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Journal of Midwifery

� 2010 by the AmericIssued by Elsevier Inc.

Managing Mental Health Conditions in Primary Care SettingsBarbara Hackley, CNM, MSN, Chanchal Sharma, PsyD, Angela Kedzior, MD,and Shared Sreenivasan, LMSW

Depression is one of the most commonly encountered conditions in women’s health, but many providers lackthe knowledge and skills needed to identify and manage depression in primary care settings. This article dis-cusses strategies that can improve the identification and treatment of depression. In addition, it describes howthese strategies were incorporated into an urban inner-city health center. These strategies used in this setting canbe adapted for use in either comprehensive health care centers or in practices providing primarily obstetric andgynecologic services. J Midwifery Womens Health 2010;55:9–19 � 2010 by the American College of Nurse-Midwives.

keywords: depression, screening, treatment

INTRODUCTION

Mental health conditions are reported to be the leadingcause of disability worldwide.1 Rates are higher forwomen than men, for minorities than whites, and for thoseliving in poverty, making mental health disorders some ofthe most commonly encountered conditions in women’shealth.1 However, because of the lack of availability andpoor insurance coverage of mental health services, manyindividuals do not receive needed care. It has been esti-mated that only 23% of those who need treatment receivecare; treatment rates are even lower for the uninsured, un-derinsured, low income, and ethnic minority populations.1

In order to improve the mental health of women in theircare, providers must be comfortable in their ability to iden-tify and manage depression. However, because the need isso great, many providers are fearful that they will not havethe knowledge, skills, resources, or time to meet the de-mand. This article will discuss screening and managementstrategies that can be used in both comprehensive healthcare centers that provide general medical, gynecologic,and prenatal care, and in practices providing primarily ob-stetric and gynecologic services. In addition, it will de-scribe how these strategies were implemented by a teamof adult and women’s health providers, social workers,and mental health specialists in an urban communityhealth center in order to maximize service delivery.

SCREENING

The diagnosis of depression is often missed in primarycare practices. It has been estimated that primary care cli-nicians fail to identify depression 50% to 70% of the time.2

nce to Barbara Hackley, CNM, MSN, Assistant Direc-, Montefiore South Bronx Health Center for Children &Professor, Yale University School of Nursing, 215

eld, CT 06824. E-mail: barbara.hackley@yale.edu

& Women’s Health � www.jmwh.org

an College of Nurse-Midwives

One reason is that screening rates are low. Only 44% ofobstetricians in one recent study routinely screened allwomen in their care for depression.3 Another reason isthat women may present with somatic complaints ratherthan feelings of sadness. Women with more than five med-ical visits per year, or those who report multiple unex-plained symptoms, weight gain or loss, sleep problems,fatigue, relationship problems, or stress should be sus-pected of having undiagnosed depression.2

Evidence suggests that the prevalence of depression ap-pears to be similar in pregnant and postpartum womencompared to women at other stages of their lives.4,5 In a re-view of 50 high-quality studies, the Agency for HealthcareResearch and Quality reports that point prevalence ratesfor minor and major depression ranged from 8.5% to11% in pregnancy and 6.5% to 12.9% in the first year post-partum.4 While this review found that the rate of depres-sion in women was unaffected by pregnancy status,a more recent study of more than 43,000 women reportedthat postpartum women were at a higher risk of developingmajor depression compared to nonpregnant women (ad-justed odds ratio [AOR], 1.52; 95% confidence interval[CI], 1.07%–2.15%).6 However, major depression wascommon in all groups, affecting 8.1% of nonpregnantwomen, 8.4% of pregnant women, and 9.3% of postpar-tum women.6 Consequently, universal screening for de-pression should be incorporated into routine care for allwomen without reference to pregnancy status, offered atleast annually and more frequently if a woman’s presenta-tion raises the suspicion that she may be depressed.

