Nada Logan Stotland
• Major depression, anxiety disorders, and other specific disorders are common and therefore are seen in general gynecologic practice.
• Appropriate referral to mental health specialists must be made in a sensitive manner.
• Suicidal and homicidal behaviors are absolute indications for referral.
• Alcohol and other substance abuse needs prompt recognition and intervention.
• Some women are vulnerable to mood symptoms at times of hormonal change. However, menopausal hormone levels are not correlated with depression, and premenstrual syndrome should not be diagnosed without 2 months of prospective daily ratings.
• Personality disorders and somatizing disorders rarely can be cured, but informed management can greatly decrease the suffering of the patient
• Withdrawal of successful psychotropic treatment is very likely to lead to relapse.
• Psychotic disorders should nearly always be managed by psychiatrists.
Psychiatric problems are a central or complicating factor for many patients who seek care on an outpatient basis (1,2). Psychiatric diagnoses are extremely common and account for considerable morbidity and mortality in the general population (3). Despite their prevalence, psychiatric disorders are often undiagnosed or misdiagnosed (4–7). Clinical depression affects up to one-fourth of women during their lives, but probably more than half of those women are neither diagnosed nor treated (8–11). More than half of the patients who commit suicide have seen a nonpsychiatric physician during the previous 3 months (12).
Table 12.1 Practitioners' Negative Reactions Toward Patients with Psychiatric Problems
1. Social stigma attached to psychiatric diagnoses, patients, and practitioners.
2. Belief that individuals with psychiatric disorders are weak, unmotivated, manipulative, or defective.
3. Belief that the criteria for psychiatric diagnoses are intuitive rather than empirical.
4. Belief that psychiatric treatments are ineffective and unsupported by medical evidence.
5. Fear that patients with psychiatric problems will demand and consume inordinate and limitless time from a medical practice.
6. Precipitation in others, including doctors, of feelings that are complementary to the strong and unpleasant emotions experienced by patients with psychiatric disorders.
7. Gynecologists' own uncertainty about their skills at psychiatric diagnosis, referral, and treatment.
8. Failure to acknowledge psychiatric problems as legitimate grounds for medical attention.
Psychiatry in the Gynecology Office
Many gynecologists feel uncomfortable diagnosing and treating psychiatric illnesses. The practice of gynecology is demanding, and patients with psychological problems can evoke a variety of negative reactions in physicians (Table 12.1). Some physicians, and some members of the public, have the misconception that psychiatric diagnoses are vague and ill-defined. Current diagnostic criteria and categories of psychiatric disorders are supported by empirical evidence that is as reliable and valid as those used in most medical treatment. Physicians are naturally reluctant to uncover problems for which there seems to be no solutions. There are effective treatments for psychiatric disorders, and they are straightforward to use in clinical practice. Although the newly enacted parity laws forbid discrimination by insurers against mental health care, gynecologists and their patients may have difficulty accessing mental health services. It is sometimes necessary for the physician and family to advocate strongly for necessary care. By incorporating the management strategies in this chapter into their practice, gynecologists can reduce clinical frustration and play a major role in improving the health and well-being of their patients.
In the past, the diagnosis of psychiatric disorders was based partially on hypotheses about a patient’s unconscious psychological conflicts, which cannot be verified (13). Current psychiatric diagnosis, as codified in the Diagnostic and Statistical Manual of Mental Disorders, fourth edition, text revision (DSM-IV-TR), produced and published by the American Psychiatric Association, is based on empirical, valid, and reliable evidence (9). The DSM-IV yields reliability comparable to that of diagnostic systems used in other areas of medicine, and its diagnoses strongly correlate with response to treatment. The criteria in DSM-IV are the basis for the diagnostic entities described in this chapter. The new edition, DSM-IV-TR, differs only in the explanations of some of the diagnoses and not in the diagnostic criteria themselves. The DSM-IV-PC is a special edition designed for the primary care provider. This volume is organized by initial signs and symptoms rather than psychiatric categories and uses algorithms and decision trees to facilitate the diagnostic process (9). The fifth edition of the DSM is scheduled for publication in 2013, and it might not contain changes of major importance for gynecology practice. Accurate diagnosis is absolutely critical to successful management, whether care is provided by a gynecologist or through referral to a mental health expert.
Approach to the Patient
Although diagnostic criteria list signs and symptoms, the interaction with a patient should not be reduced to a series of rapid-fire questions and answers. A wealth of valuable information can be obtained from the patient’s spontaneous description of her concerns and from her responses to the physician’s open-ended questions (14). A patient who is encouraged to speak for several minutes before being asked to respond to specific questions will reveal information that is useful, even vital, to her care: a thought disorder, a predominant mood, abnormally high anxiety, a personality style or disorder, and attitudes toward her diagnosis and treatment. Such information may emerge only much later, or not at all, in a question-and-answer format (15,16). It is critical that the gynecologist neither jumps to diagnostic conclusions nor proceeds directly to therapeutic interventions. One study revealed that many primary care physicians, feeling that they have too little time or training to assess psychological symptoms, tend to minimize verbal interactions with patients and to rely on the prescription of psychotropic medications (17). Allowing a few moments for open-ended discussion does not mean that the physician and the other patients awaiting care are to be held hostage by an overly talkative patient. The clinician can tell the patient with multiple, detailed symptoms how much time is available for the current appointment, invite her to focus on her most pressing problem, and offer a future appointment to continue the account.
Many gynecologists consider referral to a mental health professional, particularly a psychiatrist, to be a delicate matter. The first question is when to refer, followed by how to refer and to whom. Most mild psychiatric disorders are treated by nonpsychiatric physicians, who often prescribe antidepressants and anxiolytic medications (18). Psychiatric disorders often are overlooked, misdiagnosed, or mistreated in primary care practice. The factors that determine the decision to refer are the:
• Nature and severity of the patient’s disorder
• Expertise of the gynecologist
• Time available in the gynecologic practice
• Patient’s preference
• Gynecologist’s degree of comfort with the patient and the disorder
• Availability of mental health professionals
Patients who are suicidal, homicidal, or acutely psychotic should be referred immediately to a psychiatrist, and often are accompanied to the appointment (19). The primary provider should refer patients for psychiatric evaluation when the diagnosis is not clear or when the patient fails to respond to initial treatment. The gynecologist can resume responsibility for ongoing care of many patients after their initial or periodic assessment by a psychiatrist.
How to Refer
Some clinicians fear that patients will be insulted or alarmed by a psychiatric referral. Following are techniques that decrease the discomfort of both the gynecologist and the patient and enhance the likelihood of success (19). The referral should be explained on the basis of the patient’s own signs, symptoms, and level of distress. For a patient suffering from clinical depression, for example, this might be difficulty sleeping, loss of appetite, and lack of energy. For a patient with an anxiety disorder, it might be palpitations, shortness of breath, and nervousness. For a patient with mild Alzheimer’s disease, it might be forgetfulness or frightening episodes in which she finds herself in a neighborhood she does not recognize. With the advent of treatments that may slow dementia, these referrals are easier and more meaningful because there is now some hope for effective intervention.
When a somatizing (psychosomatic) disorder is suspected, the gynecologist should emphasize the difficulty of living with symptoms in the absence of a definitive diagnosis and treatment rather than the hypothesis that the symptoms have a psychological basis (19):
1. “It is very stressful to be suffering while we can’t pinpoint the problem. I would like you to see one of our staff who specializes in helping people cope with these difficult situations.”
2. “It must be difficult to function when you have been so sickly all your life, have seen so many doctors, have had so many diagnostic tests and medical treatments, and still don’t have an answer or feel well.”
It is counterproductive to convey the idea that because the diagnostic process has not revealed a specific disorder, the problem must be “in the patient’s head.” It alienates the patient. It is never possible to rule out an organic cause with absolute certainty; and diseases “in the head” are real diseases (19).
Although suicidal and homicidal behaviors are absolute indications for referral, many physicians fear that questioning patients about these behaviors will provoke them. That is not the case (12). An open discussion of impulses to hurt oneself or someone else helps the patient to regain control, recognize the need for mental health care, or agree to emergency interventions such as psychiatric hospitalization, whereas avoiding the subject intensifies the patient’s feelings of isolation. The management of suicidal behavior is addressed later in this chapter in the section on mood disorders.
Likewise, the possibility of psychosis need not be avoided. Most patients with psychotic disorders have had previous experience with psychiatric referral. Their psychotic symptoms are often distressing, so treatment is an appealing option (19). They can discuss hallucinations and delusions quite matter-of-factly. The rare patient who comes to a gynecologist in the midst of a first episode of psychosis is likely to be frightened by her symptoms and willing to accept expert consultation.
Despite increasing public sophistication about mental illnesses and psychiatric care, some patients believe that any mention of mental health intervention implies that they are either “crazy” or that the referring physician is convinced that their physical symptoms are imaginary or feigned. It is helpful to state explicitly that this is not the case. Making the real reason for the referral clear and founded in signs and symptoms obvious to the patient will nearly always allay anxiety over a psychiatric referral (19).
It is not acceptable to refer a patient to a psychiatrist without informing her in advance and obtaining her consent, unless she is acutely psychotic, functionally incompetent, or in the throes of a suicidal or homicidal emergency. Even under those circumstances, it is highly preferable to be straightforward. A referral that begins with an unexpected clinical encounter with a psychiatrist is unfair to both the psychiatrist and the patient and is unlikely to result in a satisfactory outcome (17–19).
To allay any concern a patient may have that a mental health referral is an indication of the gynecologist’s disdain or disinterest, and to promote good patient care in general, the referring gynecologist should make it clear to the patient that he or she will remain involved in the patient’s care. The mental health professional should be introduced as a member of the health care team, and the gynecologist should ask the patient to call after the mental health appointment to report on how it went. The patient should be given a follow-up appointment with the gynecologist at the time of the referral (19).
Making a Mental Health Professional Referral
Mental disorders are treated by social workers, psychologists, members of the clergy (often the first to be consulted), and various kinds of counselors as well as by psychiatrists (17–19). The lay public or even some medical professionals may not understand the distinctions between types of mental health professionals. The criteria for membership in each profession can vary by region and institution. Social workers and psychologists can receive degrees at the bachelor, master, or doctoral level. In some states, licensure is required. Social workers require a master’s degree and psychologists receive a doctoral degree, in addition to supervised clinical experience to qualify for licensure. The category of counselor includes a wide variety of practitioners, such as marriage counselors, pastoral counselors, school counselors, and family counselors. The training of social workers may focus on social policy, institutional care, psychosocial aspects of medical illness, or individual treatment (17–19).
Practitioners of all these disciplines may or may not be trained in psychotherapy. For a patient whose symptoms do not meet criteria for a major psychiatric disorder and who is able to eat, sleep, and carry out her regular duties, supportive psychotherapy provided by a trained mental health professional may suffice. Supportive psychotherapy calls on a patient’s existing coping mechanisms to combat a stressful situation. Doctoral-level psychologists and neuropsychologists can perform testing that can be helpful in establishing a diagnosis. Such testing is especially useful in identifying and localizing brain pathology and in defining intelligence levels. Undiagnosed cognitive deficits may contribute to noncompliance with gynecologic care as well as other problems (17–19).
Trained social workers are often knowledgeable about community resources for patients and their families and about the impact of gynecologic diseases and treatments on the patients. Self-help or professionally led therapy groups can be helpful for patients reacting to gynecologic problems such as infertility or malignancy. Participation in a supportive group was said to lengthen the survival time and improve the quality of life for some patients with cancer, although this assertion is controversial (20–26).
Psychiatrists are the only medically trained mental health professionals. They play a particularly important role in resolving diagnostic dilemmas, especially when questions arise about the psychological or behavioral manifestations of medical illness and pharmacologic treatment; when a medical understanding of the gynecologic condition and treatment is essential to the care of the patient; and when such issues as drug–drug interactions must be considered (19). Psychiatrists are the only mental health professionals trained to prescribe psychoactive medications and other biologic interventions and provide psychotherapy. The legislatures of New Mexico and Louisiana have conferred prescribing rights on doctoral-level psychologists with additional training but have not defined the limits of the prescribing authority. It is highly likely that psychiatrists will continue to treat the most seriously ill patients and take ultimate responsibility for psychiatric emergencies (19).
Because psychiatric problems frequently present in gynecologic practice, it is worthwhile for the gynecologist to develop an ongoing relationship with one or more local mental health professionals.The state psychiatric society may have a list of subspecialists in “consultation liaison” psychiatry; this is an official subspecialty of the American Board of Psychiatry and Neurology. Many psychiatrists without specific fellowship training offer consultative services. The availability of familiar and trusted resources enhances the likelihood that problems will be identified and addressed. An ongoing relationship with a mental health professional allows the gynecologist to familiarize that professional with relevant developments in gynecology. It is important to keep up-to-date information on local suicide prevention hotlines and other kinds of resources for battered women and for mothers who may pose a danger to their children. Local laws may require that physicians report to the authorities their knowledge of mothers in this situation (19).
Whenever a patient’s thinking, emotions, or behaviors cause concern, the gynecologist should first consider a nonpsychiatric medical disorder or a reaction to prescribed or illicit drugs. Psychiatric disorders frequently coexist with these conditions (19). HIV/AIDS infection, some malignancies, hypothyroidism, and other diseases can present with psychiatric symptoms.
Psychiatric conditions are extremely common in gynecologic practice. Some are primary and some are related to reproductive events. All patients should be screened for depression, anxiety, domestic violence, and substance abuse, each of which can be diagnosed and treated, either by the gynecologist or by referral to a social resource or a mental health specialist (16–19).
