the mother and her offspring highlight the importance of managing (diagnosing/treating) maternal depression in primary care. Despite this heightened emphasis, many primary care physicians (PCPs) still fail to diagnose and treat maternal depression in their patients. To address this apparent gap between opportunity for care and actual care delivery, the present surveillance study examined the relationships among PCPs' beliefs, knowledge, self-efficacy, and perceived barriers toward and practices related to managing maternal depression.

METHODS

A total of 232 PCPs (obstetricians, pediatricians, and family medicine practitioners) residing in Southeastern Virginia completed a 60-item survey, by either web or mail in 2006. The 60-item survey contained questions pertaining to demographics, attitudes, beliefs, efficacy, current practices, and perceived barriers regarding the management of maternal depression. Chi-square and one-way ANOVAs analyses of survey items were conducted to compare PCPs' knowledge, beliefs, self-efficacy, perceived barriers, past training toward, and current management practices for maternal depression (i.e., frequency of assessment, referral, consultation, and treatment) across specialties.

RESULTS

Over 90% of physicians reported that it was their responsibility to recognize maternal depression; however, a large percentage of physicians rarely/never assess for depression (40%) or provide a referral (66%). Significant differences in beliefs, perceived barriers, and practices were found across specialties.

CONCLUSIONS

These findings will guide the development of future multifaceted intervention strategies to enhance physician skills and practices in managing maternal depression in primary care settings.

Sociodemographic predictors of antenatal and postpartum depressive symptoms among women in a medical group practice

OBJECTIVE

Data are scarce regarding the sociodemographic predictors of antenatal and postpartum depression. This study investigated whether race/ethnicity, age, finances, and partnership status were associated with antenatal and postpartum depressive symptoms.

SETTING

1662 participants in Project Viva, a US cohort study.

DESIGN

Mothers indicated mid-pregnancy and six month postpartum depressive symptoms on the Edinburgh postpartum depression scale (EPDS). Associations of sociodemographic factors with odds of scoring >12 on the EPDS were estimated.

MAIN RESULTS

The prevalence of depressive symptoms was 9% at mid-pregnancy and 8% postpartum. Black and Hispanic mothers had a higher prevalence of depressive symptoms compared with non-Hispanic white mothers. These associations were explained by lower income, financial hardship, and higher incidence of poor pregnancy outcome among minority women. Young maternal age was associated with greater risk of antenatal and postpartum depressive symptoms, largely attributable to the prevalence of financial hardship, unwanted pregnancy, and lack of a partner. The strongest risk factor for antenatal depressive symptoms was a history of depression (OR = 4.07; 95% CI 3.76, 4.40), and the strongest risk for postpartum depressive symptoms was depressive symptoms during pregnancy (6.78; 4.07, 11.31) or a history of depression before pregnancy (3.82; 2.31, 6.31).

CONCLUSIONS

Financial hardship and unwanted pregnancy are associated with antenatal and postpartum depressive symptoms. Women with a history of depression and those with poor pregnancy outcomes are especially vulnerable to depressive symptoms during the childbearing year. Once these factors are taken in account, minority mothers have the same risk of antenatal and postpartum depressive symptoms as white mothers.

Obstetrician-gynecologists and self-identified depression: personal and clinical

A survey was designed to explore the effect of obstetrician-gynecologists' subjective awareness of depression in themselves and close family/friends on screening patients for depression and on assessing and treating depression in three scenarios describing hypothetical patients during the adolescence, postpartum, and perimenopausal periods. Questionnaires were mailed to 397 members of the American College of Obstetricians and Gynecologists (ACOG) who participate in the Collaborative Ambulatory Research Network (CARN). Fifty-five percent of the questionnaires were returned. One third of physicians reported having suffered from depression occasionally (28.1%), often (3.8%), or all the time (2.4%) during the past year. Having personally suffered from depression was associated with elevated assessment of depression in the scenarios but not with elevated rates of screening for depression in actual practice, nor with aggressiveness of treatment choices in the scenarios. Awareness that a close friend suffered from depression was not associated with lowered mood as measured, but was associated with increased rates of screening for depression in adolescent, postpartum, and perimenopausal patients, and with elevated assessment of depression and more aggressive treatment practices for depression in hypothetical patients at these three life stages. As such, physicians' practices regarding depression may be influenced by something other than reactivity to their own emotional state.

