Patients with psychiatric disorders in gynecologic practice

Patients with psychiatric disorders in gynecologic practice Marie Bixo, MD, PhD,a Inger Sundström-Poromaa, MD, PhD,a Inger Björn, MD,a and Monica Åström, MD, PhDb Umeå, Sweden OBJECTIVE: The relationship between different gynecologic complaints and somatic symptoms was studied in a gynecologic population in which the prevalence of psychiatric disorders had been established. STUDY DESIGN: The prevalence of depression and anxiety in the unselected population of 1013 subjects was 27.2% and 12.1%, respectively, as assessed by the Primary Care Evaluation of Mental Disorders (PRIME-MD). The subjects’ medical charts were reviewed after the PRIME-MD diagnosis was made. RESULTS: Depression and anxiety disorders were significantly more common among those seeking care for abdominal pain, those who made frequent and unscheduled visits, and those who were hospitalized for acute care. All the physical symptoms indicated in the PRIME-MD Patient Health Questionnaire were more common among women with a psychiatric diagnosis compared with controls. CONCLUSIONS: The majority of cases of depression and anxiety in women are undiagnosed and untreated, and patients with these disorders often present with physical symptoms. Because gynecologic outpatients with abdominal pain, frequent and unscheduled visits, and admissions due to acute illness are more likely to have a psychiatric disorder, it is desirable that gynecologists recognize and treat these problems. (Am J Obstet Gynecol 2001;185:396-402)

Key words: Depression, anxiety, women, gynecology

Women are diagnosed much more often with mood and anxiety disorders than are men. The risk of experiencing an affective episode associated with female sex may be surpassed only by the high risk associated with a family history of depression. The lifetime prevalence of major depression among women has been reported to be between 14% and 21%.1,2 Not only is major depressive disorder 2 to 3 times more common in women than in men,3 but women also have more recurrent and longer episodes.4 In addition, comorbid anxiety disorders are more common in women.5 The reason for this difference between sexes is still obscure. One important factor might be the overwhelming reproductive events that women experience. It is well established that women are at risk for the development of affective disorders during the postpartum period; the prevalence is estimated at 12%.6 Furthermore, obsessivecompulsive disorder may first appear or may be exacerbated during pregnancy and the postpartum period.7 From the Department of Clinical Sciences, Obstetrics and Gynecologya and Psychiatry,b Umeå University. Supported by a research grant from Pfizer AB, Stockholm, Sweden, and by grants to Inger Sundström-Poromaa from the Wallenberg Foundation, Swedish Society of Medicine, and “Spjutspetsanslag, Umeå Sjukvård.” Received for publication August 17, 2000; revised February 21, 2001; accepted March 30, 2001. Reprint requests: Marie Bixo, MD, PhD, Department of Clinical Sciences, Obstetrics and Gynecology, Umeå University, S-901 85, Umeå, Sweden. Copyright © 2001 by Mosby, Inc. 0002-9378/2001 $35.00 + 0 6/1/116094 doi:10.1067/mob.2001.116094

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Premenstrual mood disturbances are common among women of fertile age, and 3.5% to 5% of these women are reported to have a true premenstrual dysphoric disorder.8 A history of depression and postpartum depression is common among women with premenstrual dysphoric disorder,9 and the disorder in itself is sometimes considered a risk factor for future depressive disorder.10 Although menopause is not associated with a higher incidence of depression, a prolonged perimenopause is a risk factor for depressive disorders.11 Depressive and anxiety disorders are strongly associated with increased reporting of physical symptoms.12-14 Somatization disorder, a chronic mental disorder occurring predominantly in women, is characterized by large numbers of unexplained symptoms, substantial impairment, and excessive health care utilization. Some of the physical symptoms reported more often by women with psychiatric disorders in primary care include dizziness, headache, fatigue, joint and limb pain, palpitations, back pain, and bowel complaints.15 The obstetrician-gynecologist is the main health care contact for approximately 1 out of 3 women of childbearing age. Psychiatric disorders are bound to be common among women visiting their gynecologist, given the high incidence of depression during these years, the relationship between depression and reproductive events, and the tendency of a woman to present a physical symptom as a sign of depression. The aim of this study was to investigate how women with psychiatric disorders present themselves at a gynecologic clinic (eg, what kinds of

