Patients who are suicidal, homicidal, or acutely psychotic should be referred immediately to a psychiatrist, and often are accompanied to the appointment (19). The primary provider should refer patients for psychiatric evaluation when the diagnosis is not clear or when the patient fails to respond to initial treatment. The gynecologist can resume responsibility for ongoing care of many patients after their initial or periodic assessment by a psychiatrist.
How to Refer Some clinicians fear that patients will be insulted or alarmed by a psychiatric referral. Following are techniques that decrease the discomfort of both the gynecologist and the patient and enhance the likelihood of success (19). The referral should be explained on the basis of the patient’s own signs, symptoms, and level of distress. For a patient suffering from clinical depression, for example, this might be difficulty sleeping, loss of appetite, and lack of energy. For a patient with an anxiety disorder, it might be palpitations, shortness of breath, and nervousness. For a patient with mild Alzheimer’s disease, it might be forgetfulness or frightening episodes in which she finds herself in a neighborhood she does not recognize. With the advent of treatments that may slow dementia, these referrals are easier and more meaningful because there is now some hope for effective intervention.
When a somatizing (psychosomatic) disorder is suspected, the gynecologist should emphasize the difficulty of living with symptoms in the absence of a definitive diagnosis and treatment rather than the hypothesis that the symptoms have a psychological basis (19): 1.
“It is very stressful to be suffering while we can’t pinpoint the problem. I would like you to see one of our staff who specializes in helping people cope with these difficult situations.” 2.
“It must be difficult to function when you have been so sickly all your life, have seen so many doctors, have had so many diagnostic tests and medical treatments, and still don’t have an answer or feel well.”
It is counterproductive to convey the idea that because the diagnostic process has not revealed a specific disorder, the problem must be “in the patient’s head.” It alienates the patient. It is never possible to rule out an organic cause with absolute certainty; and diseases “in the head” are real diseases (19).
Although suicidal and homicidal behaviors are absolute indications for referral, many physicians fear that questioning patients about these behaviors will provoke them. That is not the case (12). An open discussion of impulses to hurt oneself or someone else helps the patient to regain control, recognize the need for mental health care, or agree to emergency interventions such as psychiatric hospitalization, whereas avoiding the subject intensifies the patient’s feelings of isolation. The management of suicidal behavior is addressed later in this chapter in the section on mood disorders.
Likewise, the possibility of psychosis need not be avoided. Most patients with psychotic disorders have had previous experience with psychiatric referral. Their psychotic symptoms are often distressing, so treatment is an appealing option (19). They can discuss hallucinations and delusions quite matter-of-factly. The rare patient who comes to a gynecologist in the midst of a first episode of psychosis is likely to be frightened by her symptoms and willing to accept expert consultation.
Despite increasing public sophistication about mental illnesses and psychiatric care, some patients believe that any mention of mental health intervention implies that they are either “crazy” or that the referring physician is convinced that their physical symptoms are imaginary or feigned. It is helpful to state explicitly that this is not the case. Making the real reason for the referral clear and founded in signs and symptoms obvious to the patient will nearly always allay anxiety over a psychiatric referral (19).
It is not acceptable to refer a patient to a psychiatrist without informing her in advance and obtaining her consent, unless she is acutely psychotic, functionally incompetent, or in the throes of a suicidal or homicidal emergency. Even under those circumstances, it is highly preferable to be straightforward. A referral that begins with an unexpected clinical encounter with a psychiatrist is unfair to both the psychiatrist and the patient and is unlikely to result in a satisfactory outcome (17–19).