Patients with psychiatric disorders in gynecologic practice--a three year follow-up

OBJECTIVE

Patients with depressive disorders are commonly encountered in gynecologic practice. The prevalence rates for depressive disorders have been reported to vary between 10 and 40% among patients consulting their gynecologist. The purpose of the current study was to study health care utilization by patients with a psychiatric disorder in the gynecologic setting during a three-year period after the initial diagnosis of depression and/or anxiety.

STUDY DESIGN

In 1998 all scheduled and walk-in patients, at two gynecologic centers in northern Sweden during one month, were screened for prevalence of depression and anxiety disorders using the PRIME-MD system. Medical records for the period 16 December 1998 to 31 December 2001 have been reviewed.

RESULTS

Patients diagnosed with any anxiety disorder made significantly more appointments to the gynecologist and were acutely hospitalized more often than control subjects. Both patients with any depressive or any anxiety diagnosis made significantly more visits to health care personnel other than the gynecologist and they received counseling by phone and/or letter significantly more often than patients in the control group. Furthermore, patients with depressive and/or anxiety diagnosis were also referred to other medical specialists more often than controls.

CONCLUSION

The present study has indicated that gynecologic patients with depression and anxiety over a three-year follow-up period have an increased health care utilization with more frequent consultations and more frequent referrals.

Raising the awareness of primary care providers about postpartum depression

About 13% of women experience depression in the first year after childbirth. Postpartum depression has deleterious effects on the woman's relationships, her functional status, and her ability to care for her infant. Primary care providers have the most contact with postpartum women, but may be unable or unwilling to screen, treat, and/or refer the women. Thus, many women with postpartum depression are not receiving mental health services. The purpose of this article is to describe methods to raise the awareness of primary care providers about postpartum depression, thereby eliminating a major barrier to mental health treatments of postpartum women.

Pretreatment Beck Depression Inventory score is an important predictor for post-treatment score in infertile patients: a before-after study

BACKGROUND

The experience of infertility can be extremely stressful. Some of the risk factors for depression in infertility are being female, repeated unsuccessful treatment cycles or a 2 to 3 year history of infertility, low socioeconomic status, foreign nationality, lack of partner support, life events and previous depression. In this study, we analyzed the Beck Depression Inventory score at the beginning and the end of infertility treatment, to determine which factors may influence the BDI score after treatment of infertility.

METHODS

In a before-after study, in a university-affiliated teaching hospital, 251 women who had been visited for assisted reproductive technology infertility treatment participated in the study. BDI score was assessed before and after treatment of infertility.

RESULTS

The mean BDI score rose after unsuccessful treatment and dropped after successful treatment. Those with lower education levels had a higher BDI score before treatment. BDI score after treatment was positively correlated with pretreatment BDI scoreand duration of infertility.

CONCLUSION

BDI score after treatment was strongly connected to the BDI score before treatment, the result of therapy and to the duration of infertility. The influence of duration of infertility on BDI score after treatment of infertility is weak. So a simple method to screen patients at risk of depression after infertility treatment is determining pretreatment BDI score and predicting the result of infertility treatment by other risk factors.

Contemporary clinical issues in outpatient obstetrics and gynecology: findings of the Collaborative Ambulatory Research Network, 2001-2004: part II

Obstetrician/gynecologists are taking on more primary care responsibilities and thus are expected to have a wider base of medical knowledge on a variety of women's health issues. The Collaborative Ambulatory Research Network (CARN) was created in 1990 to investigate issues pertinent to women's health and to the practice of obstetrics and gynecology in the outpatient setting. This article summarizes the findings of CARN studies from 2001 to 2004, covering topics of abnormal pregnancy outcomes, complications of pregnancy, and psychologic disorders. Each study provides a glimpse into the current practice patterns, attitudes, and knowledge of the practicing obstetrician/gynecologist. Although aggregate results suggest that clinicians are consistent and knowledgeable in traditional areas of practice, there appears to be a need for comprehensive educational programs to increase clinicians' comfort level with and knowledge of many primary care issues.