Mood is the emotional coloration of a person’s experience. Mood may be pathologically elevated (mania) or lowered (depression) or may alternate between the two (bipolar or manic-depressive disorder) (26). Mood disorders are different from, but frequently confused with, the inevitable ups and downs of everyday life, such as the reactions to difficult situations, including gynecologic conditions. In the English language, depression is used to describe both a transient mood and a psychiatric disorder. Because of this confusion, both patients and their loved ones become frustrated when well-meaning attempts to reason with them, distract them, or do thoughtful things for them in a manner that would affect a self-limited reaction to a difficult situation, fail to influence their protractedly disturbed moods.
Mania is characterized by the following behavior (26):
1. Elevated mood, with euphoria or without irritability
3. Pressured, accelerated speech and physical activity
4. Increased energy
5. Decreased sleep
6. Reckless and potentially damaging behaviors, such as wild expenditures and promiscuity
Mania can be acute or subacute (hypomania). Hypomania can produce self-confidence, ebullience, energy, and productivity that are the envy of others, making the patient reluctant to relinquish this mood by undergoing treatment. It can be particularly difficult to arrest the condition before it progresses to full-blown mania. Acute mania is a life-threatening condition; without treatment, patients fail to maintain essential sleep and nutrition levels and literally exhaust themselves with frantic activity. Patients with bipolar illness must be taught and encouraged, and often learn from bitter experience, to recognize the early signs of disturbed mood so that treatment or treatment changes can be initiated (16).
The overall lifetime prevalence of affective disorders is 8.3%; the 6-month prevalence is 5.8%. During the reproductive years, depression is two to three times more common in women than in men (26–32). The highest incidence of depression is in the age group of 25 to 44 years, but depression occurs in every age group, from toddlers to the aged. Women have a lifetime risk of 10% to 25% and a point prevalence of 5% to 9% (33–36). Although public understanding and acceptance of mental illnesses has significantly increased, patients may have difficulty accepting, and telling others, that they are suffering from depression.
Depression is the single most common reason for psychiatric hospitalization in the United States. As many as 15% of individuals with severe depressive disorders eventually commit suicide (37). Depression is a significant risk factor for cardiovascular disease and for noncompliance with essential treatments for other diseases, including diabetes. Depression is a recurrent disorder; of those who experience a major depressive episode, 50% have a second one. Of these, 70% have a third, and the incidence continues to increase with each subsequent episode. In the past diagnostic criteria were not standardized, so it is difficult to know whether the incidence of depression has increased over recent years, as has been asserted in the popular press.
Because women’s roles in society changed a great deal over the past few decades, there is a temptation to postulate a higher rate of depression attributable to women’s work outside the home. There is no evidence that employment outside the home increases women’s vulnerability to depression. Multiple life roles actually contribute to life satisfaction, although the need to carry out multiple roles in the absence of adequate social support, as is all too common in women’s lives, is stressful (38–40).
Depression is characterized by the following (9,19):
1. Sad mood or irritability
4. Decreased ability to concentrate
5. Decreased energy
6. Interference with sleep, generally with early awakening, inability to return to sleep, and failure to feel rested; atypically, with increased sleep
7. Decreased appetite and weight; atypically, increased food intake
8. Withdrawal from social relationships
9. Inability to enjoy previously gratifying activities
10. Loss of libido
12. Psychomotor retardation or agitation
13. Thoughts of death or suicide
The patient who has five or more of the signs and symptoms of depression for most of each day for 2 weeks or more fulfills the criteria for the diagnosis of clinical depression (36–38). Depression may be acute or chronic (dysthymic disorder). Like many diseases, it is caused by genetic, neurophysiologic, and environmental factors. Trauma in early life plays a role. Serotonin is a major mediator of mood. Treatment, whether pharmacologic or psychotherapeutic, is effective for depression. The average duration of a major depressive episode is approximately 9 months (36). Patients must be cautioned to continue treatment at least that long, even if symptoms remit; relapse is common.
Depression may be precipitated by an adverse life event such as an interpersonal loss, economic reversal, or serious illness (41,42). When there is an identifiable precipitant, there is a danger that the depression will be written off as the inevitable reaction to the event rather than considered properly as a complication that requires active treatment, similar to infection or pneumonia complicating a surgical procedure. When a patient’s symptoms meet criteria for the diagnosis, treating the depression will relieve symptoms and will enable her to cope more successfully with the precipitating situation (43).
Paradoxically, patients in happy life situations, and their loved ones, may have resistance to the idea that they are depressed. They need to understand that depression is not a sign of ingratitude or lack of appreciation for their life advantages, but a disease, like any other, that can strike even otherwise fortunate people.
Concomitant gynecologic or other medical illness can cause signs and symptoms similar to those of depression—loss of energy, sleep, and appetite—but does not cause guilt, hopelessness, or helplessness (44). These observations are helpful in differentiating depression from the malaise associated with other disease states.
The incidence of depression peaks, and the gender difference prevails, during the reproductive years (45). Connections between female reproductive functions and mood changes have been posited for centuries. When it first became possible to determine circulating hormone levels, researchers expected to find specific relationships between psychological and physiological changes. These expectations were uniformly discounted. There is no serum hormone level associated with premenstrual dysphoria, postpartum depression, or depression at menopause (46). There is a subgroup of women who are vulnerable, not to absolute circulating hormone levels, but to hormonal changes (47–50). There is a correlation between the degree of hormonal change, pre- and postpartum, and the incidence of postpartum mood disorder. Women who are vulnerable to hormonal changes may experience severe premenstrual mood symptoms, postpartum depression, and, possibly, depression in association with hormonal influences such as hormonal contraceptive methods, menopause, and hormone treatments (51).
Depending on the methodology used to gather the data, most women report mood and behavioral changes associated with the menstrual cycle. Although there are both ups and downs associated with the cycle, it is the more problematic parts of the cycle that are characterized, as premenstrual syndrome, or PMS. An estimated 3% to 5% of ovulating women appear to suffer from symptoms so marked that they qualify for a diagnosis of premenstrual dysphoric disorder (PMDD) (52–54).
PMDD is included in DSM-IV-TR as an example of a depressive disorder, not otherwise specified, and as a category requiring additional research (9). Provisional diagnostic criteria are provided to standardize this research.
In most cycles over the past year, the patient had at least five of the following symptoms for most of the time during the premenstrual week, with symptoms remitting completely in the postmenstrual week (54):
• Depressed mood, hopelessness, self-deprecation
• Anxiety, tension
• Affective lability
• Anger, irritability, interpersonal conflict
• Decreased interest in usual activities
• Difficulty concentrating
• Decreased energy
• Appetite changes or cravings
• Changes in sleep
• Feeling overwhelmed or out of control
• Physical symptoms such as breast tenderness, headache, bloating
The symptoms markedly interfere with work, family, or academic responsibilities; are not exacerbations of another existing disorder; and are corroborated by at least 2 months of prospective daily ratings (54).
Premenstrual syndrome, as differentiated from premenstrual dysphoric disorder, has been characterized by more than 100 different physical and psychological signs and symptoms, making it difficult to define scientifically. Methodological problems further complicate the situation; in the United States, the prevalence of attitudes linking the menstrual cycle to adverse mood and behavioral changes is so high that it skews women’s perceptions, the way they report symptoms to researchers, and the factors to which they attribute negative feelings. No specific circulating hormone levels or markers are associated with premenstrual symptoms (55). When prospective daily ratings are obtained systematically, the symptoms of most women who seek care for PMS are not related to the menstrual cycle(56,57). Therefore, careful assessment is essential. Before the diagnosis of PMS or PMDD can be established, a woman must record symptom ratings daily for at least two full cycles. Records of emotions and behaviors should be kept separate from menstrual records to avoid confounding patients' perceptions. At the same time, the patient must be screened for other psychiatric disorders, including depression and personality disorders, and for domestic abuse and other life circumstances that may contribute to her psychological state (58).
No treatment for PMS has been validated by empirical studies (59). Studies of St. John’s wort, possibly the most popular alternative treatment, are contradictory (60). A number of lifestyle changes and other benign interventions alleviate symptoms for some patients with PMS (61):
• Elimination of caffeine from the diet
• Smoking cessation
• Regular exercise
• Regular meals and a nutritious diet
• Adequate sleep
• Stress reduction
Stress reduction can be accomplished by reducing or delegating responsibilities, insofar as that is possible, and devoting part of every day to relaxation techniques such as meditation and yoga. Many women experience stress factors over which they have no control (59).
For premenstrual dysphoric disorder, several selective serotonin reuptake inhibitors (SSRIs) proved effective in clinical trials (62–65). Although SSRIs and all other antidepressants require about 2 weeks of daily administration to achieve therapeutic effect for other depressive disorders, it appears that fluoxetine is effective for PMDD when taken in the usual daily doses for the 1 to 2 weeks preceding menstruation. The medication is packaged for this specific indication and dosage. It is thought that the mode of action of SSRIs when used in this fashion differs from that which alleviates major depression (65). Other medications for the treatment of PMS and PMDD are shown in Table 12.2. There is some interest in the role of oral contraceptives in management of PMDD, and for patients interested in contraception, trials of oral contraceptives are a reasonable approach (66). Symptoms must be carefully monitored to determine whether the hormonal intervention improves or exacerbates the problem mood changes.
Table 12.2 Scientific Basis of Selected Medications Used to Treat Premenstrual Syndrome
Other Reproductive Events
Infertility is described by most women who undergo treatment for it as the most stressful event of their lives. Each unsuccessful treatment episode is experienced as the loss of a hoped-for pregnancy (67). The loss of a fetus or newborn induces grief, with some of the same symptoms as depression. Depression is associated with guilt, whereas bereavement is not. However, women who lose pregnancies or infants often do feel guilty, regardless of whether these feelings are logically justified. Patients should not be pressed to “put the loss behind them” or expected to be “over it” within several months. Some feelings of sadness may persist for years. However, their sleep, appetite, and other vital functions and behaviors should begin to improve after a few weeks (68). Grief that persists and interferes with normal function is characterized as pathologic. Depression can complicate grief and should be treated (69).
There is no convincing evidence that induced abortion causes clinical depression or any other negative psychiatric sequelae. Studies purporting to demonstrate negative sequelae fail to take into account the circumstances under which women conceive unintended pregnancies and elect to terminate them—abuse, abandonment, poverty, rape, and incest—or the circumstances in which they occur—familial pressure or disapproval, the presence of clinic demonstrators (70).
Peripartum Psychiatric Disorders
The incidence of depression in women during their reproductive years is approximately 10%. The incidence of depression does not decrease during pregnancy; most postpartum depression is a continuation of antepartum depression (71–73). Although there are some cross-cultural variations under study, postpartum depression is found around the globe (74). Risk factors include social isolation, lack of social supports, history of depression, and past or present victimization (75). It is important to remember that women without risk factors may become depressed. Postpartum depression must be distinguished from the transitory, self-limited, and very common “baby blues,” which are associated with changes in hormone levels and are better characterized as mood intensity and lability rather than depression. Mild depression can be managed with psychotherapy (76). Moderate to severe cases often require antidepressant medications (77). Electroconvulsive treatment acts rapidly and effectively, appears to be safe during and after pregnancy, and can be a life-saving option for the most severe cases (78). Treatment with artificial light may alleviate milder symptoms (79). Although no agent can be declared perfectly safe for use during pregnancy and lactation, older SSRI agents are well studied, yielding little or no evidence of adverse effects on the fetus or nursing infant (80–82). These agents are used in the treatment of obsessive-compulsive disorder (83).
Medication should not be stopped arbitrarily, nor should breastfeeding be prohibited. The withdrawal of antidepressant medication during pregnancy is very likely to result in postpartum depression; both antenatal and postnatal depression have demonstrable, long-term ill effects for mother and child (84–91). There is concern about withdrawal syndromes in neonates whose mothers took SSRIs (92). These concerns arise from anecdotal reports and do not include data about the number of births from which the reports emerged, nor about confounding variables. Some observers recommended that pregnant women be withdrawn from SSRIs some days or weeks before delivery. However, delivery dates are often uncertain; maternal withdrawal might subject the fetus, rather than the newborn, to withdrawal symptoms; and the likelihood of postpartum depression, with its effects on both mother and infant, would be greatly increased. Researchers are exploring ways to prevent postpartum depression, but thus far nothing has proved effective (93,94).
Sertraline appears to be the safest medication for pregnant and lactating women, and paroxetine is the cause of most concern. If treatment is begun during pregnancy or lactation sertraline is the reasonable choice. Switching a patient successfully treated with another antidepressant to sertraline is not indicated. The fetus would be exposed to a second medication, and the patient may not respond as well to sertraline as to the currently effective antidepressant (80–82).
Studies of the relationship between hysterectomy and mental illnesses are contradictory (95,96). Probably the determining factors in psychiatric outcomes are the reason for the procedure and the context, whether the patient loses valued fertility as a result, including the reactions of significant others and cultural beliefs about the importance of an intact uterus (97).
Although menopause was assumed for many years to be associated with an increased incidence of depression, empirical studies led to conflicting results and controversy. Menopause appears to have mood effects in some women that can be differentiated from the secondary effects, such as hot flashes interfering with sleep. Psychosocial studies indicate that some patients are upset by their loss of fertility or the departure of grown children from the home (empty nest syndrome), but many women find menopause liberating (98,99). For some women the return of adult children to the maternal home, or responsibilities for the care of grandchildren, seems to be a precipitating factor for depression. Patients who suffered PMS or postpartum depression may be vulnerable to a recurrence of depression at this new time of hormonal change. Patients with depression at the time of menopause should be assessed for psychosocial precipitants and domestic abuse. There are conflicting reports on the effectiveness of hormones for treatment of mood symptoms during menopause (100–105). Treatment with SSRIs may ameliorate hot flashes (106).
