Brief reportAddressing depression in obstetrics/gynecology practice☆
Introduction
Recent studies suggest that the prevalence of mental disorders in obstetrics and gynecology (OB/GYN) practices ranges from 4–22% for major depression, 13–40% for any depressive disorder and 20–48% for any mental health or substance abuse disorder, with higher rates found in clinics serving low-income women [1], [2], [3], [4]. In addition, there is evidence that certain reproductive conditions may be specifically associated with depressive symptoms [5], [6], [7], [8], [9]. Currently, in the absence of targeted screening programs, depression is infrequently recognized and treated in OB/GYN practices. In a population-based retrospective study in Olmsted County, Minnesota, Bryan et al. found a 3.7% incidence of diagnosed or treated postpartum depression compared to reported prevalence rates of 7–15% [10]. A recent chart review of depressed pregnant women found reports of treatment for only 23% of those women diagnosed with depression [2]. In addition, Spitzer and colleagues’ large multi-site study that demonstrated the validity of a brief depression screening tool in OB/GYN practice also showed that clinicians rarely initiated treatment based on the results of the questionnaire [3].
While successful efforts to improve the recognition and treatment of depression have been demonstrated in internal medicine and family practice [11], [12], [13], [14], no similar efforts have been documented in obstetrics and gynecology practices. Understanding opportunities for improved recognition and treatment of depression is compelling given that obstetrician/gynecologists provide a significant amount of primary and preventive services for women. OB/GYNs provide the majority of non-illness visits for women under age 65 years and about one-third of all visits for women age 18 to 45 years (not including pregnancy care) [15]. OB/GYNS often serve as primary care physicians for many women, with 1998 national survey finding that 41% of women use an OB/GYN and a generalist (family physician or internist) for primary care and 7% use an OB/GYN alone [16]. Young, low-income women who are at the greatest risk for depression [17] are also the most likely to depend on an OB/GYN practice (often a hospital or community clinic) for their primary care needs [18].
Specialized adaptation may be needed to promote successful primary care interventions to OB/GYN practice. In general, proven programs build on a chronic disease care model [19], combining components such as routine screening, specific personnel to assist in patient support, education and follow-up, and timely referral or collaboration with specialty mental health care [12]. Studies using this collaborative model of chronic disease care have shown the ability to decrease depressive symptoms, and to improve individual functioning and even household wealth [11], [13], [20], [21], [22].
Applying these care models in OB/GYN practice requires consideration of the diversity of OB/GYN settings as well. Data from the American Medical Association’s socioeconomic monitoring survey show that most obstetrician/gynecologists work in self-employed solo or group practices (68.1%), with the remainder serving as an employee of centers, hospitals, academic organizations or government [23]. Data from nationally representative surveys of visits to obstetrician/gynecologists in private offices and hospital outpatient and community clinics (the National Ambulatory Medical Care Survey and the National Hospital Ambulatory Care Survey) show that over 90% of OB/GYN visits made by American women occur in private office settings [24]. However, the data also show that OB/GYN clinics serve a substantially different population of women, including higher proportions of women who are poor and belong to racial/ethnic minority groups. OB/GYN clinics also differ widely from private physician offices both in staffing and procedural routines. Further exploration of the potential for improving depression care in these diverse settings and populations is critically needed.
To meet this need, we conducted a study to explore the feasibility and acceptability of a depression screening and care management intervention in three diverse OB/GYN settings: a suburban office practice, a hospital outpatient clinic, and a suburban community clinic. Depression screening was implemented at each site and a care management intervention offered to all depressed women. The data from this project were used to address the following questions: 1) What is the prevalence of depression among OB/GYN outpatients identified through routine screening procedures? 2) Are these women receiving treatment? 3) Is a care management intervention to improve treatment of depression in OB/GYN outpatients feasible and acceptable; and 4) What do patients perceive as barriers to obtaining care?