Mental and physical distress and high-risk behaviors among reproductive-age women

OBJECTIVE

To examine the prevalence of mental and physical distress indicators among women of reproductive age and the association of these indicators with cigarette smoking and alcohol use, by pregnancy status.

METHODS

The Behavioral Risk Factor Surveillance System data for several years were aggregated across states and weighted for this analysis. Seven measures of self-reported mental and physical distress and general health were examined along with demographic variables.

RESULTS

Overall, 6.7% (95% confidence interval [CI] 6.5-6.9) of women reported frequent physical distress, 12.3% (95% CI 12.0-12.6) reported frequent mental distress, 9.9% (95% CI 9.4-10.4) reported frequent depression, 18.4% (95% CI 17.8-19.1) reported feeling anxious, and 34.3% (95% CI 33.5-35.1) reported that they frequently did not get enough rest. At the time of the survey 4.6% of the women were pregnant. Pregnant women were less likely than nonpregnant women to report frequent mental distress. Although there was attenuation of cigarette smoking and alcohol use during pregnancy, those with mental and physical distress were more likely to consume cigarettes and alcohol than were those without such experiences.

CONCLUSION

High proportions of reproductive-age women report frequent mental and physical distress. Women experiencing mental and physical distress were more likely to report consuming cigarettes and alcohol than women without such experiences.

Identifying depression in the first postpartum year: guidelines for office-based screening and referral

BACKGROUND

Some 10-15% of women experience postpartum-onset major depression (PPMD). The objective of this study was to determine if the Edinburgh Postnatal Depression Scale (EPDS) is an effective screen for major depression (MD) prospectively. The outcome of the study was identification of a recurrence of major depression in the first year postpartum by a clinical interview and the EPDS. We had the unique opportunity to examine the relationship between EPDS scores and PPMD.

METHODS

Participants were pregnant women who had experienced an episode of previous PPMD but were well during their index pregnancy. This study was part of a double-blind, randomized clinical trial in which new mothers received nortriptyline or placebo within 24 h following delivery for prevention of PPMD. Recurrence of depression was established according to Research Diagnostic Criteria. Participants completed the EPDS weekly through 20 weeks postpartum and into a 1-year follow-up phase.

RESULTS

Out of 50 women, 13 experienced recurrence of MD in the first 20 weeks postpartum with a total of 20 out of 50 recurring in the first year. The EPDS score of >9 at week 4 postpartum identified 60% of women who nurtured in the first 20 weeks and 80% who recurred in the first postpartum year.

LIMITATIONS

The study population included only women who had a previous episode of postpartum depression. The generalizability to all women is limited.

CONCLUSIONS

The EPDS is an effective depression screen for women who had a previous episode of PPMD. Clinical guidelines are provided for use of the EPDS to identify MD in the first postpartum year in primary care settings.

Condições afetivo-emocionais em mulheres com síndrome pré-menstrual através do Z-Teste e do IDATE

A presente pesquisa visou constatar as condições afetivo-emocionais em mulheres com síndrome pré-menstrual (SPM), comparadas com outras mulheres sem sintomas pré-menstruais. A amostra foi constituída de 43 universitárias, na faixa etária de 18 e 35 anos, distribuídas em dois grupos: Grupo 1, constituído de 25 mulheres com SPM, e Grupo 2 (Controle), de 18 mulheres sem estas disfunções. Foram utilizados como instrumentos a técnica de Zulliger (Z-Teste forma coletiva) e o Inventário de Ansiedade-Traço-Estado - IDATE (Spielberger), e para tratamento estatístico na análise comparativa dos dados o t-Teste para amostras independentes. O nível de significância escolhido foi p < 0.05. Os resultados indicaram que as mulheres do grupo com síndrome pré-menstrual reagem emocionalmente de forma mais intensa e têm tendência à perda de controle emocional em índice maior que as mulheres do grupo sem sintomas pré-menstruais.