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physical symptoms or diagnoses they had, whether their appointments were scheduled or unscheduled, and whether they made frequent visits). The study consisted of a population of patients in which the prevalence of psychiatric disorders had been reported earlier.16 Material and methods Study population. From November 16, 1998, to December 15, 1998, all patients with scheduled appointments and patients who made walk-in visits for medical care at two gynecologic practices in northern Sweden (Umeå University Hospital and a private clinic in Piteå) were approached for participation in the study. The two centers mainly offer gynecologic expertise, whereas obstetric patients in the second or third trimester of pregnancy receive care elsewhere. Both the patients with scheduled appointments, with or without referral, and those who made walk-in visits receive care at the clinics. Exclusion criteria for the study were (1) age younger than 18 years, (2) severe illness and/or pain, (3) inability to read and understand the questionnaire because of language difficulties or cognitive impairment, (4) previous evaluation with the Primary Care Evaluation of Mental Disorders (PRIMEMD; Pfizer Inc, New York, NY) at an earlier visit during the study period, and (5) lack of informed consent. Diagnoses of psychiatric disorders were made using the PRIME-MD system, which was developed to help primary care physicians to screen, evaluate, and diagnose mental disorders. Given its utility and ease of use, PRIME-MD was considered to be a suitable tool for assessing the prevalence of psychiatric disorders in a gynecologic setting, in particular since the spectrum of psychiatric disorders found among gynecologic patients can be expected to resemble that found in a primary care practice. The PRIMEMD system was constructed to conform to criteria of the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV), and has been validated for use in a primary care setting.17-19 The agreement between PRIMEMD and independent psychiatric diagnoses guided by a structured interview is generally excellent across modules, with an overall accuracy of 88%.17 The PRIME-MD system, which is fully described elsewhere,17 consists of two components: a 1-page Patient Health Questionnaire (PHQ) and a 12-page clinician evaluation guide, which is a structured interview for the clinician to use when evaluating the responses on the PHQ. The clinician evaluation guide contains modules for somatoform disorders, eating disorders, mood disorders, anxiety, alcohol abuse, obsessivecompulsive disorders, and social phobia and a question about how patients perceive their general health. Clinicians administer only the modules that are indicated by the patient on the PHQ. Normally, the PRIME-MD screening questionnaire contains 4 questions concerning alcohol abuse, but these questions were omitted in this study. The PRIME-MD system evaluates the presence of 20 possi-