Depression in elderly patients can cause a pseudodementia, characterized by decreased activity and interest and what appears to be forgetfulness. Unlike patients with genuine dementia, these patients report memory loss rather than trying to compensate and cover up for it. The early stages of dementia can precipitate depression as patients react to the loss of cognitive abilities (107).
Approach to the Patient
The severity of depression is determined by the patient’s emotional pain and the degree of interference with her normal functioning. Depression is an agonizingly painful and disabling, but readily diagnosable and treatable, disease (108). Nevertheless, it shares the stigma of all psychiatric disorders. Patients and their families often attribute the signs and symptoms of depression to life circumstances or to a medical condition, either diagnosed or undiagnosed. The persistence of symptoms in the face of a pleasant life situation or the failure of the patient to respond to attempts at cheering, such as changes of scene, often exacerbate suffering by provoking guilt in the patient and frustration in her significant others. Some patients report low energy and general malaise rather than depressed mood. Physical symptoms are especially common in Asian and some other cultures and in the elderly (107). Some patients with severe depression continue to function and can appear normal and cheerful. The only way to rule out depression is by asking about symptoms and using the diagnostic criteria (108).
Both antidepressant medication and psychotherapy are effective treatments for depression. There is evidence that a combination of the two produces the best outcomes (109–111). Reports about the efficacy of alternative treatments, the most common of which is St. John’s wort, are conflicting, but mostly negative (112). Patients should be specifically questioned about their use of herbal and other preparations and encouraged to use those whose components are standardized. Transcranial magnetic stimulation is a promising research intervention (113,114).
There are many forms of psychotherapy. Those that were specifically studied for efficacy in the treatment of depression are cognitive-behavioral therapy and interpersonal therapy. These forms of therapy are focused on present thoughts, feelings, relationships, and behaviors. Therapy continues for a set number of sessions, usually no more than 16 weekly sessions, in a prescribed, predetermined progression (115). There is increasing evidence that supportive and psychodynamic psychotherapy is effective.
It is especially important for the patient to have the opportunity to work out her feelings about having a psychiatric disorder, understand how it has affected her life, and feel comfortable taking medication or undergoing psychotherapy (115). Patients often attribute depression to weakness, laziness, or immorality, and they often confuse antidepressants with stimulants, tranquilizers, and other psychoactive drugs. Although written materials cannot substitute entirely for verbal instruction, it is useful to provide the patient with written material about depression so that she can review it at her leisure and with her family and friends if they have difficulty understanding her condition. There is widespread difficulty understanding written information, especially about medicine. Many or most antidepressant prescriptions are either not filled or not taken as prescribed (116).
Depression in one individual has a powerful effect on other members of the family, particularly children. This can be a motivating factor for patients who are reluctant to accept treatment.
The types and characteristics of antidepressants are presented in Table 12.3. All antidepressants have comparable therapeutic efficacy, and all require up to 2 to 4 weeks to take full effect. It is not yet possible to identify those patients who will respond best to certain medications, but there is early evidence that depression may be related to specific neurotransmitters and respond differentially to medications affecting a given neurotransmitter. The response to treatment may differ with gender, but the data are not sufficient to drive clinical decisions (117).
It is sensible to use a more activating agent (fluoxetine) in a lethargic patient and a more sedating agent (paroxetine) in an agitated patient (118). Nonetheless, responses vary on an individual basis, even within the same class of medications. The choice of antidepressant is based on side effects, dosage, cost, and the physician’s clinical experience (Table 12.4). Patients tend to respond to medications that worked for them in the past and to those that worked for depressed family members. Many patients require successive trials of two or more antidepressants before the one that is effective for them is identified. It is essential to continue active management through the usual duration of a depressive episode—9 to 12 months for major depression, until the patient has responded sufficiently that she has returned to her previous level of mood and function. If the patient does not recover completely, she should be referred to a psychiatrist (118).
Table 12.3 Pharmacology of Antidepressant Medications
Table 12.4 Side-Effect Profiles of Antidepressant Medications
Tricyclic antidepressants are the oldest antidepressants still in use and are available in generic preparations (118–122). They all have significant anticholinergic side effects that may be problematic in medically ill and elderly patients. They are associated with some slowing of intracardiac conduction; this side effect can be tolerated and managed in all but a few patients, and it can be therapeutic for those with hyperconductibility. Tricyclic antidepressants should be taken in divided doses through the day, although bedtime dosing may help patients who have difficulty sleeping. Some tricyclic agents, such as nortriptyline, have “therapeutic windows”—blood levels above or below which they are not effective—that must be monitored. The average dose for tricyclic agents is 225 mg per day in divided doses (122). The most important drawback of tricyclic medications is their lethality in overdose, which is especially important because they are used with depressed patients who are already at risk for suicide. In the rare event that they must be used by a potentially suicidal patient, the patient must be given only a few pills at a time (121). Some medication plans, private or public, require that treatment begin with the least expensive generic medication, and that the patient first fail with that medication before a newer compound will be provided. The clinician may have to serve as advocate for the patient when this is not a clinically acceptable approach.
Monoamine Oxidase Inhibitors
Monoamine oxidase (MAO) inhibitors are especially effective for atypical depression, which is associated with abnormally increased, rather than decreased, sleep and appetite. They require dietary restrictions and can be used only in patients who are able to understand and comply with those restrictions to avoid hypertensive crises (117).
Selective Serotonin Reuptake Inhibitors
SSRIs pose few risks of medical complications. Side effects include anxiety, tremor, headache, and gastrointestinal upset (either diarrhea or constipation), and usually abate within a few days of the onset of treatment. A more serious side effect is loss of libido and interference with orgasm (119). Patients may be reluctant to report sexual side effects, but they may discontinue treatment because of them. Some women are willing to accept the sexual side effects of SSRIs as an acceptable price to pay for recovery, especially considering that depression already interferes with their sexual functioning. Female patients are frequently concerned about weight gain. In one study, it appeared that a weight gain of 5 to 7 pounds might be attributed to an SSRI; the return of normal appetite may lead to weight gain. Concerned patients should be advised to watch their diets carefully while taking the medication. There is some evidence that bupropion causes less weight gain than SSRIs. SSRIs appear to interfere with the efficacy of tamoxifen, resulting in excess mortality from breast cancer (120).
SSRIs are administered in a once-a-day regimen, with little need for dosage adjustments in most cases. SSRIs have long half-lives, so occasional late or missed doses do not constitute a problem. Withdrawal, especially sudden withdrawal, from SSRIs causes flulike symptoms and sleep problems in a small proportion of patients (121). Patients should be cautioned not to discontinue their medications without consulting the physician, and only then by gradually decreasing the dose. As with most medications, antidepressants were not initially tested in older women, but several are under consideration by the U.S. Food and Drug Administration (FDA) for use in this age group (122). The FDA mandated so-called black box warnings on SSRIs when used in adolescents and young adults. This decision is highly controversial. The studies upon which the decision was based included no subject who had committed suicide. Suicidal thoughts, which are extremely common, were conflated with serious attempts, all lumped together as suicidality. SSRI prescriptions decreased after the warning was imposed, and there is some evidence that suicides have gone up as a result (123–125).
Medications considered atypical include venlafaxine, lithium salts, and anticonvulsants, which are effective mood stabilizers used for bipolar disorders (126–130). Bupropion is available in a once-a-day preparation. It lowers the seizure threshold slightly more than other antidepressants and should be avoided or used with caution in patients who have a history of head trauma. It is used, under a separate trade name, for smoking cessation, and is particularly useful for smokers who are depressed. Bupropion seems to cause fewer sexual side effects than the SSRIs and may decrease these side effects when added to an SSRI regimen.
The most acute issue in the assessment and referral of depressed patients is the possibility of suicide (131). Following are the risk factors for suicide:
• Recent losses
• Previous suicide attempts, even if seemingly not serious
• Concurrent alcohol or substance abuse
• Current or past physical or sexual abuse
• Family history of suicide
• A plan to commit suicide
• Access to the means to carry out the plan
Women attempt suicide more frequently than men, but men complete the act more frequently than women (131,132). This is probably because men use more drastic or irreversible means, such as firearms, whereas women tend to overdose, which can be treated if discovered. It might seem that someone who repeatedly makes suicidal gestures is more interested in the responses of others than in ending her life. However, past attempts or gestures increase the risk of completed suicide. Patients who made a suicide attempt should be queried about the following risk factors: the intent to die (rather than escape, sleep, or make people understand her distress); increasing numbers or doses of drugs taken in a progression of attempts; and drug or alcohol misuse, especially if it, too, is increasing. Inquiry about suicidal ideation and behavior is an inherent part of every mental status examination and is mandatory for every patient with past or current depression or evidence of self-destructive behavior. The inquiry can follow from discussion of difficulties in the patient’s life or mood or be introduced with a comment that almost everyone has thoughts of death at one time or another. Nonsuicidal patients will immediately volunteer that they have had such thoughts and that they have no intention of acting on them. They will often add reasons: they have too much to look forward to, it is against their religion, or it would hurt their family.
It is important to distinguish among thoughts of death, the wish to be dead, and the intention to kill oneself (132). A patient in a painful life situation—a chronic, painful, or terminal medical condition, the birth of a severely damaged child, or a grievous loss—may express a wish to die, and even refuse recommended medical care but emphatically and honestly disavow any intention of actively harming herself. The patient must be directly asked (132).
If the patient previously engaged in impulsive self-destructive behavior, without a plan or warning, it is wise to consult a psychiatrist. If a patient is actively contemplating suicide, she must see a psychiatrist immediately(132,133). Other mental health professionals may be helpful but are less likely to have dealt extensively with and assumed responsibility for suicidal patients, to be able to determine whether the patient should be hospitalized, and to have admitting privileges. Until she is in the physical presence of a psychiatrist, or in a safe environment such as a hospital emergency room, a suicidal patient should be observed and protected at all times—every second—whether she is in the consulting room or the bathroom. The staff member assigned to remain with her may not leave to make a telephone call, go to the bathroom, or get a cup of coffee. Family members may offer to monitor the patient and can sometimes be effective, but the health care professional is responsible for ensuring that they understand and implement this level of supervision. It is better to risk inconvenience and possible embarrassment to both the gynecologist and the patient than to risk a fatal outcome. When suicide is an immediate consideration, only a psychiatrist can make the decision that a patient is safe (133). Psychiatric referral can be useful in less dramatic cases: when the gynecologist lacks experience or is overloaded with patients, when a first trial of treatment is unsuccessful or there is uncertainty about the diagnosis, when domestic violence or substance abuse may be present, and when the depression is recurrent.
Many people are not aware that approximately half of suicides are not associated with depression. Suicide can occur in the context of an anxiety disorder, personality disorder, psychotic illnesses, or as an impulsive response to an adverse life event (133). Suicide is not an inevitable consequence of any of these conditions, including depression. Most people rescued from potentially lethal suicide attempts do not ultimately commit suicide. That is why barriers on bridges and other devices to prevent impulsive suicides are necessary.
Alcohol and Substance Abuse
Alcohol and substance abuse are major causes of morbidity and mortality (134). The essential feature of substance dependence, or addiction, is the continued use of the substance despite serious resulting problems. Alcohol and substance abuse are among the most common—and most frequently overlooked—conditions in medical practice.
In the DSM-IV-TR, the term “substance” can mean a medication, a toxin, or a drug of abuse. Nicotine is included among “substances,” and women appear to be more susceptible to nicotine addiction than men, but smoking cessation is more a topic for general medicine than for psychiatry (9,135).
Substance abuse leads to major complications, including intoxication and withdrawal. Withdrawal is major problem because, as mentioned in this chapter in the section on benzodiazepines, patients often fail to inform clinicians of their alcohol and substance use before being hospitalized or undergoing procedures, when they may experience unanticipated undiagnosed withdrawal (136–138).
Significant problems caused by continued use of the substance may include symptoms of withdrawal, interference with family and work obligations, and the depletion of, or criminal activity to obtain, resources to obtain the substance. Other features include tolerance, or the need to consume more of the substance to obtain the same effect, and compulsive use (139).
Patients frequently use alcohol along with other substances of abuse. The abuse of prescription medication, especially in younger populations, has increased (140). Patients should be advised to take care that their medications are not accessible to others.
Alcohol is the most frequent substance of abuse. Legal and accepted by society, it nevertheless causes a high proportion of morbidity, mortality, and life complications. Women’s alcohol abuse is more likely to take place in private than is men's; society frowns more on women who are drunk or create disturbances in public than on men who do the same. Women are more likely than men to use a substance because an intimate partner uses or abuses that substance, and to trade sexual favors for access to the substance (141). There is strong evidence for a genetic link for alcoholism, but not for the other substances of abuse.
The most successful treatment for substance abuse disorders is a so-called 12-step program such as Alcoholics Anonymous. Most of the programs for the treatment of substance abuse were developed for men. Women are less responsive to the usual confrontational approach (142,143). Many women with substance abuse issues have children. Such women, and women who are pregnant, are often reluctant to enter treatment for fear of prosecution or losing custody. Treatment programs for women with primary responsibility for children must include arrangements for child care. Recidivism after treatment is very common, but that does not mean that treatment is useless. On average, patients require three episodes of treatment before achieving sobriety (139). The essential obligation of the primary physician is to ask each patient about substance consumption and any problems arising from it (141). Buprenorphine is a useful adjunct medication; physicians are required to undergo specific training in order to prescribe buprenorphine (144).