Major depressive disorder and response to citalopram treatment in women attending menopause clinic

INTRODUCTION The authors investigated the prevalence of depressive disorders and response to citalopram among perimenopausal women visiting menopause clinics. METHOD One hundred and eighty-five consecutive outpatients were screened using the short Beck Depression Inventory. A psychiatrist investigated persons who showed medium or severe Beck depression. In the case of DSM-IV major depressive episode, a 6-week open trial with citalopram (20-40 mg daily) was started. The 17-item Hamilton Depression Rating Scale (HDRS) measured the severity of depression at baseline and at weeks 3 and 6. The primary outcome measure was the rate of responders at weeks 3 and 6 (more than 50% drop in the total HDRS score at weeks 3 and 6 compared to baseline). RESULTS Of the 185 consecutive outpatients screened, 48 (26%) have experienced medium or severe Beck depression, and 37 of them (20%) had DSM-IV major depression. Citalopram was started in 30 patients (daily doses ranged from 20 to 40 mg) and 21 (70%) finished the trial. The rate of responders at week 3 was 7/22 (32%) and at week 6 was 13/21 (62%). CONCLUSIONS Depressive disorders are common among perimenopausal women visiting menopause clinics, and the majority of those with depression respond well to citalopram. Interdisciplinary cooperation is the key point of the detection and follow up of these patients.

Psychiatric symptoms, functional impairment, and receptivity toward mental health treatment among obstetrical patients

OBJECTIVE

To examine psychiatric symptomatology and associated functional impairment among pregnant women; and to examine the obstetrical patient's receptivity to discussion of and intervention regarding emotional distress.

METHODS

Fifty-seven patients 16 weeks or less pregnant presenting for routine obstetrical appointments at a faculty practice at a major medical center participated in this study. Each completed a self-administered assessment packet regarding psychopathology, functional impairment and service utilization attitudes. Statistical analyses were performed using chi-square and Mann-Whitney tests.

RESULTS

Seventeen subjects (29.8 percent) screened positive for at least one anxiety disorder. Fourteen of those subjects also screened positive for depression. Those with positive screens for either anxiety and/or depression had significantly higher levels of functional impairment. Only five (29.4 percent) of the 17 subjects with positive screens reported having discussed an emotional issue with their Ob/Gyn, although 14 (82.4 percent) said that they would be willing to do so. All subjects (100 percent) reported that they would see a mental health professional if their Ob/Gyn referred them.

CONCLUSION

Routine screens for mental disorders in early pregnancy appear to be a useful adjunct in an obstetrical setting. Although most had never discussed their emotional concerns with their Ob/Gyn, a substantial proportion of our study sample reported psychiatric symptomatology and significant levels of functional impairment that had not been recognized by their Ob/Gyn. All of the patients in our study sample reported a willingness to see a mental health professional if their Ob/Gyn referred them. Further studies investigating the benefits of antenatal diagnosis and treatment of psychiatric disorders are warranted.

Validity and utility of the PRIME-MD patient health questionnaire in assessment of 3000 obstetric-gynecologic patients: the PRIME-MD Patient Health Questionnaire Obstetrics-Gynecology Study

OBJECTIVE

This study was undertaken to determine the prevalence of mental disorders among obstetric-gynecologic patients and to assess the validity and utility of the PRIME-MD Patient Health Questionnaire (PHQ) in this population.

STUDY DESIGN

A total of 3000 patients were assessed by 63 clinicians at seven obstetrics-gynecology outpatient care sites. The main outcome measures were PRIME-MD PHQ diagnoses, psychosocial stressors, independent diagnoses made by mental health professionals, functional status measures, disability days, health care use, and treatment or referral decisions.

RESULTS

Current mental disorders were fairly prevalent, present in 1 in 5 obstetric-gynecologic patients. Patients with PRIME-MD PHQ diagnoses had more functional impairment, disability days, health care use, and psychosocial stressors than did patients without PRIME-MD PHQ diagnoses (P <.005 for all measures). Although most clinicians judged the PRIME-MD PHQ to be useful in management decisions, the questionnaire diagnosis of mental disorder rarely led to therapeutic intervention.

CONCLUSION

The PRIME-MD PHQ is a useful instrument for the assessment of mental disorders, functional impairment, and recent psychosocial stressors in the busy obstetrics-gynecology setting.