Bixo et al 397

ble mental disorders, and this study focused on 13 of those diagnoses. Of the 13 diagnoses of interest, 8 disorders were considered to be “threshold” diagnoses because they correspond to the specific requirements of DSM-IV (ie, major depressive disorder, dysthymia, partial remission of major depressive disorder, generalized anxiety disorder, panic disorder, obsessive-compulsive disorder, social phobia, and bulimia nervosa). An additional 4 diagnoses were considered to be “subthreshold” diagnoses (ie, minor depressive disorder, anxiety not otherwise specified, eating disorder not otherwise specified, and binge eating disorder). Subthreshold diagnoses have fewer symptoms than what is required for a specific DSM-IV diagnosis but are included because they are associated with impairment of function. Finally, a rule-out diagnosis of bipolar disorder was included. All patients completed and handed in the PRIME-MD PHQ before seeing their physician, who was often unaware of the ongoing study. To pursue a diagnosis, a structured telephone interview was conducted 1 to 2 weeks later with screen-positive patients who had signed an informed consent for that. Patients were considered to be screen positive if they responded to any key question for mental disorders on the PHQ. Screen-negative patients were those who acknowledged no items on the PHQ or who acknowledged only the key questions for somatoform disorder or social phobia. Each telephone interview lasted 10 to 15 minutes. The physical symptoms indicated by the patient in the somatoform module of the PHQ were registered but not followed up in the interview. The study population and procedure are thoroughly described elsewhere.16 In short, 1101 patients were eligible for the study, and 1013 patient questionnaires were distributed—818 at the hospital center and 195 at the private clinic. The response rate was 88.6%, and 784 (77.4%) patients also consented to a telephone interview. Of those, 413 (52.7%) responded to 1 or more of the key questions about mental disorders, and 18 (2.3%) could not be reached by telephone within the stipulated 14-day period. Hence, a telephone interview was conducted in 413 cases, and the study population wherein a possible confirmation of a PRIMEMD diagnosis could be obtained consisted of 766 subjects. The control group consisted of patients who were screen negative (n = 353) and those who were screen positive but who after the follow-up telephone interview were not considered to have a psychiatric diagnosis (n = 179). The mean age of the patients who consented to a telephone interview was 43.8 ± 14.3 years. The study identified 234 (30.5%) patients with a PRIME-MD diagnosis. Full DSMIV diagnoses were present in 16.3%, whereas 14.2% had only a subthreshold diagnosis. Depressive disorder was diagnosed in 208 (27.2%) patients and anxiety disorder in 93 (12.1%) patients. Comorbidity was common—34.6% of the patients had 2 or more psychiatric diagnoses.16

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Table I. Number of patients with or without psychiatric diagnosis with respect to their primary gynecologic diagnosis Controls

Patients with any psychiatric diagnosis

Diagnosis

No.

%

No.

%

Abdominal pain Climacteric symptoms Cervical dysplasia Vulva diseases Legal abortion Menometrorrhagia Urogynecologic problems Infertility Family planning Pregnancy-related problems Infection Others

29 98 58 58 12 83 17 34 24 20 7 78

53.7 73.7 78.4 73.4 50.0 74.1 53.1 72.3 66.7 76.9 70.0 66.7

25 35 16 21 12 29 15 13 12 6 3 39

46.3 26.3 21.6 26.6 50.0 25.9 46.9 27.7 33.3 23.1 30.0 33.3

Table II. Risk factors influencing the probability of having any depression diagnosis (n = 199) Cases Variable Diagnosis Abdominal pain Legal abortion Menometrorrhagia Cervical dysplasia Endocrinology/infertility Pregnancy-related problems Infections Climacteric symptoms Family planning Urogynecologic problems Vulva diseases Others No. of visits 1 2-3 ≥4 Hospitalization for acute care 0 ≥1 Surgery planned No Yes Appointment Scheduled Unscheduled

Controls

No.

%

No.

%

Odds ratio (95% confidence interval, bivariate analysis)

23 10 23 14 11 4 3 34 12 14 17 34

11.6 5.0 11.6 7.0 5.5 2.0 1.5 17.1 6.0 7.0 8.5 17.1

29 12 83 58 30 20 7 98 24 21 58 78

5.6 2.3 16.0 11.2 5.8 3.9 1.4 18.9 4.6 4.1 11.2 15.1

2.17 (1.22-3.84) 2.20 (0.93-5.17) 0.70 (0.42-1.14) 0.62 (0.33-1.33) 0.88 (0.42-1.84) 0.50 (0.17-1.49) 1.10 (0.28-4.31) 0.87 (0.57-1.33) 1.30 (0.64-2.66) 1.76 (0.88-3.54) 0.68 (0.38-1.22) 1.14 (0.73-1.77)

55 23

27.6 11.6

138 41

26.6 7.9

1 1.13 (0.77-1.64) 1.58 (0.91-2.75)

9

4.5

9

1.7

1 2.64 (1.03-6.75)