Anxiety is a sense of dread without objective cause for fear, accompanied by the usual physical concomitants of fear. Although every human being has anxious feelings from time to time, anxiety disorders are diagnosed when anxiety becomes disabling or so painful as to interfere with an individual’s quality of life. Anxiety disorders place patients at risk for suicide (145).
The anxiety disorders include generalized anxiety disorder, panic disorder, agoraphobia, specific phobias, obsessive-compulsive disorder, and posttraumatic stress disorder (146–148).
Generalized Anxiety Disorder
Generalized anxiety disorder is a condition in which anxiety pervades every aspect of a patient’s life. She suffers from restlessness, easy fatigability, difficulty concentrating, irritability, muscle tension, and sleep disturbances. Whereas depressed patients fall asleep more or less normally and then awaken earlier than intended, anxious patients tend to have difficulty falling asleep (146,147).
Panic disorder is characterized by panic attacks: acute periods, generally lasting about 15 minutes, with intense fear and at least four of the following symptoms (146–152):
• Shortness of breath
• A choking sensation
• Chest discomfort
• Gastrointestinal distress
• A sense of unreality
• Fear of going crazy or dying
• Chills or hot flashes
The attacks can recur with or without specific precipitating events (148). The patient is preoccupied with them and makes behavioral changes she hopes will avert future attacks: avoiding specific situations, assuring herself there is an escape route from certain situations, or refusing to be alone.
The symptoms of panic attacks are often confused with the symptoms of cardiac or pulmonary disease. They lead to many fruitless trips to the emergency department and to costly, even invasive, medical investigations. A careful history can establish the correct diagnosis in most cases (153–155).
Agoraphobia is the avoidance of situations in which the patient fears she may be trapped, such as the center of a row in the theater or driving over a bridge. She fears that such a situation will trigger anxiety or a panic attack and therefore tends more and more to stay at home or limit her sphere of activity to an increasingly short list of venues. Agoraphobia and panic disorder can occur separately or together (150–154).
Specific phobias are irrational fears of certain objects or situations, although the patient recognizes that the object or situation poses no real danger. Of particular concern in gynecology are fear of needles and fear of vomiting (150).
Social phobia causes the patient to fear and avoid situations in which the patient anticipates, without rational cause, that she will be perceived in a humiliating light. Such situations include giving a business-related presentation, making an announcement at a meeting, and having a casual dinner with friends. Patients may alter their lives to avoid these anxieties, interfering with their interpersonal relationships and their ability to carry out their responsibilities, or they may manage to carry on despite considerable psychological pain (150).
Obsessive-compulsive disorder (OCD) is characterized by obsessions: recurrent impulses, images, or thoughts that the patient recognizes as her own, but dislikes and cannot control; or compulsions: intrusive, repetitive behaviors that the patient feels she must perform to prevent some dire consequence (155–157). The disorder can be mild or totally crippling; in half of the cases, it becomes chronic. This disorder is classified as an anxiety disorder because the obsessions are anxiety provoking, and the compulsions are performed to avoid overwhelming anxiety. The term OCD has made its way into popular parlance to describe people who focus on petty details and have trouble making up their minds. This is an incorrect use of the term.
Posttraumatic Stress Disorder
Posttraumatic stress disorder (PTSD) is the result of exposure to an event that threatens the life or bodily integrity of the patient or others. At the time of the trauma, the patient experiences horror, terror, or a sense of helplessness. Afterward, the patient may lose conscious memory of all or part of the event, avoid situations reminiscent of it, and become acutely distressed when she cannot avoid them. She feels numb and detached, without a sense of the future. She is hyperarousable and irritable and has difficulty sleeping and concentrating. She re-experiences the event in nightmares, flashbacks, and intrusive thoughts (149).
Panic disorder without agoraphobia is twice as common in women as it is in men; panic disorder with agoraphobia is three times more common in women (149). Onset is generally in young adulthood, often following a stressful event. The lifetime prevalence is 1.5% to 3.5%; the 1-year prevalence is 1% to 2%. A substantial percentage of patients experience depressive episodes as well. Phobias are somewhat more common in women, depending on the object of the phobia. The 1-year prevalence is 9%, and the lifetime prevalence is 10% to 11%. Obsessive-compulsive disorder is equally common in women and men, with evidence of familial transmission. Prevalence is 2.5% for lifetime and 1.5% to 2.1% for 1 year. Posttraumatic stress disorder has a lifetime prevalence of 1% to 14%; victims of violence (including child abuse and wife battering) and war are at increased risk. Men and women differ in the types of violence to which they tend to be exposed. Rape, for example, poses a similarly high risk of PTSD in both men and women, but women are more often the victims of rape (149).
Given the relationship between anxiety disorders and traumatic experiences, the presence of signs and symptoms of anxiety disorders should trigger inquiries about abuse (146,147). Before making attempts to treat these disorders, it is important to know how long the patient has suffered from the disorder, what previous attempts were made to diagnose and treat it, and the effect it had on her psychological development, life choices, lifestyle, and relationships. In some cases, the entire family will have organized their schedules and activities around the patient’s symptoms and limitations; they may not volunteer this information.
Treatment should not be limited to antianxiety medications. Managing, even tolerating, patient anxiety is an anxiety-provoking process; anxiety is contagious and raises the specter of unlimited demands on the gynecologist’s time and energy. Prescribing medication is a familiar and comfortable, if not optimal, way to end a medical interview. Overprescribing benzodiazepines is a cause for medical and media concern. It is useful to defer the administration of anxiolytic medications until the impact of the physician’s support and interest can be assessed (150). Treatment should address the effects on the patient’s life and family and the signs and symptoms of the specific disease (151).
Benzodiazepines are most useful in acute situations (150). Use can quickly become chronic, with escalating dosages, diminishing therapeutic effects, and increasing demands on the physician. Women taking benzodiazepines may forget to include them in their medical history. When admitted to the hospital, they may suffer unrecognized withdrawal symptoms, complicating their treatment, or may continue to take medications from a personal supply without informing the medical staff (150).
There are many patients who could benefit from anxiolytics but who are inordinately worried about becoming dependent or addicted. A patient with no history of addictive behaviors is unlikely to get into trouble with a standard dose of medication (156,157). It is important to ascertain the source of anxiety or obsessive behavior. Many patients and their families are anxious because of misinformation or misunderstanding about a medical problem or treatment. Few patients can absorb all the information about significant gynecologic conditions at a single visit, but many feel that asking questions will burden the physician or make the patient appear stupid. Patients suffer anxiety when there is disagreement among family members or medical staff about the diagnosis or recommended treatment. Many patients dread certain aspects of care, sometimes on the basis of past experience or outdated information (157). A simple explanation or alteration in procedure can alleviate the anxiety. For example, a reassuring family member or friend can be allowed to stay with the patient during a diagnostic test, sedation can be administered orally or by inhalation before an intravenous line is inserted, or the patient can be allowed control over her own analgesia.
Behavioral interventions are extremely useful in managing anxiety disorders without problematic side effects. They include hypnosis, desensitization, and relaxation techniques (152–163). These techniques provide a patient with tools to cope with her own anxiety. Specialists in behavioral medicine, usually psychologists, are expert in these techniques. A local medical school department of psychiatry or behavioral medicine is a good source for referrals. Interested gynecologists can master some of the techniques.
Table 12.5 Compounds Used for Anxiety
It is easy to be trapped into a cat-and-mouse game with an anxious and needy patient who has an anxiety or personality disorder (153). Faced with an obsessive or anxious, talkative, and needy patient in the midst of bedside rounds, clinic, or office hours, the clinician can develop a pattern of avoidance, sometimes alternating with overindulgence stemming from feelings of guilt. This kind of behavior results in sporadic, unpredictable reinforcement of the patient’s symptoms and demands for attention and is very likely to increase them. Attempting to escape by appearing distracted or harassed or yielding with despair to the destruction of the day’s schedule and the care of other patients simply heightens the patient’s anxiety (154–160).
It is preferable to develop a prospective approach (153,162,163). Gynecologists tend to underrate the power of their personal interactions with patients and their own ability to structure and limit those interactions appropriately. A patient with a long list of symptoms can be informed at the beginning of the visit how much time is available and asked to focus on her most important problem, with other problems to be discussed at future, scheduled appointments (162). Instead of scheduling appointments and returning telephone calls grudgingly in response to patient demands, the gynecologist should inform the patient that her condition requires brief regular scheduled visits. If she is contacting the office more often than visits can reasonably be scheduled, she should be asked to call between visits, at prearranged times, to advise the staff of her progress. There are useful self-help groups for patients with various psychiatric conditions and their families. Although groups focused only on victimization can validate patients' experiences and pain and help them build new lives, they may interfere with their motivation to find other ways to identify themselves and obtain gratification (159). The gynecologist can monitor the patient’s responses to the self-help group interaction.
Medication does have a place in the management of anxiety disorders (164–166). Table 12.5 describes many of these agents. SSRIs are effective for a variety of anxiety disorders, sometimes in different dosage regimens than those used for depression. Benzodiazepines are effective when taken for acute anxiety or during relatively brief, time-limited (several days) stressful situations. The specific agent should be chosen on the basis of onset of action and half-life. The patient must be admonished to avoid concomitant use of alcohol and to exercise extreme care about driving or engaging in other activities requiring attention, concentration, and coordination.
Patients who fail to respond to a trial of office counseling or medication, who are unable to fulfill their responsibilities, who exhaust the patience and resources of significant others, who pose a diagnostic dilemma, who consume inordinate quantities of medical resources, or whose symptoms are becoming increasingly worse should be evaluated by a psychiatrist (166).
Somatizing disorders are those in which psychological conflicts are expressed in the form of physical symptoms. There is a spectrum of somatizing disorders based on the degree to which the patient is aware of or responsible for the onset of the symptoms. The spectrum ranges from the deliberate malingerer to the so-called hysteric, who is completely unaware of the link between her psyche and her physical symptom (167).
Malingering is the deliberate mimicking of signs and symptoms of physical or mental illness to achieve a tangible personal gain, such as exemption from dangerous military duties or exoneration from criminal responsibility. Factitious disorder, or Munchausen syndrome, is a poorly understood condition in which the patient actively causes physical damage to herself or feigns somatic symptoms that result in repeated hospital admissions and painful, dangerous, invasive diagnostic and therapeutic procedures (167). These patients may introduce feces or purulent material into wounds or intravenous lines, inject themselves with insulin, or produce hemorrhages. Given enough diagnostic and therapeutic interventions, significant iatrogenic conditions, such as adhesions from surgery or Cushing syndrome from the administration of steroids, may develop in these patients (167).
These patients are initially engaging but eventually frustrate the medical staff. Declaring that the patient “only wants attention” is not helpful (167). Most people want attention, but very few are willing to go to these lengths to get it. Confirming the diagnosis is a delicate process. When staff members become suspicious, they will be tempted to validate their suspicions by spying on the patient or sending her out of her hospital room on a pretext and then searching her belongings. The latter is illegal, and either action, followed by a confrontation, will end the therapeutic relationship and provoke the patient to flee rather than addressing the problem. Calls for a psychiatric consultation may provoke resentment in the patient and family. Patients soon reappear in another medical facility. As a result, there are few data about the etiology, incidence, and management of this condition. Often these patients are medically sophisticated because they or their family members had some kind of medical training or they gained knowledge during previous hospitalizations. Mothers may enact this disorder through their children by deliberately making them ill, a condition called Munchausen’s by proxy (167). Munchhausen’s by proxy gained some popular notoriety, and it resulted in accusations and loss of custody for some mothers whose children had serious, chronic diseases requiring multiple medical interventions. Shared electronic records might affect the occurrence of these conditions.
Somatization disorder consists of multiple physical symptoms for which adequate medical bases cannot be established, with these symptoms leading either to numerous medical visits or to impairment in the patient’s function (168). Symptoms begin before age 30 and continue for many years thereafter. The diagnosis requires symptoms of pain related to at least four different anatomic sites or physiologic functions: two gastrointestinal symptoms, one sexual or reproductive symptom, and one pseudoneurologic symptom or deficit other than pain (seizures, paresis). The patient’s perception is that she is “sickly” (168). She responds accurately to questions about her past symptoms and treatments but may not volunteer information about them unless she is asked.
Conversion disorder is the condition formerly called hysteria. The patient’s loss of a voluntary motor or sensory function cannot be explained by medical illness, is not deliberately produced by the patient, and appears to be related to psychological stress or conflict. The prognosis is directly related to the length of time from onset to diagnosis and treatment (169–172).
Other Somatizing Disorders
Pain disorder is a conversion condition with pain as the only symptom. Body dysmorphic disorder is preoccupation with a trivial or imagined defect in bodily appearance, a preoccupation that is not alleviated by the many medical and surgical treatments that the patient pursues (167,173). The gynecologist should hesitate to refer such a patient to a plastic or cosmetic surgeon, although specialists tend to be familiar with the condition and should hesitate to perform procedures on these patients.
Hypochondriasis is not a matter of a particular number or type of symptoms. It is a patient’s (nonpsychotic) conviction or fear that she suffers from a serious disease despite evidence and reassurance to the contrary(167). When one disease is ruled out, the patient is either convinced that the diagnosis was overlooked or switches her concerns to some other disease.