CHOICE OF SCREENING TOOLS

A number of instruments are available to screen for de-pression. Some of the most commonly used include theCenter for Epidemiological Studies–Depression Scale(CES-D), the Patient Health Questionnaire (PHQ-9),Beck Depression Inventory (BDI), and the Edinburgh

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1526-9523/10/$36.00 � doi:10.1016/j.jmwh.2009.06.004

Table 1. Two-Question Screen for Depression

Over the previous month, have you been bothered by:1. Little interest or pleasure in doing things?2. Feeling down, depressed, or hopeless?

Source: Arroll et al.8

Postnatal Depression Scale (EPDS). These screening in-struments have been reported to have good sensitivity(0.8–0.9) and fair specificity (0.7–0.85) for identifying de-pression; no one test appears to be more accurate than an-other.5,7 Most take 5 to 10 minutes to complete, are writtenat a sixth-grade level, and vary in length from 9 to 21items.7

Clinicians may choose to verbally screen their patientsinstead of using a questionnaire. Incorporating two ques-tions into the history, one about mood, and the other aboutanhedonia (loss of pleasure) has been found to be useful inidentifying individuals with depression (Table 1). A studyof more than 421 individuals seen in primary care prac-tices found that this verbal 2-question screen had a sensitiv-ity and specificity of 97% and 67%, respectively, foridentifying depressed individuals.8 Women who answeraffirmatively to either question need a more in-depth as-sessment. In order to meet the diagnostic criteria for majordepression, women must be experiencing either depres-sion or anhedonia and have other frequent persistentsymptoms that are severe enough to impede their abilityto function (Table 2).

MAKING THE DIAGNOSIS

Women suspected of having depression need further eval-uation to determine the exact diagnosis. Depending on theextent, severity, and persistence of symptoms, womenmay be experiencing dysthymia, major or minor depres-sion, or premenstrual dysphoric disorder. Women in thedepressive phase of bipolar disorder will also appear sadand may be misdiagnosed with unipolar depression. De-pression can also be a result of a medical condition, suchas hypothyroidism, or present as a comorbid psychiatriccondition.9,10 Depression is also commonly found inwomen with chronic conditions, such as diabetes or

Barbara Hackley, CNM, MSN, is an Associate Professor at Yale UniversitySchool of Nursing, Nurse-Midwifery Specialty. She earned her master’s de-gree from Columbia University School of Nursing and is currently in clinicalpractice at Montefiore South Bronx Health Center, Bronx, NY.

Chanchal Sharma, PsyD, is currently a licensed child psychologist at Mon-tefiore South Bronx Health Center, Bronx, NY, and an adjunct professorin the Department of Psychology at Pace University, New York, NY. Dr.Sharma earned her doctorate in child/adolescent clinical psychology fromPace University, her master’s in clinical psychology from the Teachers Col-lege at Columbia University, and her master’s in education in school psy-chology from Pace University.

Angela Kedzior, MD, is a graduate of Columbia University College of Phy-sicians and Surgeons and completed her residency in psychiatry at the PayneWhitney Clinic of New York Hospital/Cornell Medical Center, New York,NY. She has worked in emergency psychiatry, directed a mobile crisisunit, and now is a general psychiatrist at the New York Children’s HealthProject. She is also an Assistant Professor of Psychiatry at the Albert EinsteinSchool of Medicine.

Sharad Sreenivasan, LMSW, is a graduate of the Columbia UniversitySchool of Social Work. For the last 7 years, he has been at the MontefioreSouth Bronx Health Center, Bronx, NY, where he currently directs theirmental health and social services.

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cancer, and as a side effect of some medications, in partic-ular oral corticosteroids and some antihypertensives2

(Table 2).Providers may mistake depression for premenstrual

syndrome (PMS) or premenstrual dysphoric disorder(PMDD), because many women with depression reportworsening of their symptoms just before and during men-ses. However, in both PMS and PMDD, women are free ofsymptoms during the follicular phase of their menstrualcycle, whereas those with depression have symptomsthroughout their menstrual cycle. PMS and PMDD canbe distinguished based on the severity of symptoms.PMS, which has been reported to occur in 50% to 80%of menstruating women, is milder and may not occurwith every cycle.11 In contrast, PMDD is rare; the symp-toms occur consistently each cycle and are severe enoughto impede a woman’s ability to function.11 In addition,women with PMDD are more likely to report emotional la-bility and irritability than women who are experiencingmajor depression.11

Other comorbid psychiatric conditions can also be pres-ent. Anxiety and posttraumatic stress disorder are particu-larly common among women. Lastly, women withdepression may self-medicate with alcohol, marijuana, orillicit or prescription drugs. Therefore, all women present-ing with depressive symptoms need to be assessed forother possible diagnoses.