15

7.5

34

6.4

1 1.14(0.61-2.15)

37

18

52

14.7

1 1.14 (0.71-1.84)

The study was approved by the Ethics Committee, Umeå University, Sweden. Review of medical charts. When all the telephone interviews were completed and the PRIME-MD diagnoses were obtained, the medical charts of all the patients were thoroughly reviewed. Apart from the gynecologic diagnosis registered at the patient’s visit during the study period, data regarding type of appointment, number of visits and acute hospitalizations during the last year, and whether surgery was planned for the patient were noted. In addition, information in the gynecologic medical records regarding psychiatric history and treatment was obtained. Statistics. Continuous variables were compared by

P

.0081

.0425

using the t test and are displayed as mean ± SD. Logistic regression was used for estimating association between PRIME-MD diagnoses, gynecologic diagnoses, type of appointment, number of visits and hospitalizations for acute care, and whether surgery was planned for the patient. All statistical analyses were performed using SPSS 7.5 for Windows (SPSS, Inc, Chicago, Ill). A P value < .05 was considered significant. Results Gynecologic diagnoses in relation to PRIME-MD diagnoses. Factors influencing the risk of having any depressive, anxiety, or full DSM-IV disorder, according to gyne-

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Table III. Risk factors influencing the probability of having any anxiety diagnosis (n = 90) Cases Variable Diagnosis Abdominal pain Legal abortion Menometrorrhagia Cervical dysplasia Endocrinology/infertility Pregnancy-related problems Infections Climacteric symptoms Family planning Urogynecologic problems Vulva diseases Others No. of visits 1 2-3 ≥4 No. of acute hospitalizations 0 ≥1 Surgery planned No Yes Appointment Scheduled Unscheduled

Controls Odds ratio (95% confidence interval, bivariate analysis)

No.

%

No.

%

15 3 9 7 4 5 2 15 2 6 8 14

16.7 3.3 10.0 7.8 4.4 5.5 2.2 16.7 2.2 6.7 8.9 15.6

29 12 83 58 30 20 7 98 24 21 58 78

5.6 2.3 16.0 11.2 5.8 3.9 1.4 18.9 4.6 4.1 11.2 15.1

3.34 (1.71-6.50) 1.44 (0.40-5.22) 0.60 (0.29-1.23) 0.70 (0.31-1.57) 0.58 (0.17-1.94) 1.45 (0.53-3.98) 1.65 (0.34-8.06) 0.85 (0.47-1.54) 0.46 (0.11-2.00) 1.68 (0.66-4.28) 0.77 (0.35-1.67) 1.03 (0.56-1.91)

28 16

31.1 17.8

138 41

26.6 7.9

1 1.59 (0.95-2.66) 3.06 (1.58-5.92)

.0013

6

6.7

9

1.7

1 4.01 (1.39-11.54)

.01

7

7.8

34

6.4

1 1.19 (0.51-2.78)

52

14.7

1 1.86 (1.08-3.21)

24

26

P

.0004

.024

Table IV. Risk factors influencing the probability of having a full DSM-IV diagnosis (n = 122) Cases Variable Diagnosis Abdominal pain Legal abortion Menometrorrhagia Cervical dysplasia Endocrinology/infertility Pregnancy-related problems Infections Climacteric symptoms Family planning Urogynecologic problems Vulva diseases Other causes No. of visits 1 2-3 ≥4 No. of acute hospitalizations 0 ≥1 Surgery planned No Yes Appointment Scheduled Unscheduled

Controls

No.

%

No.

