Failure to acknowledge psychiatric problems as legitimate grounds for medical attention.
that is as reliable and valid as those used in most medical treatment. Physicians are naturally reluctant to uncover problems for which there seems to be no solutions. There are effective treatments for psychiatric disorders, and they are straightforward to use in clinical practice. Although the newly enacted parity laws forbid discrimination by insurers against mental health care, gynecologists and their patients may have difficulty accessing mental health services. It is sometimes necessary for the physician and family to advocate strongly for necessary care. By incorporating the management strategies in this chapter into their practice, gynecologists can reduce clinical frustration and play a major role in improving the health and well-being of their patients.
Psychiatric Assessment In the past, the diagnosis of psychiatric disorders was based partially on hypotheses about a patient’s unconscious psychological conﬂicts, which cannot be verified (13). Current psychiatric diagnosis, as codified in the Diagnostic and Statistical Manual of Mental Disorders, fourth edition, text revision (DSM-IV-TR), produced and published by the American Psychiatric Association, is based on empirical, valid, and reliable evidence (9). The DSM-IV yields reliability comparable to that of diagnostic systems used in other areas of medicine, and its diagnoses strongly correlate with response to treatment. The criteria in DSM-IV are the basis for the diagnostic entities described in this chapter. The new edition, DSM-IV-TR, differs only in the explanations of some of the diagnoses and not in the diagnostic criteria themselves. The DSM-IV-PC is a special edition designed for the primary care provider. This volume is organized by initial signs and symptoms rather than psychiatric categories and uses algorithms and decision trees to facilitate the diagnostic process (9). The fifth edition of the DSM is scheduled for publication in 2013, and it might not contain changes of major importance for gynecology practice. Accurate diagnosis is absolutely critical to successful management, whether care is provided by a gynecologist or through referral to a mental health expert.
Approach to the Patient Although diagnostic criteria list signs and symptoms, the interaction with a patient should not be reduced to a series of rapid-fire questions and answers. A wealth of valuable information can be obtained from the patient’s spontaneous description of her concerns and from her responses to the physician’s open-ended questions (14). A patient who is encouraged to speak for several minutes before being asked to respond to specific questions will reveal information that is useful, even vital, to her care: a thought disorder, a predominant mood, abnormally high anxiety, a personality style or disorder, and attitudes toward her diagnosis and treatment. Such information may emerge only much later, or not at all, in a question-and-answer format (15,16). It is critical that the gynecologist neither jumps to diagnostic conclusions nor proceeds directly to therapeutic interventions. One study revealed that many primary care physicians, feeling that they have too little time or training to assess psychological symptoms, tend to minimize verbal interactions with patients and to rely on the prescription of psychotropic medications (17). Allowing a few moments for open-ended discussion does not mean that the physician and the other patients awaiting care are to be held hostage by an overly talkative patient. The clinician can tell the patient with multiple, detailed symptoms how much time is available for the current appointment, invite her to focus on her most pressing problem, and offer a future appointment to continue the account.
Psychiatric Referral Many gynecologists consider referral to a mental health professional, particularly a psychiatrist, to be a delicate matter. The first question is when to refer, followed by how to refer and to whom. Most mild psychiatric disorders are treated by nonpsychiatric physicians, who often prescribe antidepressants and anxiolytic medications (18). Psychiatric disorders often are overlooked, misdiagnosed, or mistreated in primary care practice. The factors that determine the decision to refer are the:
Nature and severity of the patient’s disorder
Expertise of the gynecologist
Time available in the gynecologic practice
Gynecologist’s degree of comfort with the patient and the disorder
Availability of mental health professionals