Somatization is believed to be among the most common and most difficult psychological conditions in office practice. It is estimated that 60% to 80% of the general population experiences one or more somatic symptoms in a given week, providing an ample substrate for the patient preoccupied with her health (167). Somatization disorder occurs almost exclusively in women; menstrual symptoms may be an early sign. Lifetime prevalence in women is 0.2% to 2.0%. Conversion disorder occurs 2 to 10 times more frequently in women than in men (there is no difference for gender in children), and it is more common in rural and disadvantaged populations with little medical sophistication (167). Cases have become relatively rare. Conversion disorder may develop into somatization disorder. Reported rates of somatization disorder range from 11 to 300 per 100,000. Pain disorder is extremely common in both genders. Hypochondriasis is equally distributed between men and women; prevalence in general medical practice is estimated to be 4% to 9%. There are few statistics about body dysmorphic disorder, but it seems to be equally distributed between men and women, with an average age of onset of about 30 years (167).
Most somatizing disorders are chronic. The goal of treatment in primary care is not to eliminate all the somatic symptoms but to help the patient cope with them and minimize their effect on her relationships and responsibilities (167). Because patients often seek care simultaneously or sequentially from several physicians, it is crucial to ask about all past and current diagnostic procedures, diagnoses, treatments, and responses. Patients' level of function over the years is important; prognosis is inversely related to chronicity. Chronicity should not be an excuse for a failure to treat the patient. The impact on the lives of patients and their families can be mitigated even if the condition is not entirely eliminated. For these and most other patients, the gynecologist needs to know what the patient believes is wrong with her and what she believes she needs in the way of diagnostic and therapeutic interventions. When the patient does not receive what she expects or desires, she is unlikely to comply with the recommended course of action, although she may accept it and pretend to be following it so as to avoid criticism from the physician. This behavior is actually very common among patients in general (167).
The management of somatizing disorders is focused on the avoidance of unnecessary medical interventions, iatrogenic medical or psychological complications, and disability. It is never possible to rule out all potential medical causes of a symptom. The literature is full of case presentations of patients with multiple sclerosis, brain tumors, and intermittently flaring infections that for years were mislabeled as psychosomatic until a correct diagnosis of the condition was made (167,173). Organic pathology can befall patients with somatizing disorders. Patients who have benign gastrointestinal symptoms for extended periods can get appendicitis. Often a difficult differentiation must be made in each specific case and presentation.
Patients who have a somatizing disorder often approach each new clinician as the one who, “unlike the incompetent and insensitive physicians consulted in the past,” will finally get to the bottom of her troubles and cure her symptoms. The gynecologist must not get caught up in these expectations, but rather remind the patient that symptoms that have resisted diagnosis and treatment for many years are likely to be challenging ones. As with anxious patients, it is important to structure the doctor–patient relationship to avoid giving the patient attention inconsistently and only in response to escalating symptoms and demands (173). It is best to schedule frequent, brief office visits during which the clinician allots a small amount of time to listen to and sympathize with the patient’s somatic symptoms and spends the bulk of the time reinforcing the patient’s efforts to function despite her symptoms. Family members should be encouraged to facilitate functionality rather than invalidism.
Unmasking patently psychologically based symptoms by tricking the patient (shouting “Fire!” in the vicinity of a “paralyzed” patient), or documenting the patient’s behavior when she does not realize she is being observed, is momentarily gratifying for medical staff but humiliating for the patient. It may force her to relinquish a symptom, at least temporarily, but she will seek care elsewhere, exacerbating her dysfunction, distrust, and demands on the health care system (173).
Patients with conversion, somatization, and hypochondriacal disorders often benefit from prescriptive behavioral regimens aimed at saving face and improving function (174). It was once believed that a patient relieved of one symptom would soon substitute another, but this assumption is not confirmed by empirical evidence. The behavioral regimen should consist of health-promoting activities relevant to the target symptoms, planned in a stepwise progression, and recommended with reasonable medical conviction and authority. For example, the patient with psychogenic difficulty swallowing could be advised to drink only clear liquids, at specified intervals, for a specified number of days, and then go on similarly to full liquids, purees, soft foods, and finally a regular diet. The patient with difficulties in the extremities can undertake an exercise regimen. The patient’s preoccupation with her symptoms can be channeled into documentation of her progress in a log that she brings to her medical appointments. The physician is not bound to peruse the entire document at each visit. If it is too long, the patient can be asked to prepare a summary. This process may enlighten both her and the physician to the relationships between her symptoms and her diet, relationships, or activities. She should be advised not to dwell on her symptoms apart from this important notation (174).
It is critical to remember that patients whose somatic symptoms result from depression, posttraumatic stress disorder and other anxiety disorders, and domestic violence frequently seek care from gynecologists. In the case of domestic violence, the gynecologist is often the only human contact the abuser allows the patient outside the domestic situation (175–177). These possibilities must be ruled out before care is directed to symptom management. Several medical associations have drawn attention to the need to screen women for domestic violence and the infrequency with which this is actually done. It appears that screening alone does not significantly change outcomes. Acknowledging domestic violence and finding and accessing resources are part of an often prolonged and incremental process—of which screening can be an important first step (178).
There is considerable cross-cultural variation in the extent to which feelings and psychological conflicts are somatized. In many Asian cultures, for example, presenting problems with feelings, behaviors, and interpersonal relationships are almost unheard of; these problems are expressed, diagnosed, and treated somatically. Conversely, some very sophisticated and psychologically informed patients in Western society may dismiss serious somatic signs and symptoms as indications of psychological conflict (177).
Patients with somatizing disorders may resist mental health referral more adamantly than any other single class of patients (167). Focused as they are on physical symptoms, these patients can regard referral as a message that their symptoms are not being taken seriously and as a sign of contempt and rejection by the gynecologist. It is particularly useful with these patients to emphasize that distinctions between mind and body are artificial. The brain is part of the body. Our language expresses this synthesis; anxiety causes “butterflies in the stomach,” aggravation “gives us a headache,” and unwelcome news “gives us a heart attack.”
The referral should be framed as support for the patient’s suffering rather than as a statement that her problems are “all in her head” (168). The mental health professional should be introduced as a member of the medical team. Some medical institutions have dedicated psychiatric consultation, medical psychiatry, or behavioral medicine services offering expertise in the psychological complications of disease and in somatization disorders. Because so-called somatic and psychological symptoms often coexist and interact, the gynecologist should work in collaboration with the mental health professional. Patients should be given a return appointment with the primary physician, or a request for a telephone contact, at the time of the original mental health referral to reassure them that they are not being dismissed and to inform the primary physician of the results of the consultation (168).
Personality disorders are pervasive, lifelong, maladaptive patterns of perception and behavior (177–179). Patients with personality disorders believe that whatever unpleasant feelings they have are caused by the behavior of others. They view their own behaviors, which can wreak havoc in the health care setting as well as in patients' lives, as normal, expectable, inevitable reactions to these perceived circumstances. To make matters worse, their behaviors tend to provoke in others the very responses that confirm their expectations; for example, a patient who is convinced that people always abandon her will cling desperately to others, eventually driving them away.
Personality disorders are organized into clusters in DSM-IV (9). Patients often manifest characteristics of several disorders within a cluster and between clusters.
Paranoid personality disorder
Schizoid personality disorder
Schizotypal personality disorder
Narcissistic personality disorder
Histrionic personality disorder
Borderline personality disorder
Antisocial personality disorder
Avoidant personality disorder
Dependent personality disorder
Obsessive-compulsive personality disorder
Individuals with Cluster A disorders are isolated, suspicious, detached, and odd. Narcissistic patients are grandiose, arrogant, envious, and entitled. Histrionic individuals are flamboyant and provocative. Antisocial patients disregard laws and rules of common decency toward others. Borderline personality disorder causes patients to have difficulty controlling their impulses and maintaining stable moods and relationships (177). They engage in self-destructive behaviors. They fluctuate between overvaluation and castigation of the same person or direct these feelings alternately between one person and another. When this happens on a gynecology service or in the office, it can precipitate significant tensions among the staff. There is one caveat: research reveals that many women who were abused are diagnosed as borderline when posttraumatic stress disorder more accurately fits their symptoms (175–178). Posttraumatic stress disorder is a less stigmatizing and more treatable condition than borderline personality disorder.
Lifetime prevalence of personality disorders as a group is 2.5% (177–179). Cluster A disorders are more common in men. Within Cluster B disorders, 75% of cases are women; the prevalence in the general population is 2%. Personality disorders such as narcissistic personality are more common in the clinical population than in the general population. Among Cluster C disorders, dependent personality is one of the most frequently diagnosed. Obsessive-compulsive personality is twice as common in men as in women. It is important to distinguish the personality disorder from the symptomatic obsessive-compulsive disorder. There is a strong association between personality disorders and a history of childhood abuse. The possibility of an ongoing abusive situation should be considered. There is so much overlap among the clusters that the diagnostic structure may well change in the forthcoming DSM revision (179).
The impact of personality disorders ranges widely (177–179). At one end of the spectrum, the disorder is an exaggerated personality style. At the other end of the spectrum, the individual suffers terrible emotional pain and is unable to function in work roles or relationships, spending significant periods of time in psychiatric hospitals. She characterizes her symptoms of despair as inevitable responses to abandonment or other mistreatment. As the definition implies, the patient will not seek treatment for the signs and symptoms listed in the diagnostic criteria but instead will have complaints about her treatment by others, their responses to her, and the unfairness and difficulties of life in general. Taking the history, the clinician should frame questions in those same terms: How long have these troubles gone on, and how much do they interfere with her ability to work and relate to others? Personality disorders do not bring patients to gynecologists' offices directly, but they greatly complicate things when patients arrive.
Intense and lengthy psychotherapy is required to effect significant improvement in patients who have personality disorders (177). There is increasing evidence that expert, targeted therapeutic interventions can be successful and that the long-term prognosis is more hopeful than previously believed. The challenge in the gynecology setting is to minimize contention and drain on medical staff while maximizing the likelihood of effective diagnosis and treatment of the patient’s medical problems. The most helpful single step is the identification of the personality disorder. Diagnosis enables the gynecologist to recognize the reasons for a patient’s problem behaviors, to avoid becoming entangled in fruitless interactions with the patient, and to set appropriate limits.
There is increasing evidence that psychotropic medications are useful adjuncts in the treatment of personality disorders (179). Treatment should be provided in consultation with a psychiatrist. The patient’s ability to use the medication can be compromised by impulsivity, self-destructive tendencies, and unstable relationships. Low doses of major tranquilizers are sometimes helpful, especially when the patient has brief psychotic episodes. Minor tranquilizers or anxiolytics pose significant risk of overdose and physical and psychological habituation (179). They can be prescribed for temporary stresses, but only in a quantity sufficient for several days and with no refill allowed. Some patients' anxiety, demands, and power struggles are eased when they are given control over their own use of medication. Such an approach requires enough familiarity with the patient to ensure her safety and should be managed by an expert. Because the patient with a personality disorder attributes her problems to others, her symptoms cannot be adduced as reasons for psychiatric referral, but her suffering can be. If a diagnosis of a personality disorder absolutely must be noted in the patient’s chart or on insurance forms, it is essential that she be so informed. It is useful to review the DSM-IV-TR criteria with her so that she understands the basis for the diagnosis (9). All psychiatric diagnoses, but particularly personality disorders, carry a significant stigma.
Adjustment disorders are temporary, self-limited responses to life stressors that are part of the normative range of human experience (unlike those that precipitate posttraumatic stress disorder)(180). The patient has mood or anxiety symptoms that are sufficient to lead her to seek medical care but that do not meet criteria of sufficient quantity or quality to qualify for psychiatric diagnosis. The diagnosis requires an identifiable stressor, onset within 3 months after the stress begins, and spontaneous resolution within 6 months after the stressor ends. Obviously the latter cannot be determined until the symptoms resolve—but they do rule out the disorder if the symptoms persist beyond that time (180,181).
Adjustment disorders can be distinguished from normal grieving (180,181). Grieving produces symptoms similar to those of depression, although depression is more likely to cause guilt. Interference with function should not persist beyond several months, but some degree of sadness and preoccupation with the lost loved one often goes on for years. Patients with persistently disabling grief should be referred to a mental health professional.
Adjustment disorders affect men and women equally. An estimated 5% to 20% of patients undergoing outpatient mental health treatment suffer from adjustment disorders. There is little literature on the subject; one study reported a prevalence of 2.3% among a sample of patients receiving care in a walk-in general health clinic (180).
Patients with adjustment disorders can be treated effectively with brief counseling in the primary care setting (180). The counseling can be provided by the gynecologist or by a nurse clinician, social worker, or psychologist, preferably a member of the office or hospital staff who is familiar with the gynecologist and the practice. The medical setting is sometimes the only place where the patient can vent her feelings and think through her situation. Counseling is aimed at facilitating the patient’s own coping skills and helping her to make thoughtful decisions about her situation. The gynecologist should follow the patient’s progress and facilitate referral to a psychiatrist if symptoms do not resolve.
The etiology of eating disorders is neurobiological as well as psychosocial (182). Preoccupation with thinness, sometimes to the point of pathology, is a major problem for women in North America(183). Only a small number of women profess to be satisfied with their weights and body shapes. Nearly all admit to current or recent attempts to limit food intake. Physicians often share social prejudices against overweight patients and can easily exacerbate patients' concerns by making chance comments. In some cases, such comments by the physician or others can precipitate, if not cause, an eating disorder.
