On the alert: mood disorders during 2020 stressors

 

The pandemic and its associated economic disruption are stressful. Associated worries over what could happen can be overwhelming and cause strong emotions. Add the needed public health actions such as social distancing, and many people can feel isolated and lonely.[1] Any accompanying or pre-existing depression and anxiety are risks in themselves. These emotions can place women at greater risk of experiencing an unintended pregnancy, compared to women without depression and anxiety.[2],[3],[4],[5] The role of the reproductive health provider should, at a minimum, entail screening for common mood disorders, differentiating sub-clinical symptomatology from a diagnosable disorder, ruling out differential diagnoses, and providing or referring for further psychiatric evaluation and treatment when indicated, write Kelly Stidham Hall and Julia Steinberg in Contraceptive Technology.[6]

Among the leading causes of disability worldwide, depression is commonly experienced by patients in their reproductive years.[7],[8] Compared to men, women in the United States are approximately 1.5 to 3 times more likely to experience depression.⁹ One-fifth of adult women in the United States will experience a depressive disorder in their lifetime; one in ten will experience one each year; one in nine will experience postpartum depression.[9]

Unfortunately, detection and treatment rates for depression and related disorders are low among reproductive-aged women,[10] as are rates of mental health service use.[11] Recent population-and clinic-based studies have suggested that less than half of pregnant and non-pregnant reproductive-aged U.S. women with a major depressive episode or those meeting criteria for clinical depression receive a mental health diagnosis or treatment, even though the majority (e.g. >70%) have had contact with a health provider in the last year.⁹ Compared to white women, black and Hispanic women are even less likely to receive a mental health diagnosis or treatment.[9],[12]

The causes of mood disorders are not fully understood. Clinical studies of depression and anxiety suggest that deficiencies in neurotransmitters that affect mood are likely involved.[13] But it is apparent that psychosocial stressors­­­—such as a pandemic and financial troubles—may further contribute to or exacerbate the onset and symptomatology of a mood disorder. Gene-environmental interactions exacerbate these risks, as biological dysfunction associated with the stress process is believed to result in altered neuronal size, functioning, repair capabilities, production of new neurons, and reduced hippocampus volume and neurocircuitry changes as a result of elevated cortisol—all of which may contribute to depression.

Clinical Management of Depression In Reproductive Health Care Settings

Patients’ mental health status can have an impact on their contraceptive behaviors. Thus, detecting and diagnosing of depression and related disorders is not only important in its own right but may help patients to achieve their sexual and reproductive health goals, advise Contraceptive Technology authors Hall and Steinberg.

Patients are likely to feel more comfortable and open to discussion with providers who exude patience, empathy, and a non-judgmental tone—qualities found in reproductive health providers, whose focus is often on patients’ health promotion and disease prevention. Reflective listening, use of open-ended questions, and simple educational statements can normalize the experience, reduce stigma, and foster trust. For example, a statement like, “Depression is one of the most common issues affecting reproductive-aged patients, and so I like to check in with all my patients about their own mental health status,” may be an effective approach to initiate a conversation, whereas directive, confrontational questions should be avoided.

Subtle cues of an underlying mood or anxiety disorder may be detected through careful observation of a sad voice, anxious expressions, or lethargic posture. Health providers should be attuned to transference (i.e., feeling down, sad, or upset after seeing a patient with depression or anxiety) and take the opportunity to reflect on their own feelings, emotions, and mood during and after the clinical encounter.[14] Helping a patient to understand that her mental health is as important as her reproductive health and that the two are interrelated may facilitate honesty, trust, and effective communication.

Assessment of personal or family risk factors for new, recurring, or chronic mental health conditions begins with the past and family medical histories, including prior psychiatric diagnoses, cognitive behavioral and/or pharmacologic treatments, hospitalizations, suicide attempts, and social history for co-occurring issues like substance use and violence, write Hall and Steinberg. Suspicions of an undiagnosed or diagnosed mental health issue may arise as early during the interview as the history of present illness. Clinical presentations of mood disorders in reproductive health settings may be directly related to depression symptomatology (e.g., sad or depressed mood) but may also include more indirect presentations. An underlying problem may present with multiple and vague complaints; non-specific symptoms or pain-related syndromes, such as non-specific vulva, pelvic, vaginal, coital, or menstrual-related pain, headaches; or gastrointestinal disturbances. If so, the history of present illness provides a moment to assess co-occurring mental health symptoms, including their onset, severity, and degree of functional impairment.