Psychosocial and economic impact of chronic pelvic pain

According to a population-based estimate, chronic pelvic pain (CPP) affects approximately 15% of women aged 18-50. The psychosocial impact of CPP is reflected in mood disturbance, disruption of normal activity and relationships as well as pain. Identification of psychosocial factors as cause or effect remains problematic. Results of a study of 105 women with CPP using the British version of the SF-36 Health Survey Questionnaire are presented, together with analyses of face validity and reliability. While generally reflecting health status, specific problems with the questionnaire are identified related to the episodic nature of pelvic pain, and avoidance as a means of preventing pain exacerbations. Health economic analyses relating to CPP are reviewed and the implications for future directions in treatment strategy are discussed in the context of limited options of proven efficacy.

Steroid regulation of tryptophan hydroxylase protein in the dorsal raphe of macaques

BACKGROUND

Tryptophan hydroxylase (TPH) is the rate-limiting enzyme for the synthesis of serotonin, and serotonin is a pivotal neurotransmitter in the regulation of mood, affective behavior, pituitary hormone secretion, and numerous autonomic functions. We previously demonstrated that estradiol (E) and progesterone (P) increase TPH mRNA levels in the dorsal raphe of macaques.

METHODS

This study employed western blotting and densitometric quantitation to determine whether the changes observed at the level of gene expression were manifested by changes in TPH protein expression and whether modified estrogens or progestins had actions similar to the native ligands. In addition, the effect of the antiestrogen tamoxifen was examined. Ovariectomized (ovx) rhesus and cynomolgus macaques were untreated or treated with E, P, E+P, equine estrogens (EE), medroxyprogesterone (MPA), EE+MPA, or tamoxifen. The dorsal raphe region was subjected to Western analysis.

RESULTS

E treatment for 28 days increased TPH protein mass four to six fold over ovariectomized controls. Addition of P to the E regimen or treatment with P for 28 days after E priming did not alter TPH from E treatment alone. Treatment of ovx macaques with a low dose of P caused a two-fold increase in TPH protein. Treatment of ovariectomized macaques for 30 months with EE alone or MPA alone significantly increased TPH protein; however, unlike P, the addition of MPA to the EE regimen blocked the stimulatory effect of EE. Tamoxifen treatment significantly reduced TPH protein compared to EE and ovariectomized control animals.

CONCLUSION

The stimulatory effect of E and P on TPH protein in the dorsal raphe of macaques correlates with the previously observed effect at the level of mRNA expression. P had no effect on the stimulatory action of E, whereas MPA blocked the stimulatory effect of EE. Tamoxifen acted as a potent antiestrogen on TPH protein expression. If TPH protein mass influences serotonin synthesis, then these steroids will impact many autonomic systems that are regulated by serotonin.

Self-recognition of depression in public care women's clinic patients

Because young women seen in public care gynecology clinics are at very high risk for depression, it is important to find ways to increase detection of depression in this patient population. This study examined rates and predictors of self-recognition of depression in a sample of 95 depressed public care women's clinic patients. We found that fewer than half of the women (44%) identified their problems as depression, suggesting that the majority of women were not likely to receive treatment for their problems. Predictors of self-recognition included being told by a doctor in the past that they were depressed, endorsing medical/psychiatric causes of mental illness, and use of the coping strategies of facing a problem, alcohol or drug use, and prayer. These findings indicate the need for gynecology settings to (1) provide education about depression to women, (2) encourage them to discuss emotional problems with their physicians, and (3) provide increased education and training to physicians and staff about depression detection and assessment.

Depression in women

Depression is a common and serious psychiatric disorder, more common in women than in men. It can be triggered by abrupt hormonal changes, life events, or nothing at all. It causes enormous debility and significant mortality, and it costs the American economy hundreds of millions of dollars a year. Depression can be readily diagnosed and treated, but, more often than not, it is neither diagnosed nor effectively treated in the primary care setting. The stigma of mental illness and misconceptions about depression in particular, hinder recognition. The signs and symptoms of clinical depression as outlined in the Diagnostic and Statistical Manual of Mental Disorders, 4th Edition, are valid and reliable. Both psychotherapeutic and psychopharmacologic treatments are effective. The obstetrician/gynecologist plays a crucial role in identifying depression, helping the patient, and sometimes her family, to understand the nature of the problem, suggesting treatment, and facilitating either referral or treatment within the Ob-Gyn setting.