%

Odds ratio (95% confidence interval, bivariate analysis)

16 8 18 5 10 4 2 16 6 9 8 20

13.1 6.6 14.8 4.1 8.2 3.3 1.6 13.1 4.9 7.4 6.6 16.4

29 12 83 58 30 20 7 98 24 21 58 78

5.6 2.3 16.0 11.2 5.8 3.9 1.4 18.9 4.6 4.1 11.2 15.1

2.55 (1.34-4.85) 2.96 (1.18-7.41) 0.94 (0.54-1.63) 0.35 (0.14-0.90) 1.35 (0.62-2.92) 0.85 (0.28-2.52) 1.22 (0.25-5.94) 0.65 (0.37-1.15) 1.07 (0.43-2.67) 1.89 (0.84-4.23) 0.56 (0.26-1.20) 1.10 (0.65-1.89)

33 17

27.0 13.9

138 41

26.6 7.9

1 1.17 (0.74-1.86) 2.04 (1.09-3.81)

.024

6

4.9

9

1.7

1 2.93 (1.02-8.39)

.0452

8

6.6

34

6.4

1 1.00 (0.45-2.22)

52

14.7

1 1.83 (1.10-3.02)

30

24

P

.045 .020 .03

.019

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Table V. Frequency of physical symptoms by prevalence of any PRIME-MD diagnosis Percentage of patients reporting symptoms All physical symptoms

Diagnosed PRIME-MD (n = 234)

Nondiagnosed PRIME-MD (n = 532)

P

Abdominal pain Back pain Bowel complaints Chest pain Dizziness Dyspnea Headache Fatigue Insomnia Joint or limb pain Nausea Palpitations Fainting Menstrual problems Sexual problems

44.9 56.4 41.6 26.8 39.7 12.4 52.8 89.7 48.7 52.4 57.8 31.2 3.9 42.5 23.4

25.0 36.6 22.0 12.5 16.3 4.4 35.7 48.5 21.6 40.3 29.4 12.7 0.9 30.9 14.8

.0001 .0001 .0001 .0001 .0001 .0001 .0001 .0001 .0001 .002 .0001 .0001 .017 .003 .005

cologic diagnosis, are presented in Tables I through IV. Patients with any mood disorder, including those with minor depression, were identified more often among patients seeking treatment for abdominal or pelvic pain (see Table II). These patients made 1.86 visits to gynecologic clinics during 1998 compared with 1.68 visits made by patients with no psychiatric diagnosis. Furthermore, patients presenting with abdominal or pelvic pain had a more than 3-fold increased risk of having an anxiety disorder (see Table III). Patients with abdominal or pelvic pain and patients undergoing legal abortion had 2 to 3 times increased risk of fulfilling full DSM-IV criteria for any psychiatric disorder at the time of the interview (see Table IV). Patients within the screening program for cervical dysplasia or with cervical dysplasia were less often diagnosed with a full DSM-IV diagnosis than other gynecologic patients (see Table IV). Patients with anxiety disorders made more visits to the gynecologic center during 1998 than patients without psychiatric diseases (2.31 visits vs 1.68 visits, P < .0001). Patients with a full DSM-IV diagnosis were also frequent visitors, with a mean number of visits during 1998 of 2.03, which differed significantly from the control group, P < .05. Within the study group, 19 patients at some time during 1998 had been hospitalized for acute care. Women with any mood or anxiety disorder or any full DSM-IV diagnosis were more likely to have a history of hospitalization for acute care, whatever the gynecologic cause was, than control subjects (see Tables II through IV). However, patients who had planned for surgery during the study period, regardless whether the operation was performed during or after the study period, did not display an increased risk for having any mood or anxiety disorder. Psychiatric history in the gynecologic records. Very little on psychiatric history and treatment was found in the medical records at the gynecologic centers. Among pa-

