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Clinical Reviews


Does your OB patient have a psychiatric complaint? And can you manage it?

Here’s how to handle 5 challenges, including postpartum depression, an attempt to leave the hospital against advice, and denial of pregnancy

June 2009 · Vol. 21, No. 06

IN THIS ARTICLE

The authors report no financial relationships relevant to this article.

There’s a full moon tonight—and you’re the obstetrician on call. Not that you should expect any more funny business than usual. Despite stories of werewolves and other deviants coming out of the woodwork, there is no “full moon effect”—at least not one that can be documented. Nevertheless, chances are good that you will encounter at least one of the following psychiatric challenges as you end your day in the clinic and move on to an extended vigil:

  • postpartum depression
  • leaving against medical advice
  • agitation
  • antenatal illicit drug use
  • denial or concealment of pregnancy.

In this article, we describe the management of these challenges and make recommendations to help increase your comfort level with patients who exhibit psychiatric problems. In some situations, our suggestions may help you manage the problem without a psychiatric consult.

Postpartum depression

CASE 1: Is it just the blues?

It is the end of your day in the clinic, and your last patient is a 30-year-old G3P3 who is 6 weeks postpartum. She describes repeated tearful episodes over the course of several weeks, decreased concentration, and poor appetite. She feels guilty because she is tired all the time and not bonding with her baby. She denies having suicidal or homicidal thoughts, or any hallucinations. She had expected her energy to return to normal over the first few postpartum weeks, but it has not. She is worried because she will soon be returning to work as a medical resident.

Does this patient have postpartum depression? Or is it another condition with overlapping symptoms?

If a mother tells you that she is suicidal or having thoughts of harming her child or others, she should be sent immediately to the nearest emergency department for psychiatric evaluation. Short of such a dramatic situation, how do you know when you should manage a patient’s depression on your own and when she should see a psychiatrist? Thorough assessment is the key.

Don’t mistake transient feelings for depression

Transient feelings of sadness, bereavement, and grief are not the same as depression, which must last 2 weeks or longer to confirm the diagnosis.

A quick mnemonic for symptoms of depression is SIG: E CAPS (as if writing a prescription for energy capsules) (TABLE 1).1 This mnemonic helps remind you to assess the patient’s sleep, interest, guilt, energy, concentration, appetite, and psychomotor function, as well as identify any suicidal ideation.

It is important to assess a woman’s sleep and appetite in addition to mood. However, differences may be difficult to ascertain due to normal changes in the postpartum period. One useful question is whether the mother is able to sleep when the baby sleeps. If she isn’t, this wakefulness may be a symptom of depression.

The Edinburgh Postnatal Depression Scale is an easy, 10-question screening tool that is completed by the patient; it can be used both during pregnancy and postpartum. It is available on the Web at a number of sites, including www.fresno.ucsf.edu/pediatrics/downloads/edinburghscale.pdf.

TABLE 1

SIG: E CAPS—a mnemonic to assess for depression1

Decreased (sometimes increased) Sleep

Decreased Interests

Feelings of Guilt

Decreased Energy

Decreased Concentration

Decreased (sometimes increased) Appetite

Psychomotor retardation, slowness

Suicidal thoughts, plans, or intent

Differential diagnosis

Besides postpartum depression, the differential diagnosis for altered mood in the postpartum period includes several entities.

Baby blues generally occurs quite soon after birth and resolves within 2 weeks. It involves crying, emotional lability, and irritability.2 It occurs in around 50% to 75% of new mothers (compared with postpartum depression, which affects 10% to 20%).3-5

Postpartum psychosis often involves the onset of psychotic symptoms within 1 week after delivery. The patient may exhibit both mood symptoms and psychosis. For example, she may believe that the baby is not hers or hear voices commanding her to kill the baby or warning her not to trust her healthcare providers.6 Postpartum psychosis has a prevalence of about 0.2%.3-6

This psychosis can be organic in nature or can arise from a preexisting mood disorder or schizophrenia. Because treatment varies, depending on the cause, a thorough medical workup is needed.

Bipolar disorder may present as depression, but it also consists of manic periods of elevated, expansive, or irritable mood that last several days to weeks. Many symptoms appear to be the opposite of depression, such as increased energy and elevated self-esteem.7,8

It is important to consider bipolar disorder in the differential diagnosis. If a woman who has unrecognized bipolar disorder is given an antidepressant, a manic state could be precipitated. Women who have bipolar disorder require different drugs than women who have depression only, and they should be evaluated by a psychiatrist, at least initially.

Start treatment as soon as possible

Once you confirm that the patient has postpartum depression—and not another psychiatric disorder—prescribing an antidepressant may be the next step. Keep in mind that these drugs take several weeks before their benefits are felt. Therefore, it is best to start an antidepressant before depression becomes severe. The mother may also benefit from psychotherapy.