Anorexia nervosa is characterized by severe restrictions on food intake, often accompanied by excessive physical exercise and the use of diuretics or laxatives. Clinical features include menstrual irregularities or amenorrhea, intense and irrational fear of becoming fat, preoccupation with body weight as an indicator of self-worth, and inability to acknowledge the realities and dangers of the condition. Some patients approach gynecologists for treatment of infertility (184).
Bulimia is characterized by eating binges followed by self-induced vomiting or purging. Patients' weights may be normal or somewhat higher than normal. Patients have drastically low self-esteem, and the condition frequently coexists with depression (185).
Obesity is an increasingly frequent health problem, and there is little evidence that any nonsurgical approach is effective over time. Sensible eating should be encouraged, and fad or crash diets, which are rampant, are medically and psychologically counterproductive (186). Given the stigma against being overweight in our society, patients may avoid the doctor’s office just because they will be weighed there. The best approach with overweight patients is to acknowledge that being overweight is detrimental to health but that changing one’s diet and lifestyle, and losing weight, is very difficult. Primary care physicians should indicate that they are not going to judge the patient, but are available to provide support and information at the patient’s request.
More than 90% of cases of anorexia and bulimia occur in female patients. The prevalence is 0.5% to 1.0% in late adolescence and 1% to 3% in early adulthood. There is some evidence of familial transmission (182–185).
The clinician treating the anorexic patient needs to know how much insight she has into her problem and to assess her mood, relationships, and general level of function. Anorexia poses significant risks of severe metabolic complications and death, often from cardiac consequences of electrolyte abnormalities. Thorough physical and laboratory examination is critical; immediate hospitalization may be necessary (182–185).
Patients with anorexia or bulimia should be treated by mental health professionals, preferably those with subspecialization in this area. The conditions are highly refractory to treatment; patients can resort to elaborate subterfuges to conceal their failure to eat and gain weight (185–187). There are Web sites dedicated to anorexia, with information about the minimum calories necessary to sustain life, and photographs of individuals who seem pleased with their skeletal appearance. Up to 50% of cases will become chronic, and approximately 10% of those will ultimately die of the disease. Antidepressant medication is sometimes helpful. Amenorrheic patients should not be treated with ovulation induction. Evaluation for osteopenia and osteoporosis is necessary (187).
Schizophrenia affects approximately 1% of persons worldwide (188). Since the deinstitutionalization of persons with severe and persistent mental illnesses several decades ago, most affected individuals live in the community. Often health care and other services are inadequate, leaving these women vulnerable to sexual abuse and involuntary impregnation. Overall, the fertility of women with schizophrenia approximates that of matched populations. Schizophrenia is not an absolute contraindication to successful parenting, but there is considerable stigma against psychotic disorders, and patients may avoid prenatal care because they fear loss of custody (189,190).
Psychotic disorders are characterized by major distortions of thinking and behavior. They include schizophrenia, schizophreniform disorders, schizoaffective disorders, delusional disorders, and brief psychotic disorders. General medical and toxic conditions must be ruled out in determining the diagnosis. Distinctions between the disorders are based on symptoms, time course, severity, and associated affective symptoms. The hallmark of psychosis is the presence of delusions or hallucinations. Hallucinations are sensory perceptions in the absence of external sensory stimuli. Delusions are bizarre beliefs about the nature of motivation of external events(188). Because there is no reliable definition of “bizarre,” a physician working with a patient from an unfamiliar culture must determine whether a given belief is normal in that culture. Delusions and hallucinations are the positive symptoms of schizophrenia. The negative symptoms include apathy and loss of connection to others and to interests. The negative symptoms may be more disabling than the positive. There is increasing evidence that schizophrenia is associated with cognitive deficits (191).
Onset of schizophrenia is in the late teens to mid-30s. Women succumb later in life and have more prominent mood symptoms and a better prognosis than men (191,192). The risk is 10 times greater for first-degree biologic relatives and for individuals of low socioeconomic status (192). It is unclear whether indigent status is a precipitating stress or a result of psychotic illness, but, especially as extremely few individuals have private or public coverage for adequate treatment, most people with schizophrenia are indigent.
There is wide variability in the functional impact of psychotic disorders. Patients must not be assumed to be incompetent to make medical decisions or lead independent lives, especially if they comply with treatment. Patients must be asked specifically about their living situations and coping skills. When psychotic women have responsibility for the care of children, their ability to do so should be assessed in consultation with a mental health expert. Motherhood and child custody are exceedingly sensitive matters for these vulnerable patients (191).
A relentlessly downhill course is not inevitable; remissions and recovery can occur (192). Therefore, the patient’s mental status must be examined carefully. Under the pressures of a busy medical setting, psychotic illnesses can be overlooked, only to erupt in the labor room, operating room, or recovery room. Patients who believe that conspiracies or aliens are responsible for their symptoms can answer yes-or-no medical questions without revealing their delusions. Open-ended questions (“Tell me about your symptoms”) are more useful (191).
Sensationalized media accounts of violent crimes committed by psychotic patients exacerbate public misconceptions about these diseases. Statistically, individuals with psychoses are more likely to be victims than perpetrators of crime. Untreated patients, especially when under the influence of alcohol or other substances, are at somewhat increased risk of violent behavior; treated patients are no more violent than the general public (192).
Psychotic illnesses are usually managed by psychiatrists. A primary care practitioner can assume responsibility, in consultation with a psychiatrist, for a stable patient who complies with treatment. When a patient expresses delusions, the clinician may indicate that he or she does not share these delusions, but should not debate with the patient (193–195). It is important to concentrate on the patient’s strengths. She can be humiliated easily by thoughtless epithets or behaviors that betray the expectation of violence or incompetence. Patients with severe cases must be treated with an integrated system of social services, family support, rehabilitation, general medical care, psychotherapy, and psychopharmacology. In the process of referral to a mental health professional, the primary clinician should be clear, matter-of-fact, open, and confident of the possibility of successful treatment (192).
1. Schurman RA, Kramer PD, Mitchell JB. The hidden mental health network: treatment of mental illness by nonpsychiatrist physicians. Arch Gen Psychiatry 1985;42:89–94.
2. Dubovsky SL. Psychotherapeutics in primary care. New York: Grune & Stratton, 1981.
3. Berndt ER, Koran LM, Finkelstein SN, et al. Lost human capital from early-onset chronic depression. Am J Psychiatry 2000;157:940–947.
4. Smith I, Adkins S, Walton J. Pharmaceuticals: therapeutic review. New York: Shearson, Lehman, Hutton International Research, 1988.
5. Pierce C. Failure to spot mental illness in primary care is a global problem. Clin Psychiatry News 1993;21:5.
6. Margolis RL. Nonpsychiatric house staff frequently misdiagnose psychiatric disorders in general hospital inpatients. Psychosomatics 1994;35:485–491.
7. Perez-Stable EJ, Miranda J, Munoz RF, et al. Depression in medical outpatients: underrecognition and misdiagnosis. Arch Intern Med 1990;150:1083–1088.
8. American Psychiatric Association. Diagnostic and statistical manual of mental disorders, 4th ed. Washington, DC: American Psychiatric Press, 1994.
9. American Psychiatric Association. Diagnostic and statistical manual of mental disorders, 4th ed. Text revision. Washington, DC: American Psychiatric Association, 2000.
10. Depression Guideline Panel. Depression in primary care: Vol. 1, detection and diagnosis. Clinical practice guideline no 5. AHCPR, Publication No 93-0550. Rockville, MD: U.S. Department of Health and Human Services, Public Health Service, Agency for Health Care Policy and Research, 1993.
11. Cassem NH. Depression. In: Cassem NH, ed. Massachusetts General Hospital handbook of general hospital psychiatry. St. Louis, MO: Mosby Year Book, 1991:237–268.
12. Murphy GE. The physician’s responsibility for suicide. II: Errors of omission. Ann Intern Med 1975;82:305–309.
13. Veith I. Hysteria: the history of a disease. Chicago: University of Chicago Press, 1965.
14. Roter DL, Hall JA, Kern DE, et al. Improving physicians' interviewing skills and reducing patients' emotional distress: a randomized clinical trial. Arch Intern Med 1995;155:1877–1884.
15. Beckman HB, Frankel RM. The effect of physician behavior on the collection of data. Ann Intern Med 1984;101:692–696.
16. Scheiber SC. The psychiatric interview, psychiatric history, and mental status examination. In: Hales RE, Yudofsky SC, Talbott JA, eds. Textbook of psychiatry, 2nd ed. Washington, DC: American Psychiatric Press, 1994:187–219.
17. Orleans CT, George LK, Houpt JL, et al. How primary care physicians treat psychiatric disorders: a national survey of family practitioners. Am J Psychiatry 1985;142:52–57.
18. Dubovsky SL, Weissberg MP. Clinical psychiatry in primary care, 3rd ed. Baltimore, MD: Williams & Wilkins, 1986.
19. Stotland NL, Garrick TR. Manual of psychiatric consultation. Washington, DC: American Psychiatric Press, 1990.
20. Spiegel D, Bloom JR, Kraemer HL, et al. Effect of psychosocial treatment on survival of patients with metastatic breast cancer. Lancet 1989;2:888–891.
21. Fawzy FI, Cousins NI, Fawzy NW, et al. A structured psychiatric intervention for cancer patients. I: Changes over time in methods of coping and affective disturbance. Arch Gen Psychiatry 1990;47:720–725.
22. Cunningham AJ, Edmonds CV, Jenkins GP, et al. A randomized controlled trial of the effects of group psychological therapy on survival in women with metastatic breast cancer. Psychooncology 1998;7:508–517.
23. Maunsell E, Brisson J. Social support and survival among women with breast cancer. Cancer 1995;76:631–637.
24. Gellert GA, Maxwell RM, Siegel BS. Survival of breast cancer patients receiving adjunctive psychosocial support therapy: a 10-year follow-up study. J Clin Oncol 1993;11:66–69.
25. Blake-Mortimer J, Gore-Felton C, Kimerling R, et al. Improving the quality and quantity of life among patients with cancer: a review of the effectiveness of group psychotherapy. Eur J Cancer 1999;35:1581–1586.
26. Goldman N, Ravid R. Community surveys: sex differences in mental illness. In: Guttentag M, Salasin S, Belle D, eds. The mental health of women. New York: Academic Press, 1980.
27. Nolen-Hoeksema S. Sex differences in depression. Stanford, CA: Stanford University Press, 1990.
28. Weissman MM, Leaf PJ, Holzer CE, et al. The epidemiology of depression: an update on sex differences in rates. J Affect Disord 1984;7:179–188.
29. Leibenluft E, ed. Gender differences in mood and anxiety disorders: from bench to bedside. Washington, DC: American Psychiatric Press, 1999.
30. Kornstein SG, Schatzberg AF, Thase ME, et al. Gender differences in chronic major and double depression. J Affect Disord 2000;60:1–11.
31. Sloan DM, Kornstein SG. Gender differences in depression and response to anti-depressant treatment. Psychiatr Clin North Am 2003;26:581–594.
32. Kornstein SG. Gender differences in depression: implications for treatment. J Clin Psychiatry 1997;58:12–18.
33. Regier DA, Boyd JK, Burke JD Jr, et al. One-month prevalence of mental disorders in the United States—based on five epidemiologic catchment area sites. Arch Gen Psychiatry 1988;45:977–985.
34. Robins LN, Helzer JE, Weissman MN, et al. Lifetime prevalence of specific psychiatric disorders in three sites. Arch Gen Psychiatry 1984;41:949–958.
35. Boyd JH, Weissman MM. Epidemiology of affective disorders: a reexamination and future directions. Arch Gen Psychiatry 1981;38:1039–1046.
36. Andrade L, Caraveo-Anduaga JJ, Berglund P, et al. The epidemiology of major depressive episodes: results from the International Consortium of Psychiatric Epidemiology (ICPE) surveys. Int J Methods Psychiatr Res 2003;12:3–21.
37. Bolton JM, Pagura J, Enns MW, et al. A population-based longitudinal study of risk factors for suicide attempts in major depressive disorder. J Psychiatry Res 2010;44:817–826.
38. Sainsbury P. Depression, suicide, and suicide prevention. In: Baltimore RA, ed. Suicide. Baltimore, MD: Williams & Wilkins, 1990:17–38.
39. Radloff LS. Sex differences in depression: the effects of occupation and marital status. Sex Roles 1975;1:249–265.
40. Roberts RE, O'Keefe SJ. Sex differences in depression reexamined. J Health Soc Behav 1981;22:394–399.
41. Swanson KM. Predicting depressive symptoms after miscarriage: a path analysis based on the Lazarus paradigm. J Womens Health Gend Based Med 2000;9:191–206.
42. Dugan E, Cohen SJ, Bland DR, et al. The association of depressive symptoms and urinary incontinence among older adults. J Am Geriatr Soc 2000;48:413–416.
43. Schwenk TL, Evans DL, Laden SK, et al. Treatment outcome and physician-patient communication in primary care patients with chronic, recurrent depression. Am J Psychiatry 2004;161:1892–1901.
44. McGrath E, Keita GP, Strickland BR, et al. Women and depression: risk factors and treatment issues. Final report of the American Psychological Association’s National Task Force on Women and Depression. Washington, DC: American Psychological Association, 1990.
45. Born L, Steiner M. The relationship between menarche and depression in adolescence. CNS Spectrums 2001;6:126–138.
46. Pearlstein TB. Hormones and depression: what are the facts about premenstrual syndrome, menopause, and hormone replacement therapy? Am J Obstet Gynecol 1995;173:646–653.
