Postpartum Psychosis: A Preventable Psychiatric Emergency.

Postpartum psychosis is the most severe psychiatric disorder associated with childbirth. Although rare, it is considered a psychiatric emergency that warrants immediate medical attention and inpatient care to ensure safety, complete diagnostic evaluation, and treatment initiation. This article describes the phenomenology of postpartum psychosis, clinical evaluation, treatment guidelines, and prevention strategies.

A randomized trial of collaborative depression care in obstetrics and gynecology clinics: socioeconomic disadvantage and treatment response.

OBJECTIVE: The authors evaluated whether an obstetrics-gynecology clinic-based collaborative depression care intervention is differentially effective compared with usual care for socially disadvantaged women with either no health insurance or with public coverage compared with those with commercial insurance. METHOD: The study was a two-site randomized controlled trial with an 18-month follow-up. Women were recruited who screened positive (a score of at least 10 on the Patient Health Questionnaire-9) and met criteria for major depression or dysthymia. The authors tested whether insurance status had a differential effect on continuous depression outcomes between the intervention and usual care over 18 months. They also assessed differences between the intervention and usual care in quality of depression care and dichotomous clinical outcomes (a decrease of at least 50% in depressive symptom severity and patient-rated improvement on the Patient Global Improvement Scale). RESULTS: The treatment effect was significantly associated with insurance status. Compared with patients with commercial insurance, those with no insurance or with public coverage had greater recovery from depression symptoms with collaborative care than with usual care over the 18-month follow-up period. At the 12-month follow-up, the effect size for depression improvement compared with usual care among women with no insurance or with public coverage was 0.81 (95% CI=0.41, 0.95), whereas it was 0.39 (95% CI=-0.08, 0.84) for women with commercial insurance. CONCLUSIONS: Collaborative depression care adapted to obstetrics-gynecology settings had a greater impact on depression outcomes for socially disadvantaged women with no insurance or with public coverage compared with women with commercial insurance.

Approach to the patient with multiple somatic symptoms.

Primary care providers play a crucial role in the recognition and appropriate treatment of patients with multiple somatic complaints. Both the number of somatic symptoms and the persistence of symptoms are associated with co-occurring depression or anxiety disorders. It can be challenging to simultaneously address possible medical causes for physical symptoms while also considering an associated psychiatric diagnosis. In this article, strategies to improve the care and outcomes among these patients are described, including collaboration, education about the interaction between psychosocial stressors and somatic symptoms, regularly scheduled visits, focus on improving functional status, and evidence-based treatment of depression and anxiety.

Improving care for depression in obstetrics and gynecology: a randomized controlled trial.

OBJECTIVE: To evaluate an evidence-based collaborative depression care intervention adapted to obstetrics and gynecology clinics compared with usual care. METHODS: A two-site, randomized controlled trial included screen-positive women (Patient Health Questionnaire-9 score of at least 10) who met criteria for major depression, dysthymia, or both (Mini-International Neuropsychiatric Interview). Women were randomized to 12 months of collaborative depression management or usual care; 6-month, 12-month, and 18-month outcomes were compared. The primary outcomes were change from baseline to 12 months in depression symptoms and functional status. Secondary outcomes included at least 50% decrease and remission in depressive symptoms, global improvement, treatment satisfaction, and quality of care. RESULTS: Participants were, on average, 39 years old, 44% were nonwhite, and 56% had posttraumatic stress disorder. Intervention (n=102) compared with usual care (n=103) patients had greater improvement in depressive symptoms at 12 months (P<.001) and 18 months (P=.004). The intervention group compared with usual care group had improved functioning over the course of 18 months (P<.05), were more likely to have at least 50% decrease in depressive symptoms at 12 months (relative risk [RR] 1.74, 95% confidence interval [CI] 1.11-2.73), greater likelihood of at least four specialty mental health visits (6-month RR 2.70, 95% CI 1.73-4.20; 12-month RR 2.53, 95% CI 1.63-3.94), adequate dose of antidepressant (6-month RR 1.64, 95% CI 1.03-2.60; 12-month RR 1.71, 95% CI 1.08-2.73), and greater satisfaction with care (6-month RR 1.70, 95% CI 1.19-2.44; 12-month RR 2.26, 95% CI 1.52-3.36). CONCLUSION: Collaborative depression care adapted to women's health settings improved depressive and functional outcomes and quality of depression care. CLINICAL TRIAL REGISTRATION: ClinicalTrials.gov, www.clinicaltrials.gov, NCT01096316. LEVEL OF EVIDENCE: I.