The selective serotonin reuptake inhibitor sertraline (Zoloft) is a reasonable first choice in pregnancy and lactation when the depression is of new onset.9,10 Start it gradually (e.g., 25 mg for sertraline, which can cause nausea if it is initiated too rapidly) and titrate it over time, if necessary. When there is comorbid anxiety, it sometimes is helpful to prescribe low dosages of lorazepam (Ativan, Temesta) on an as-needed basis, while the patient is waiting for the antidepressant to “kick in.” Also consider follow-up—do you plan to follow her frequently or refer her to psychiatry?

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Remember to discuss the risks, benefits, side effects, and alternatives of antidepressant medication—and document that you have done so. In addition, discuss medication specifically in regard to lactation. Consultation with pediatrics is optimal.

Adjunctive or alternative options include psychotherapy, group therapy, and music therapy. Referral to a psychiatrist is warranted if the patient does not respond to the initial antidepressant agent.

Also be aware that untreated depression can become so severe that a woman can begin to experience psychosis, warranting rapid referral. Also refer any woman who reports a complex history of previous depression—unless the previous episode was easily controlled with a medicine safe for use during pregnancy and lactation.

If the patient is not lactating, a greater range of agents may be considered. (A full discussion of the risks and benefits of antidepressant use in pregnancy is outside the scope of this article. The interested reader is referred to an article on the subject by Wisner and colleagues.11)

CASE 1 RESOLVED

A comprehensive discussion with the mother reveals that she is suffering from postpartum depression. No history of bipolar or psychotic symptoms is discovered. After discussing treatment options, you prescribe sertraline. Over the next 2 months, the patient’s symptoms improve, and she bonds with her infant and successfully returns to work. She is also referred to a psychologist to work through some underlying issues.

Leaving against medical advice

CASE 2: Patient threatens to leave the hospital

At midnight, you are paged to attend to a 32-year-old G1P0 at 27 weeks’ gestation who is threatening to leave against medical advice. She was admitted earlier in the day with uncontrolled gestational diabetes and is refusing her insulin.

How do you respond?

Use the relationship that you have established with this patient to the best of your ability. Make sure that you have explained fully, and in language she can easily comprehend, the reasons she needs to stay for treatment.

Don’t overlook the obvious, either: Why does she want to leave? Sometimes the reason makes sense (e.g., one mother wanted to leave to protect her daughter from an abusive husband). Other reasons may be related to psychosis, addiction, lack of sleep in the hospital, or a desire to smoke, drink, or use drugs. Can you convince her to postpone her decision until morning, when her physician will be available?

It is important to document in the medical record your explanations and her reasoning. Can she coherently verbalize an understanding of the consequences of her decision to leave, including the risks and implications to herself and the fetus?12 Can she describe alternatives and the reasoning against them?

If she is able to do these things, and you find her thought processing and reasoning to be lucid, then she may have the capacity to leave against medical advice. Keep in mind that rational persons do have the right, constitutionally, to refuse treatment, even if doing so will lead to morbidity. (A Jehovah’s Witness who refuses treatment is the typical example.12) Contact the hospital’s attorney—tonight—and document that you did so. The attorney may recommend that the patient sign a letter stating that she recognizes the maternal and fetal risks of leaving.

Sometimes a patient must be held against her will

Some mothers lack the capacity to refuse treatment. They may be unable to verbalize an understanding of the situation and its risks. Their reasoning may be abnormal, with disorganized or delusional thinking, or both. The patient may be tangential or talk “in circles” rather than answer your questions.

Try to ascertain whether mood symptoms are contributing to her irrational thinking. For example, is her rationale for going home—“just to be with my husband because I don’t want to be alone”—due to her depression, despite the risk to herself and the fetus? Try to be flexible and creative. For example, you could call the husband and ask him to come to the hospital to sit with the patient.

Is the patient psychotic? For example, does she believe she has to leave now because the staff has been replaced by aliens who plan to kill her and her fetus? If so, you have the authority to continue her hospitalization—but contact the psychiatry department for medication recommendations. A urine toxicology screen would also be prudent.

If the patient is irrational and lacks the capacity to decide whether to stay or leave, document your conversation with her, as well as the reasoning behind your decision to intervene further. Other steps include:

  • contacting the hospital’s attorney
  • completing an emergency detention form
  • calling security
  • ensuring that the patient’s environment is safe for her and others (TABLE 2).13

If the patient is psychotic or delirious, look for organic causes and treat her to maintain her safety (see Case 3).

TABLE 2

5 steps to sound management of a patient who wants to leave
against medical advice

1. Ask the patient why she wants to leave now

2. Inform her of the risks to herself and to her fetus

3. Ask her to verbalize the risks to herself and to her fetus

4. Determine whether the patient’s request is rational

  • If it is, call the hospital’s attorney at once; forms may need to be signed
  • If it isn’t, and she is not convinced to stay, complete an emergency detention form; in addition, you may need to contact psychiatry, security, and the hospital’s attorney

5. Document the medical explanation and reasoning in the chart

Continued...
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