Section snippets
Setting
Seeking to include examples of different OB/GYN practice settings, we conducted the screening and care management intervention in three practices. The first was a suburban office practice of ten OB/GYNs that predominantly served white women of all ages. The second was an urban hospital outpatient clinic that provides comprehensive OB/GYN care to a young, racially diverse, and primarily low-income population. The clinic is staffed by OB/GYN residents who are assigned to teams for the duration of
Analyses
From the screening data, we describe the prevalence of depression and recent mental health care. We conducted multivariate logistic regressions to determine whether the site differences in the prevalence of depression and mental health service data remained after controlling for the limited number of sociodemographics and health care variables available on the screening form.
Screening
A total of 1090 women completed the depression screen, 708 patients in the office practice, 293 patients in the hospital outpatient clinic and 89 in the community clinic. Of these, 891 (81.7%) patients consented to research review of their screening results, and there was no difference by site in the proportion that consented to research review. As shown in Table 1, women in the hospital and suburban clinics were younger, more often minority, and more likely to be seen for pregnancy care. In
Discussion
Our study demonstrates the feasibility of depression screening and a care management intervention within diverse obstetrics and gynecology settings. The screening results illustrate differences in the clients served and rates of depression that may occur across different OB/GYN practices, with the highest prevalence of depressive symptoms found among hospital clinic patients (20%). About half of depressed women reported recent mental health care, with such care being less likely among women who
Conclusions
This study demonstrates that depression screening and care management interventions developed in primary care settings can be adapted for diverse obstetrics and gynecology practices. Routine screening found 8–20% of women with elevated depression symptoms, and 48–63% had not had recent mental health care. The intervention achieved good participation rates and high satisfaction scores from patients, and a substantial number of women gained access to new services. Physician attitudes, patient’s
Acknowledgements
The authors thank Catherine Beurchner, M.D.; Pam Dodge, R.N.; Dennis English, M.D.; Traci Salopek, MSW; Margaret Watt-Morse, M.D.; and the staff and patients at the three ob/gyn practices for their assistance in this project.
References (31)
- et al.
Unmet mental health needs of women in public sector gynecologic clinics
Am J Obst Gynec
(1998) - et al.
Validity and utility of the PRIME-MD Patient Health Questionnaire in assessment of 3000 obstetric-gynecologic patientsthe PRIME-MD Patient Health Questionnaire Obstetrics-Gynecology Study
Am J Obst Gynec
(2000) - et al.
Prevalence and predictors of premenstrual dysphoric disorder (PMDD) in older premenopausal women. The Harvard Study of Moods and Cycles
J Affective Disord
(2002) - et al.
Trends in women’s health services by type of physician seen: data from the 1985 and 1997–98
NAMCS; Women’s Health Issues
(2002) - et al.
Managed care and women’s healthaccess, preventive services, and satisfaction
Women’s Health Issues
(2001) - et al.
Designing and implementing a primary care intervention trial to improve the quality and outcome of care for major depression
Gen Hosp Psych
(2000) - et al.
Women’s satisfaction with primary careA new measurement effort from the PHS National Centers of Excellence in Women’s Health
Women’s Health Issues
(2000) - et al.
The detection and treatment of psychiatric disorder and substance use among pregnant women cared for in obstetrics
Am J Psychiatry
(2001) - et al.
Onset and persistence of postpartum depression in an inner-city maternal health clinic system
Am J Psychiatry
(2001) - et al.
Characteristics of women with premenstrual dysphoric disorder (PMDD) who did or did not report history of depressiona preliminary report from the Harvard study of moods and cycles
J Womens Health and Gender Based Medicine
(2001)
Epidemiology of depression throughout the female life cycle
J Clin Psychiatry
Psychologic distress during the menopausal years in women attending a menopause clinic
Inter J Psychiat Med
Incidence of postpartum depression in Olmsted County, MinnesotaA population-bases, retrospective study
J Reproduc Med
Impact of disseminating quality improvement programs for depression in managed primary carea randomized controlled trial
JAMA
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This study was supported by the Staunton Farms Foundation (Scholle); the National Institute of Mental Health (MH30915, Kupfer); and the Federal Office on Women’s Health.