Clinical Review

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

OBG Manag. 2009 June;21(6):44-53

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

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IN THIS ARTICLE

5 steps to take when a patient wants to leave against your advice
Here are some causes of agitation
Commonly abused drugs and their effects

References

1. What does SIGECAPS stand for? Available at: www.acronymfinder.com/Sleep,-Interest,-Guilt,-Energy,-Concentration,-Appetite,-Psychomotor,-Suicidal-(mnemonic-for-characteristics-of-major-depression)-(SIGECAPS).html. Accessed May 18, 2009.

2. Chaudron LH, Pies RW. The relationship between postpartum psychosis and bipolar disorder: a review. J Clin Psychiatry. 2003;64:1284-1292.

3. Grigoriadis S, Romans S. Postpartum psychiatric disorders: what do we know and where do we go? Curr Psychiatry Rev. 2006;2:151-158.

4. Forray A, Ostroff RB. The use of electroconvulsive therapy in postpartum affective disorders. J ECT. 2007;23:188-193.

5. Sadock BJ, Sadock VA. Psychiatry and reproductive medicine. In: Kaplan HI, Sadock BJ, eds. Kaplan & Sadock’s Synopsis of Psychiatry: Behavioral Sciences/Clinical Psychiatry. 9th ed. New York: Lippincott Williams & Wilkins; 2003:868-878.

6. Friedman SH, Resnick PJ, Rosenthal M. Postpartum psychosis: strategies to protect infant and mother from harm. Curr Psychiatry. 2009;8(2):40-46.

7. American Psychiatric Association. Diagnostic and statistical manual of mental disorders. 4th ed. Text revision. Washington, DC: American Psychiatric; 2000.

8. Friedman SH, Stankowski JE, Sajatovic M. Bipolar disorder in women. The Female Patient. 2007;32:15-24.

9. Gentile S. Use of contemporary antidepressants during breastfeeding: a proposal for a specific safety index. Drug Saf. 2007;30:107-121.

10. Rahimi R, Nikfar S, Abdollahi M. Pregnancy outcomes following exposure to serotonin reuptake inhibitors: a meta-analysis of clinical trials. Reprod Toxicol. 2006;22:571-575.

11. Wisner KL, Zarin DA, Holmboe ES, et al. Riskbenefit decision making for treatment of depression during pregnancy. Am J Psychiatry. 2000;157:1933.-

12. Roberts LW, Hoop JG. Professionalism and ethics. Washington, DC: American Psychiatric Publishing; 2008.

13. Ohio Criteria for Commitment, Section 5122.01.

14. Harris LH, Paltrow L. The status of pregnant women and fetuses in US criminal law. JAMA. 2003;289:1697-1699.

15. Drugs, Police & The Law: Whitner vs. the State of South Carolina. June 23, 2004. Available at: www.drugpolicy.org/law/womenpregnan/whitnervsth_/. Accessed April 30, 2009.

16. Gray P. Prosecution of prenatal substance abuse allowed to stand in McKnight case. Available at: www.law.uh.edu/healthlaw/perspectives/reproductive/040202prosecution.pdf. Accessed April 30, 2009.

17. Parks AW. New mothers fight endangerment convictions. Public Justice Center. April 10, 2006. Available at: www.publicjustice.org/news/index.cfm?newsid=106. Accessed April 30, 2009.

18. Parks AW. Using cocaine while pregnant is not reckless endangerment. The Daily Record. August 4, 2006. Available at: www.publicjustice.org/pdf/Cruzdailyrecord.pdf. Accessed April 30, 2009.

19. American Pregnancy Association. Using illegal street drugs during pregnancy. May 2007. Available at: www.americanpregnancy.org/pregnancyhealth/illegaldrugs.html. Accessed April 30, 2009.

20. Neuspiel DR, Zingman TM, Templeton VH, et al. Custody of cocaine-exposed newborns: determinants of discharge decisions. Am J Public Health. 1993;83:1726-1729.

21. Friedman SH, Heneghan A, Rosenthal M. Disposition and health outcomes among infants born to mothers with no prenatal care. Child Abuse Negl. 2009;33:116-122.

22. Friedman SH, Heneghan A, Rosenthal M. Characteristics of women who deny or conceal pregnancy. Psychosomatics. 2007;48:117-122.

23. Miller LJ. Denial of pregnancy. In: Spinelli MG, ed. Infanticide: Psychosocial and Legal Perspectives on Mothers Who Kill. Washington, DC: American Psychiatric Publishing; 2003.

24. Bonnet C. Adoption at birth: prevention against abandonment or neonaticide. Child Abuse Negl. 1993;17:501-513.

25. Heroin withdrawal. Available at: www.addictionwithdrawal.com/heroin.htm. Accessed April 29, 2009.

26. Kwong TC, Ryan RM. Detection of intrauterine illicit drug exposure by newborn drug testing. Clin Chem. 1997;43:235-242.

27. Bada HS, Reynolds EW, Hansen WF. Marijuana use, adolescent pregnancy, and alteration in new born behavior: how complex can it get? J Pediatr. 2006;149:742.-

Fast Track

The differential diagnosis for altered mood in the post partum period includes depression, baby blues, post partum psychosis, and bipolar disorder

Untreated depression can become so severe that a woman begins to experience psychosis or suicidality

If a patient is irrational, wants to leave the hospital, and lacks the capacity to make such a decision, you may need to contact the hospital’s attorney and complete an emergency detention form

Among the criteria for substance dependence are tolerance to the drug, withdrawal when the drug is cut back or stopped, and continued use of the drug despite evidence of its dangers

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.