TARGET AUDIENCE

Obstetricians & Gynecologists, Family Physicians

LEARNING OBJECTIVES

After completion of this article, the reader will be able to understand the stigmata and misconceptions associated with a depression, to be aware of the various etiologies of depression and typical and atypical presentations, as well as the various management strategies for depression, and have a better understanding of which patients should be referred.

[Sex differences relating to psychiatric treatment]

OBJECTIVE

This paper reviews the literature discussing the influence of gender factors on the efficacy of the most frequently used psychiatric treatments. It recommends taking into account patient gender in order to optimize the treatment efficacy and tolerance.

METHOD

Pharmaceutical and psychotherapeutic treatments as well as other types of therapy (psychosurgery, electroconvulsive therapy [ECT]) are discussed in the overview. Each section draws intermediate conclusions.

RESULTS

Literature on the subject is scarce and uneven. From a pharmaceutical perspective, gender differences are marked; they affect substance absorption, distribution, metabolism, and elimination. As a result, differences in bioavailability affect efficacy and side effects of antidepressants, neuroleptics, and lithium as well as of hypnotics, sedatives, and anxiolytics. The menstrual cycle and birth-control pills also produce significant interactions. Few studies have discussed the influence of the gender-specific effect on the outcome of psychotherapy. However, some differences might exist, and serious further research is required before repeatable conclusions can be reached. Patient gender does not seem to affect certain physical kinds of treatment such as psychosurgery or ETC as much.

CONCLUSIONS

Patient gender has a definite influence on the efficacy of the treatment administered. This influence, however, is often limited and should be considered for the optimization of treatment response and tolerance. Research in this field of psychiatry should be encouraged.

Social subordination stress, behavior, and central monoaminergic function in female cynomolgus monkeys

BACKGROUND

Social subordination in female cynomolgus monkeys is stressful and activates the hypothalamic-pituitary-adrenal axis. In a previous experiment behavioral depression was observed in a subset of subordinates.

METHODS

In the experiment reported here behavioral and physiological indicators of stress were evaluated in dominant and subordinate female cynomolgus monkeys, and brain dopaminergic activity was assessed, as reflected in the prolactin response to haloperidol, a dopamine2 (D2) receptor antagonist.

RESULTS

Subordinates were aggressed more, spent more time in fearful scanning of the social environment, spent less time as the recipients of the active affiliative behavior of being groomed, had more variable heart rates in response to a novel environment, and were hypercortisolemic compared to dominants. Prolactin responses to haloperidol challenge were lower in subordinates than dominants, an observation consistent with the hypothesis that subordinate females have decreased D2 receptor function.

CONCLUSIONS

These observations suggest that social subordination is stressful and may alter brain dopaminergic function in primates. The neurophysiological characteristics of social subordinates may contribute to their susceptibility to depression.

Depressive symptoms are often unrecognized in gynaecological practice

We performed a study on depressive symptoms in gynaecological practice in Belgium, identifying depressive symptoms according to both practitioners' opinions and the scores on a scale developed to detect depression in general medical settings. According to the 170 participating gynaecologists, 12% of the 2174 women they interviewed had symptoms of depression. However, 35% had two or more positive answers on the Depression Scale, and 19% had four or more positive answers. Our results suggest that depressive symptoms are often not identified in clinical gynaecological practice.

Behavior and physiology of social stress and depression in female cynomolgus monkeys

The hypothesis that social subordination is stressful, and results in a depressive response in some individuals, was examined in socially housed female cynomolgus monkeys. Social status was manipulated such that half of the previously subordinate females became dominant and half of the previously dominant females became subordinate. Current subordinates hypersecreted cortisol, were insensitive to negative feedback, and had suppressed reproductive function. Current subordinates received more aggression, engaged in less affiliation, and spent more time alone than dominants. Furthermore, they spent more time fearfully scanning the social environment and displayed more behavioral depression than dominants. Current subordinates with a history of social subordination were preferentially susceptible to a behavioral depression response. The results of this experiment suggest that the stress of social subordination causes hypothalamic-pituitary-adrenal and ovarian dysfunction, and support the hypothesis that chronic, low-intensity social stress may result in depression in susceptible individuals.