tients with any psychiatric PRIME-MD diagnosis, 23 (9.8%) had a notation regarding psychiatric history in their medical record, and 38 patients (16.2%) presented with psychiatric symptoms in addition to their gynecologic problems. Thirty-five patients (15.0%) with any psychiatric PRIME-MD diagnosis had been prescribed antidepressant medications; the majority of these cases were discovered during the telephone interviews. In addition, a number of patients not detected by PRIME-MD as having any psychiatric disorder had evidence of ongoing or prior psychiatric diseases. Among these, 18 patients (3.3%) had a psychiatric history in their gynecologic records, 10 (1.9%) were taking antidepressant medication, and 30 (5.6%) presented with psychiatric symptoms in addition to their gynecologic problems. A number of patients received a psychiatric diagnosis by their gynecologist: 7 patients were diagnosed with premenstrual dysphoric disorder, 6 patients were diagnosed with major depression, and 1 patient was diagnosed with panic disorder. Among patients diagnosed with major depression, 3 received only a psychiatric diagnosis. Of the patients with premenstrual dysphoric disorder, 6 had an additional psychiatric diagnosis according to PRIME-MD. Four patients reported prior eating disorders from which they most likely had recovered, as PRIME-MD was unable to recognize any present eating disorder. However, 2 of these patients still suffered from endocrine aberrations due to their eating disorder (eg, amenorrhea and menstrual disturbances). Physical symptoms. Table V summarizes the frequency of physical symptoms reported by the patients on the PHQ with respect to prevalence of any PRIME-MD diagnosis. Virtually all somatic symptoms were significantly more commonly reported by patients with a PRIME-MD diagnosis. Among diagnosed patients, the prevalence of sexual problems was 23.4%, whereas menstrual problems and abdominal pain were reported to be 42.5% and 44.9%, respectively.

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Comment The results of this study suggest that women attending a gynecologic clinic with abdominal pain as their main problem are more likely to have a psychiatric disorder than those seeking care for other reasons. Both depression and anxiety are more common in this group than among those seeking care for other reasons, but this is not surprising considering the high frequency of this kind of comorbidity among women. A higher prevalence of psychiatric disorders among women seeking care for pelvic pain at a gynecologic clinic has been reported earlier.20 However, even though chronic physical illness is a risk factor for psychiatric disease, it is impossible to know the exact nature of the relationship in an individual patient. Because the current opinion among psychiatrists is that secondary psychiatric disorders should be treated, it is important to identify patients with these types of disorders. It is well established that women are more prone to develop somatoform disorders than men21 and that physical symptoms overall are more common in women, regardless of psychiatric disease, as assessed in primary care.15 In women, physical symptoms such as headache, chronic fatigue, pain, and bleeding irregularities are often associated with psychiatric disorders.22 Depressive symptoms are often not recognized in clinical gynecologic practice.23 In this study, gynecologists did not recognize the psychiatric diagnosis in most patients and therefore those patients were not treated. Only 10% of the patients were administered antidepressant therapy.16 Epidemiologic data indicate that two thirds of depressed subjects had not been prescribed any treatment.19 It is evident from our results that gynecologic patients with psychiatric disorders are prone to seek medical care more frequently and at unscheduled times and are also hospitalized for acute care more often. The consequences of not identifying and treating these women properly is, apart from the prolonged suffering for the patients, an unnecessary burden on medical units. Given the high rates of mental disorders among gynecologic patients, it is desirable that gynecologists become familiar with these conditions and become more willing to treat and refer for treatment women with depression and other common mental disorders. In this study, women applying for induced abortion had an almost 3-fold risk of having a full DSM-IV diagnosis. On the other hand, studies focused more on social and psychologic factors have found that abortion is unlikely to be followed by severe psychologic responses.24,25 Rather, psychologic aspects were considered to be best understood as normal reactions of stress and coping. However, one explanation for our results might be that at the time of the telephone interview the women were in the midst of the abortion process since the procedure is typically performed 1 to 2 weeks after the first visit. In conclusion, women with psychiatric disorders are commonly found in a gynecologic setting. They have

more somatic symptoms in general, and abdominal pain is the most common diagnosis in their medical chart. In addition, their visits are more frequent and more often unscheduled, and hospitalization for acute care is more common in this group. Dr Karin Bishop Bondestam is greatly appreciated for the English language revision. REFERENCES

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