Improving depression treatment for women: integrating a collaborative care depression intervention into OB-GYN care.

BACKGROUND: Women have higher rates of depression and often experience depression symptoms during critical reproductive periods, including adolescence, pregnancy, postpartum, and menopause. Collaborative care intervention models for mood disorders in patients receiving care in an OB-GYN clinic setting have not been evaluated. Study design and methodology for a randomized controlled trial of collaborative care depression management versus usual care in OB-GYN clinics and the details of the adapted collaborative care intervention and model implementation are described in this paper. METHODS: Women over age 18 years with clinically significant symptoms of depression, as measured by a Patient Health Questionnaire-9 (PHQ-9) score ≥10 and a clinical diagnosis of major depression or dysthymia, were randomized to the study intervention or to usual care and were followed for 18 months. The primary outcome assessed was change over time in the SCL-20 depression scale between baseline and 12 months. BASELINE RESULTS: Two hundred five women were randomized: 57% white, 20% African American, 9% Asian or Pacific Islander, 7% Hispanic, and 6% Native American. Mean age was 39 years. 4.6% were pregnant and 7.5% were within 12 months postpartum. The majority were single (52%), and 95% had at least the equivalent of a high school diploma. Almost all patients met DSM IV criteria for major depression (99%) and approximately 33% met criteria for dysthymia. CONCLUSIONS: An OB-GYN collaborative care team, including a social worker, a psychiatrist, and an OB-GYN physician, who met weekly and used an electronic tracking system for patients was the essential element of the proposed depression care treatment model described here. Further study of models that improve quality of depression care that are adapted to the unique OB-GYN setting is needed.

Presenting symptoms of women with depression in an obstetrics and gynecology setting.

OBJECTIVE: To describe the presenting symptoms of women with depression in two obstetrics and gynecology clinics, determine depression diagnosis frequency, and examine factors associated with depression diagnosis. METHODS: Data were extracted from charts of women screening positive for depression in a clinical trial testing a collaborative care depression intervention. Bivariate and multivariable analyses examined patient factors associated with the diagnosis of depression by an obstetrician-gynecologist (ob-gyn). RESULTS: Eleven percent of women with depression presented with a psychologic chief complaint but another 30% mentioned psychologic distress. All others noted physical symptoms only or presented for preventive care. Ob-gyns did not identify 60% of women with a depression diagnosis. Depression severity was similar in women who were or were not diagnosed by their ob-gyns. Bivariate analyses showed four factors significantly associated with depression diagnosis: reporting a psychologic symptom as the chief complaint or associated symptom (72% compared with 18.6%, P<.001), younger age (35.5 years compared with 40.8 years, P<.005), being within 12 months postpartum (13.9% compared with 2.8%, P<.005), and a primary care-oriented visit (72% compared with 30%, P<.001). Multivariable analysis showed that reporting a psychologic symptom (adjusted odds ratio [OR] 8.90, 95% confidence interval [CI] 4.15-19.10, P<.001), a primary care oriented visit (adjusted OR 2.46, 95% CI 1.14-5.29, P=.03), and each year of increasing age (adjusted OR 0.96, 95% CI 0.93-0.96, P=.02) were significantly associated with a depression diagnosis. CONCLUSION: The majority of women with depression presented with physical symptoms; most women with depression were not diagnosed by their ob-gyn, and depression severity was similar in those diagnosed and those not diagnosed. LEVEL OF EVIDENCE: III.