Abbreviated screens are the most feasible options for busy clinical practices where large volumes of patients are seen and time per patient is limited. The two-item Patient Health Questionnaire (PHQ-2), which is a validated shortened version of the PHQ-9 used to assess “little interest or pleasure in doing things” or “feeling down, depressed or hopeless” has documented high sensitivity (83%) and specificity (92%) rates or detecting major depressive disorder.[15]

Patient Health Questionnaire 2 (PHQ-2)

Over the past 2 weeks, how often have you been bothered by any of the following problems	Not at all	Several days	More than half of the days	Nearly every day
Little interest or pleasure in doing things	0	1	2	3
Feeling down, depressed, or hopeless	0	1	2	3

Similarly, commonly used mnemonics offer easy-to-remember guides for assessing diagnostic symptoms. For instance, with the mnemonic “SIG E CAPS,” a positive screen would entail reports of at least five of the following symptoms present for at least 2 weeks, all of which represent DSM-5 criteria:

• Sleep – increased or decreased (if decreased, often early morning awakening)
• Interest – decreased
• Guilt/worthlessness”
• Energy – decreased or fatigued
• Concentration/difficulty making decisions
• Appetite and/or weight increase or decrease
• Psychomotor activity – increased or decreased
• Suicidal ideation

Differential diagnoses of patients presenting with new onset mental health symptoms in reproductive health contexts may include pregnancy, reproductive endocrine conditions that cause estrogen deficiency, and chronic diseases like hypothyroidism, diabetes mellitus, anemia, cancer, and multiple sclerosis. These differential diagnoses are not uncommon among reproductive-aged women and can cause mood-related symptoms that mimic depression. Moreover, medications such as glucocorticoids and GnRH analogues can cause mood symptoms. Laboratory evaluation to help rule out such alternative diagnoses may include serum testing for complete blood counts, basic metabolic panel, fasting glucose, fasting lipid profile, prolactin, and thyroid stimulating hormone, as well as urine testing for pregnancy.

The role of the reproductive health provider should, at a minimum, entail screening for common mood disorders, differentiating sub-clinical symptomatology from a diagnosable disorder, ruling out differential diagnoses, and providing or referring for further psychiatric evaluation and treatment when indicated.

For a clinical diagnosis of a mood or anxiety disorder, typically a more comprehensive, formal structured psychiatric interview, such as the Composite International Diagnostic Interview or the Structured Clinical Interview for DSM, is required and should be conducted by a trained mental health professional.[16] Having readily available materials and information on local social work counselors, psychology or psychiatric services, and insurance or medication assistance programs can help providers further address patients’ mental health needs. Any patient exhibiting suicidal ideation or other severe symptoms should be assessed with a suicide screening instrument and immediately referred to specialized or emergency care.[17]

[1] Centers for Disease Control and Prevention. Pandemics can be stressful. Accessed July 23, 2020. At: https://www.cdc.gov/coronavirus/2019-ncov/daily-life-coping/managing-stress-anxiety.html

[2] Steinberg JR, McCulloch CE, Adler NE. Abortion and mental health: Findings from the National Comorbidity Survey-Replication. Obstet Gynecol 2014;123:263–270.

[3] Steinberg JR, Russo NF. Abortion and anxiety: What’s the relationship? Soc Sci Med 2008;67:238–252.

[4] Hall KS, Kusunoki Y, Gatny H, Barber J. Unintended pregnancy risk among young women with psychological stress and depression symptoms. Soc Sci Med 2014;100:62–71..

[5] Brooks TL, Harris SK, Thrall JS, Woods ER Association of adolescent risk behaviors with mental health symptoms in high school students. J Adolesc Health 2002;31:240–46.

[6] Hall KS, Steinberg J. Mental health and contraception. In: Hatcher RA, Nelson AL, Trussell J, Cwiak C, Cason P, Policar MS, Edelman A, Aiken ARA, Marrazzo J, Kowal D, eds. Contraceptive technology. 21st ed. New York, NY: Ayer Company Publishers, Inc., 2018.

[7] Kessler RC. Epidemiology of women and depression. J Affect Dis 2003;74:5–13.

[8] Kessler RC, Berglund P, Demler O, Jin R, Koretz D, Merikangas KR, et al. The epidemiology of major depressive disorder: Results from the National Comorbidity Survey Replication (NCS-R). JAMA 2003;289:3095–3105.

[9] Harvard Medical School. National Comorbidity Survey. 2009. www.hcp.med.harvard.edu/ncs/index.php. Accessed September 27, 2013.

[10] Ko JY, Farr SL, Dietz PM, Robbins CL. Depression and treatment among US pregnant and non-pregnant women of reproductive age, 2005-2009. J Women’s Health 2012;21:830–6.

[11]Wang PS, Lane M, Olfson M, Pincus HA, Wells KB, Kessler RC. Twelve month use of mental health services in the United States. Arch Gen Psychiatry 2005;62:629–640.

[12] Carrington CH. Clinical depression in African American women: Diagnosis, treatment and research. J Clin Psychol 2006;62:779–91.

[13] American Psychiatric Association. Diagnostic and statistical manual of mental disorders, 5th edition. Text revised. Washington, DC: APA. 2013.

[14] Mann JJ. The medical management of depression. NEJM 2005;353:1819–34..

[15] Kroenke K, Spitzer RL, Williams JB. The patient health questionnaire-2: validity of a two-item depression screener. Med Care 2003;41:1284–92.

[16] American Psychiatric Association. Diagnostic and statistical manual of mental disorders, 5th edition. Text revised. Washington, DC: APA. 2013.

[17] McDowell AK, Lineberry TW, Bostwick JM. Practical suicide-risk management for the busy primary care physician. Mayo Clin Proc 2011;86:792–800.