47. Freeman EW, Sammel MD, Liu L, et al. Hormones and menopausal status as predictors of depression in women in transition to menopause. Arch Gen Psychiatry 2004;61:62–70.
48. Harlow BL, Wise LA, Otto MW, et al. Depression and its influence on reproductive endocrine and menstrual cycle markers associated with perimenopause: the Harvard Study of Moods and Cycles. Arch Gen Psychiatry 2003;60:29–36.
49. Soares CN, Cohen LS, Otto MW, et al. Characteristics of women with premenstrual dysphoric disorder (PMDD) who did or did not report history of depression: a preliminary report from the Harvard Study of Moods and Cycles. J Womens Health Gend Based Med2001;10:873–878.
50. Schmidt PJ, Haq N, Rubinow DR. A longitudinal evaluation of the relationship between reproductive status and mood in perimenopausal women. Am J Psychiatry 2004;161:2238–2244.
51. Oinonen KA, Mazmanian D. To what extent do oral contraceptives influence mood and affect? J Affect Disord 2002;70:229–240.
52. Endicott J, Amsterdam J, Eriksson E, et al. Is premenstrual dysphoric disorder a distinct clinical entity? J Womens Health Gend Based Med 1999;8:663–679.
53. Halbreich U, Borenstein J, Pearlstein T, et al. The prevalence, impairment, impact, and burden of premenstrual dysphoric disorder (PMS/PMDD). Psychoneuroendocrinology 2003;28:1023–1030.
54. Freeman EW. Premenstrual syndrome and premenstrual dysphoric disorder: definitions and diagnosis. Psychoneuroendocrinology 2003;28:25–37.
55. Hamilton JA, Parry BL, Blumenthal SL. The menstrual cycle in context: I. Affective syndromes associated with reproductive hormonal changes. J Clin Psych 1988;49:474–480.
56. Jensvold MF. Psychiatric aspects of the menstrual cycle. In: Stewart DE, Stotland NL, eds. Psychological aspects of women’s health care. Washington, DC: American Psychiatric Press, 1993:165–192.
57. Bailey JW, Cohen LS. Prevalence of mood and anxiety disorders in women who seek treatment for premenstrual syndrome. J Womens Health Gend Based Med 1999;8:1181–1184.
58. Brand B. Trauma and women. Psychiatr Clin North Am 2003;26:759–779.
59. Rapkin A. A review of treatment of premenstrual syndrome and premenstrual dysphoric disorder. Psychoneuroendocrinology 2003;28:39–53.
60. Canning S, Waterman M, Orsi N, et al. The efficacy of Hypericum perforatum (St. John’s wort) for the treatment of premenstrual syndrome: a randomized, double-blind, placebo-controlled trial. CNS Drugs 2010;24:207–225
61. Wyatt KM, Dimmock PW, Jones PW, et al. Efficacy of vitamin B6 in the treatment of premenstrual syndrome: a systematic review. BMJ 1999;318:1375–1381.
62. Pearlstein TB, Halbreich U, Batzar ED, et al. Psychosocial functioning in women with premenstrual dysphoric disorder before and after treatment with sertraline or placebo. J Clin Psychiatry 2000;61:101–109.
63. Freeman EW, Rickels K, Sondheimer SJ, et al. Differential response to antidepressants in women with premenstrual syndrome/premenstrual dysphoric disorder: a randomized controlled trial. Arch Gen Psychiatry 1999;56:932–939.
64. Romano S, Judge R, Dillon J, et al. The role of fluoxetine in the treatment of premenstrual dysphoric disorder. Clin Ther 1999;21:615–633.
65. Young SA, Hurt PH, Benedek DM, et al. Treatment of premenstrual dysphoric disorder with sertraline during the luteal phase: a randomized, double-blind, placebo-controlled crossover trial. J Clin Psych 1998;59:76–80.
66. Freeman EW, Kroll R, Rapkin A, et al. Evaluation of a unique oral contraceptive in the treatment of premenstrual dysphoric disorder. J Womens Health Gend Based Med 2001;10:561–569.
67. Anderson KM, Sharpe M, Rattray A, et al. Distress and concerns in couples referred to a specialist infertility clinic. J Psychosom Res 2003;54:353–355.
68. Perlin LI. Sex roles and depression. In: Datan N, Ginsberg L, eds. Life-span developmental psychology: normative life crises. New York: Academic Press, 1975:191–207.
69. Najib A, Lorberbaum JP, Kose S, et al. Regional brain activity in women grieving a romantic relationship breakup. Am J Psychiatry 2004;161:2245–2256.
70. Major B, Cozzarelli C, Cooper ML, et al. Psychological responses of women after first-trimester abortion. Arch Gen Psychiatry 2000;57:777–784.
71. Wisner KL, Parry BL, Piontek CM. Postpartum depression. N Engl J Med 2002;347:194–199.
72. Evans J, Heron J, Francomb H, et al. Cohort study of depressed mood during pregnancy and after childbirth. BMJ 2001;323:257–260.
73. Bennett HA, Einarson A, Taddio A, et al. Prevalence of depression during pregnancy: systematic review. Obstet Gynecol 2004;103:698–709.
74. Oates MR, Cox JL, Neema S, et al. Postnatal depression across countries and cultures: a qualitative study. Br J Psychiatry 2004;184[Suppl 46]:S10–S16.
75. Robertson E, Grace S, Wallington T, et al. Antenatal risk factors for postpartum depression: a synthesis of recent literature. Gen Hosp Psychiatry 2004;26:289–295.
76. Segre LS, Stuart S, O'Hara MW. Interpersonal psychotherapy for antenatal and postpartum depression. Primary Psychiatry 2004;11:52–56.
77. Spinelli MG, Endicott J. Controlled clinical trial of interpersonal psychotherapy versus parenting education program for depressed pregnant women. Am J Psychiatry 2003;160:555–562.
78. Miller LJ. Use of electroconvulsive therapy during pregnancy. Hosp Commun Psychiatry 1994;45:444–450.
79. Oren DA, Wisner KL, Spinelli M, et al. An open trial of morning light therapy for treatment of antepartum depression. Am J Psychiatry 2002;159:666–669.
80. Miller LJ. Postpartum depression. JAMA 2002;287:762–765.
81. Iqbal MM. Effects of antidepressants during pregnancy and lactation. Ann Clin Psychiatry 1999;11:237–256.
82. Wisner KL, Gelenberg AJ, Leonard H, et al. Pharmacologic treatment of depression during pregnancy. JAMA 1999;282:1264–1269.
83. Abramowitz JS, Schwartz SA, Moore KM, et al. Obsessive-compulsive symptoms in pregnancy and the puerperium: a review of the literature. J Anxiety Disord 2003;17:461–478.
84. Suri R, Altshuler L, Hendrick V, et al. The impact of depression and fluoxetine treatment on obstetrical outcome. Arch Women Ment Health 2004;7:193–200.
85. Hendrick V, Smith LM, Suri R, et al. Birth outcomes after prenatal exposure to antidepressant medication. Am J Obstet Gynecol 2003;188:812–815.
86. Gold LH. Use of psychotropic medication during pregnancy: risk management guidelines. Psychiatr Ann 2000;30:421–432.
87. Casper RC, Fleisher BE, Lee-Ancajas JC, et al. Follow-up of children of depressed mothers exposed or not exposed to antidepressant drugs during pregnancy. J Pediatr 2003;142:402–408.
88. Chung TK, Lau TK, Yip AS, et al. Antepartum depressive symptomatology is associated with adverse obstetric and neonatal outcomes. Psychosom Med 2001;63:830–834.
89. Nulman I, Rovet J, Stewart DE, et al. Child development following exposure to tricyclic antidepressants or fluoxetine throughout fetal life: a prospective, controlled study. Am J Psychiatry 2002;159:1889–1895.
90. Andersson L, Sundstrom-Poromaa I, Wulff M, et al. Neonatal outcome following maternal antenatal depression and anxiety: a population-based study. Am J Epidemiol 2004;159:872–881.
91. Smith MV, Shao L, Howell H, et al. Perinatal depression and birth outcomes in a Healthy Start Project. Matern Child Health 2011;15:401–409.
92. Koren G. Discontinuation syndrome following late pregnancy exposure to antidepressants. Arch Pediatr Adolesc Med 2004;158:307–308.
93. Kumar C, McIvor RJ, Davies T, et al. Estrogen administration does not reduce the rate of recurrence of affective psychosis after childbirth. J Clin Psychiatry 2003;64:112–118.
94. Wisner KL, Perel JM, Peindl KS, et al. Prevention of recurrent postpartum depression. J Clin Psychiatry 2001;62:82–86.
95. Cooper R, Mishra G, Hardy R, et al. Hysterectomy and subsequent psychological health: findings from a British birth cohort study. J Affect Disord 2009;115:122–130.
96. Bhattacharya SM, Jha A. A comparison of health-related quality of life (HRQOL) after natural and surgical menopause. Maturitas 2010;66:431–434.
97. Cabness J. The psychosocial dimensions of hysterectomy: private places and the inner spaces of women at midlife. Soc Work Health Care 2010;49:211–226.
98. McKinlay JB, McKinlay SM, Brambilla DJ. Health status and utilization behavior associated with menopause. Am J Epidemiol 1987;125:110–121.
99. Hamilton JA. Psychobiology in context: reproductive-related events in men’s and women’s lives (review of motherhood and mental illness). Contemp Psych 1984;3:12–16.
100. Rossouw JE, Anderson GL, Prentice RL, et al. Risks and benefits of estrogen plus progestin in healthy postmenopausal women: principal results from the Women’s Health Initiative randomized controlled trial. JAMA 2002;288:321–333.
101. Anderson GL, Limacher M, Assaf AR, et al. Effects of conjugated estrogen in postmenopausal women with hysterectomy: the Women’s Health Initiative randomized controlled trial. JAMA 2004;291:1701–1712.
102. Hays J, Ockene JK, Brunner RL, et al. Effects of estrogen plus progestin on health-related quality of life. N Engl J Med 2003;348:1839–1854.
103. Cohen LS, Soares CN, Poitras JR, et al. Short-term use of estradiol for depression in perimenopausal and postmenopausal women: a preliminary report. Am J Psychiatry 2003;160:1519–1522.
104. Kugaya A, Epperson CN, Zoghbi S, et al. Increase in prefrontal cortex serotonin 2A receptors following estrogen treatment in post-menopausal women. Am J Psychiatry 2003;160:1522–1524.
105. Soares CN, Almeida OP, Joffe H, et al. Efficacy of estradiol for the treatment of depressive disorders in perimenopausal women: a double-blind, randomized, placebo-controlled trial. Arch Gen Psychiatry 2001;58:529–534.
106. Stearns V, Beebe KL, Iyengar M, et al. Paroxetine controlled release in the treatment of menopausal hot flashes: a randomized controlled trial. JAMA 2003;289:2827–2834.
107. Drayer RA, Mulsant BH, Lenze EJ, et al. Somatic symptoms of depression in elderly patients with medical comorbidities. Int J Geriatr Psychiatry 2005;20:973–982.
108. Jefferson JW, Greist JH. Mood disorders. In: Hales RE, Yudofsky SC, Talbott JA, eds. Textbook of psychiatry, 2nd ed. Washington, DC: American Psychiatric Press, 1994:465–494.
109. Altshuler LL, Cohen LS, Moline ML, et al. The Expert Consensus Guideline Series. Treatment of depression in women. Postgrad Med 2001 [Spec No]:1–107.
110. Nemeroff CB, Heim CM, Thase ME, et al. Differential responses to psychotherapy versus pharmacotherapy in patients with chronic forms of major depression and childhood trauma. Natl Acad Sci U S A 2003;100:14293–14296.
111. Charney DS, Berman RM, Miller HL. Treatment of depression. In: Schatzberg AF, Nemeroff CB, eds. Essentials of clinical psychopharmacology. Washington, DC: American Psychiatric Publishing, 2005:353–386.
112. Linde K, Berner M, Egger M, et al. St. John’s wort for depression: meta-analysis of randomised controlled trials. Br J Psychiatry 2005;186:99–107.
113. Janicak PG, Dowd SM, Strong MJ, et al. The potential role of repetitive transcranial magnetic stimulation in treating severe depression. Psychiatr Ann 2005;35:138–145.
114. Kozel FA, Nahas Z, Bohning DE, et al. Functional magnetic resonance imaging and transcranial magnetic stimulation for major depression. Psychiatr Ann 2005;35:130–136.
115. Wright JK, Beck AT. Cognitive therapy. In: Hales RE, Yudofsky SC, Talbott JA, eds. Textbook of psychiatry, 2nd ed. Washington, DC: American Psychiatric Press, 1994:1083–1114.
116. Akincigil A, Bowblis JR, Levin C, et al. Adherence to antidepressant treatment among privately insure patients diagnosed with depression. Med Care 2007;45:363–369.
117. Quitkin FM, Stewart JW, McGrath PJ, et al. Are there differences between women’s and men’s antidepressant responses? Am J Psychiatry 2002;159:1848–1854.
118. Druss BG, Hoff RA, Rosenheck RA. Underuse of antidepressants in major depression: prevalence and correlates in a national sample of young adults. J Clin Psychiatry 2000;61:234–237.
119. Kennedy SH, Eisfeld BS, Dickens SE, et al. Antidepressant-induced sexual dysfunction during treatment with moclobemide, paroxetine, sertraline, and venlafaxine. J Clin Psychiatry 2000;61:276–281.
120. Kelly CM, Juurlink DN, Gomes T, et al. Selective serotonin reuptake inhibitors and breast cancer mortality in women receiving tamoxifen: a population-based cohort study. BMJ 2010;340:693.
121. Tollefson GD, Rosenbaum JF. Selective serotonin reuptake inhibitors. In: Schatzberg AF, Nemeroff CB, eds. Essentials of clinical psychopharmacology. Washington, DC: American Psychiatric Publishing, 2005:27–42.
122. Masand PS, Gupta S. Selective serotonin-reuptake inhibitors: an update. Harvard Rev Psychiatry 1999;7:69–84.
123. Schneeweiss S, Patrick AR, Slolmon DH, et al. Variation in the risk of suicide attempts and completed suicides by antidepressant agent in adults: a propensity score-adjusted analysis of 9 years' data. Arch Gen Psychiatry 2010;67:497–506.
124. Singh T, Prakash A, Rais T, et al. Decreased use of antidepressants in youth after US Food and Drug Administration black box warning. Psychiatry (Edgmont) 2009;6:30–34.
125. Libby AM, Orton HD, Valuck RJ. Persisting decline in depression treatment after FDA warnings. Arch Gen Psychiatry 2009;66:633–639.
126. Kent JM. SNaRIs, NaSSAs, and NaRIs: new agents for the treatment of depression. Lancet 2000;355:911–918.
127. Horst WD, Preskorn SH. Mechanisms of action and clinical characteristics of three atypical antidepressants: venlafaxine, nefazodone, bupropion. J Affect Disord 1998;51:237–254.
128. Montgomery SA. New developments in the treatment of depression. J Clin Psychiatry 1999;60[Suppl 14]:10–15.
129. Goodwin FK, Jamison KR. Medical treatment of manic episodes. In: Goodwin FK, Jamison KR, eds. Manic-depressive illness. New York: Oxford University Press, 1990:603–629.
130. Goodwin FK, Jamison KR. Medical treatment of acute bipolar depression. In: Goodwin FK, Jamison KR, eds. Manic-depressive illness. New York: Oxford University Press, 1990:630–664.
131. Klerman GL. Clinical epidemiology of suicide. J Clin Psychiatry 1987;48[Suppl]:33–38.
132. Buda M, Tsuang MT. The epidemiology of suicide: implications for clinical practice. In: Blumenthal SJ, Kupfer DJ, eds. Suicide over the life cycle: risk factors, assessment, and treatment of suicidal patients. Washington, DC: American Psychiatric Press, 1990:17–38.
133. Pilowsky DJ, Olfson M, Gameroff MJ, et al. Panic disorder and suicidal ideation in primary care. Depress Anxiety 2006;23:11–16.
134. Han B, Gfroerer JC, Colliver JD. Associations between duration of illicit drug use and health conditions: results from the 2005–2007 national surveys on drug use and health. Ann Epidemiol 2010;20:289–297.
135. Croghan IT, Ebbert JO, Hurt RD, et al. Gender difference among smokers receiving interventions for tobacco dependence in a medical setting. Addict Behav 2009;34:61–67.
136. Rockett IR, Putnam SL, Jia H, et al. Declared and undeclared substance abuse among emergency department patients: a population-based study. Addiction 2006;101:706–712.
137. Haber PS, Demirkol A, Lange K, et al. Management of injecting drug users admitted to hospital. Lancet 2009;374:1284–1293.
138. Smith PC, Schmidt SM, Allensworth-Davies D, et al. A single-question screening test for drug use in primary care. Arch Inter Med 2010;170:1155–1160.
139. Clay SW, Allen J, Parran T. A review of addiction. Postgrad Med 2008;120:1–7.
140. Boyd CJ, Teter CJ, West BT, et al. Non-medical use of prescription analgesics: a three-year national longitudinal study. J Addict Dis 2009;28:232–242.
141. Ahern J, Galea S, Hubbard A, et al. “Culture of drinking” and individual problems with alcohol use. Am J Epidemiol 2008;167:1041–1049.
142. Tuchman E. Women and addiction: the importance of gender issues in substance abuse research. J Addict Dis 2010;29:127–138.
143. Lefebvre L, Midmer D, Boyd JA, et al. Participant perception of an integrated program for substance abuse in pregnancy. J Obstet Gynecol Neonatal Nurs 2010;39:46–52.
144. Wakhlu S. Buprenorphine: a review. J Opioid Manag 2009;5:59–64.
145. Nepon J, Belik SL, Bolton J, et al. The relationship between anxiety disorders and suicide attempts: findings from the National Epidemiologic Survey on Alcohol and Related Conditions. Depress Anxiety 2010;27:791–798.
146. Rosenbaum JF, Pollack MH. Anxiety. In: Cassem NH, ed. Massachusetts General Hospital handbook of general hospital psychiatry. St. Louis, MO: Mosby Year Book, 1991:159–190.
147. Hollander E, Simeon D, Gorman JM. Anxiety disorders. In: Hales RE, Yudofsky SC, Talbott JA, eds. Textbook of psychiatry, 2nd ed. Washington, DC: American Psychiatric Press, 1994:495–564.
148. Sheikh JI, Leskin GA, Klein DF. Gender differences in panic disorder: findings from the National Comorbidity Survey. Am J Psychiatry 2002;159:55–58.
149. Yehuda R. Post-traumatic stress disorder. N Engl J Med 2002;346:108–114.
150. Baldessrini RJ. Drugs and the treatment of psychiatric disorders. In: Gilman AG, Rall TW, Nies AS, et al, eds. Goodman and Gilman’s the pharmacological basis of therapeutics, 8th ed. New York: Pergamon, 1990:383–435.
151. Bakish D. The patient with comorbid depression and anxiety: the unmet need. J Clin Psychiatry 1999;60[Suppl 6]:20–24.
152. Barlow DH, Craske MG, Cerny JA, et al. Behavioral treatment of panic disorder. Behav Ther 1989;20:261–282.
153. Taylor S, Wald J. Expectations and attributions in social anxiety disorder: diagnostic distinctions and relationship to general anxiety and depression. Cogn Behav Ther 2003;32:166–178.
154. Pollack MH, Simon NM, Zalta AK, et al. Olanzapine augmentation of fluoxetine for refractory generalized anxiety disorder: a placebo controlled study. Biol Psychiatry 2006;59:211–215.
155. van Oppen P, van Balkom AJ, de Haan E, et al. Cognitive therapy and exposure in vivo alone and in combination with fluvoxamine in obsessive-compulsive disorder: a 5-year follow-up. J Clin Psychiatry 2005;66:1415–1422.
156. Moritz S, Rufer M, Fricke S, et al. Quality of life in obsessive-compulsive disorder before and after treatment. Compr Psychiatry 2005;46:453–459.
157. Cottraux J, Bouvard MA, Milliery M. Combining pharmacotherapy with cognitive-behavioral interventions for obsessive-compulsive disorder. Cogn Behav Ther 2005;34:185–192.
158. Furukawa TA, Watanabe N, Churchill R. Combined psychotherapy and antidepressants for panic disorder with or without agoraphobia. Cochrane Database Syst Rev 2007;1:CD004364.
159. Schnurr PP, Friedman MJ, Engel CC, et al. Cognitive behavioral therapy for posttraumatic stress disorder in women: a randomized controlled trial. JAMA 2007;297:820–830.
160. Foa EB, Steketee G, Grayson JB, et al. Deliberate exposure and blocking of obsessive-compulsive rituals: immediate and long-term effects. Behav Ther 1984;15:450–472.
161. Cooper NA, Clum GA. Imaginal flooding as a supplementary treatment for PTSD in combat veterans: a controlled study. Behav Ther 1989;20:381–391.
162. Butler G. Issues in the application of cognitive and behavioral strategies to the treatment of social phobia. Clin Psychol Rev 1989;9:91–106.
163. Craske MG, Brown TA, Barlow DH. Behavioral treatment of panic disorder: a two-year followup. Behav Ther 1991;22:289–304.
164. Roy-Byrne PP, Cowley DS. Benzodiazepines in clinical practice: risks and benefits. Washington, DC: American Psychiatric Press, 1991.
165. Jenike MA, Baer L, Summergrad P, et al. Obsessive-compulsive disorder: a double-blind, placebo-controlled trial of clomipramine in 27 patients. Am J Psychol 1989;146:1328–1330.
166. Jenike MA, Baer L. An open trial of buspirone in obsessive-compulsive disorder. Am J Psychol 1988;145:1285–1286.
167. Cassem NH, Barsky AJ. Functional symptoms and somatoform disorders. In: Cassem NH, ed. Massachusetts General Hospital handbook of general hospital psychiatry. St. Louis, MO: Mosby Year Book, 1991:131–157.
168. Frostholm L, Fink P, Christensen KS, et al. The patients' illness perceptions and the use of primary health care. Psychosom Med 2005;67:997–1005.
169. Ford CV, Folks DG. Conversion disorders: an overview. Psychosomatics 1985;26:371–377:380–383.
170. Ljundberg L. Hysteria: clinical, prognostic, and genetic study. Acta Psychol Scand 1957;32:1–162.
171. Stefansson JH, Messina JA, Meyerowitz S. Hysterical neurosis, conversion type: clinical and epidemiological considerations. Acta Psychiatr Scand 1976;59:119–138.
172. Toone BK. Disorders of hysterical conversion. In: Bass C, ed. Physical symptoms and psychological illness. London, Engl.: Blackwell Science, 1990:207–234.
173. Strassnig M, Stowell KR, First MB, et al. General medical and psychiatric perspectives on somatoform disorders: separated by an uncommon language. Curr Opin Psychiatry 2006;19:194–200.
174. Ruddy R, House A. Psychosocial interventions for conversion disorder. Cochrane Database Syst Rev 2005;19:CD005331.
175. Koss MP. The women’s mental health research agenda: violence against women. Am Psychol 1990;45:257–263.
176. Bryer JB, Nelson BA, Miller JB, et al. Childhood sexual and physical abuse as factors in adult psychiatric illness. Am J Psychol 1987;114:1426–1430.
177. Warshaw C. Women and violence. In: Stotland NL, Stewart DE, eds. Psychological aspects of women’s health care, 2nd ed. Washington, DC: American Psychiatric Press, 2001:477–548.
178. MacMillan HL, Wathen CN, Jamieson E, et al. Screening for intimate partner violence in health care settings: a randomized trial. JAMA 2009;302:493–501.
179. Clark LA. Assessment and diagnosis of personality disorder: perennial issues and an emerging reconceptualization. Ann Rev Psychol 2007;58:227–257.
180. Andreasen NC, Wasek P. Adjustment disorders in adolescents and adults. Arch Gen Psychiatry 1980;37:1166–1170.
181. Fabrega H Jr, Mezzich JE, Mezzich AC. Adjustment disorder as a marginal or transitional illness category in DSM-III. Arch Gen Psychol 1987;44:567–572.
182. Kaye W, Strober M, Jimerson D. The neurobiology of eating disorders. In: Charney DS, Nestler EJ, eds. The neurobiology of mental illness. New York: Oxford University Press, 2004:1112–1128.
183. Mickley D. Are you overlooking eating disorders among your patients? Womens Health in Primary Care 2000;3:40–52.
184. Strober M, Morell W, Burroughs J, et al. A controlled family study of anorexia nervosa. J Psych Res 1985;19:329–346.
185. Stewart DE, Robinson GE. Eating disorders and reproduction. In: Stotland NL, Stewart DE, eds. Psychological aspects of women’s health care, 2nd ed. Washington, DC: American Psychiatric Press, 2001:411–456.
186. VanItallie TB. Health implications of overweight and obesity in the United States. Ann Intern Med 1985;103:983–1038.
187. Bulik CM, Berkman ND, Brownley KA, et al. Anorexia nervosa treatment: a systematic review of randomized controlled trials. Int J Eat Discord 200740:310–320.
188. Von Korff M, Nestadt G, Romanoski A, et al. Prevalence of treated and untreated DSM-III schizophrenia: results of a two-stage community survey. J Nerv Ment Dis 1985;173:577–581.
189. Nilsson E, Lichtenstein P, Cnattinguis S, et al. Women with schizophrenia: pregnancy outcome and infant death among their offspring. Schizophr Res 2002;58:221–229.
190. Jablensky AV, Morgan V, Zubrick SR, et al. Pregnancy, delivery and neonatal complications in a population cohort of women with schizophrenia and major affective disorders. Am J Psychiatry 2005;162:79–91.
191. Goff DC, Manschreck TC, Groves JE. Psychotic patients. In: Cassem NH, ed. Massachusetts General Hospital handbook of general hospital psychiatry. St. Louis, MO: Mosby Year Book, 1991:217–236.
192. Black DW, Andreasen NC. Schizophrenia, schizophreniform disorder, and delusional (paranoid) disorder. In: Hales RE, Yudofsky SC, Talbott JA, eds. Textbook of psychiatry, 2nd ed. Washington, DC: American Psychiatric Press, 1994:411–463.
193. Beiser M, Iacono WG. Update on the epidemiology of schizophrenia. Can J Psychiatry 1990;35:657–668.
194. Michels R, Marzuk PM. Progress in psychiatry. N Engl J Med 1993;329:552–560.
195. Stotland NL. Psychiatric and psychosocial issues in primary care for women. In: Seltzer VL, Pearse WH, eds. Women’s primary health care: office practice and procedures. New York: McGraw-Hill, 1995.