EVALUATE FOR SAFETY

Once a woman has been diagnosed with depression, it isimperative that she be assessed for suicidal ideation. Indi-viduals are at lower risk of suicide if they have vaguethoughts of suicide with no intent or plan. Higher risk in-dividuals are those that have developed a specific, detailedplan. Individuals at highest risk are those who have re-hearsed their plan or who have access to lethal means(i.e., guns and prescription or street drugs).2,12 Other redflags include: 1) a history of hospitalization or violencewithin the last year; 2) previous suicidal attempts or a fam-ily history of suicide; 3) being socially isolated; 4) con-comitant drug abuse; 5) being actively psychotic; 6)current feelings of hopelessness and impulsiveness; and7) experiencing family or romantic conflicts or legalproblems.2,12

Women have significantly lower rates of successful sui-cide than men. Women who are pregnant or have childrenappear to be at even lower risk.12 However, providers must

Volume 55, No. 1, January/February 2010

Table 2. Differential Diagnoses for Women Who Have a Positive Screenfor Depression

Symptoms and Criteria for Diagnosis

Premenstrual Syndrome11

SymptomsCyclic with onset just before menses, mild, only one mood symptomIntermittent and may not occur with every menstrual cycle

Premenstrual Mood Disorder11

SymptomsMust include one of the following:

1) Depressed mood, hopelessness, or self-deprecating thoughts2) Marked anxiety or being ‘‘on edge’’3) Marked affective lability4) Anger, irritability, or interpersonal conflict

PLUS any of the following symptoms (to total five symptoms):1) Anhedonia2) Poor concentration3) Lethargy4) Change in appetite5) Sleep disturbances6) Feeling overwhelmed7) Physical symptoms, such as breast tenderness or headache

Symptoms markedly interfere with work, home, school, or personal lifeDuration

Confined to luteal phase; most severe on days 21–28 of menstrualcycle

Starts in early adulthood and worsens with age and occurs eachcycle

Ceases during pregnancy and after menopause

Dysthymia2

SymptomsFrequent low mood often with lethargy and self-criticismPLUS 2 other symptoms listed below under ‘‘Major Depression’’

Duration$ 2 yrs

Major Depression2

SymptomsMust include either depressed mood or anhedoniaPLUS any of the following symptoms (to total five symptoms):

1) Significant weight loss or gain2) Insomnia or hypersomnia3) Psychomotor agitation or retardation4) Fatigue or loss of energy nearly every day5) Feelings of worthlessness or excessive guilt6) Poor concentration7) Recurrent thoughts of death

Symptoms occur nearly every day and are severe enough to impedefunction

DurationMinimum of 2 weeks

Bipolar Disorder2

SymptomsReports episodes of severe depressionAlso at least one episode of mania (inflated self-esteem or grandiosity,

decreased need for sleep, more talkative than usual or pressure tocontinue talking, flight of ideas or feels thoughts are racing,distractibility, agitation, high energy, irritability, or pleasure-seeking)

Must have three symptoms (or four if only symptom is irritability)during the time of mood disturbance

(Continued)

Table 2 (Cont’d). Differential Diagnoses for Women Who Havea Positive Screen for Depression

Symptoms and Criteria for Diagnosis

DurationDepressive phase must last a minimum of 4 daysManic phase must last a minimum of 7 days

Generalized Anxiety2

Symptoms (any three of the following):1) Restless, ‘‘on edge’’2) Fatigue3) Poor concentration4) Irritable5) Sleep disturbance6) Muscle tension

Duration6 months

Panic Attack2

Symptoms (any four of the following):Intense period with abrupt onset and peaks within 10 minutes

1) Sweating2) Trembling or shaking3) Sensation of shortness of breath or smothering4) Nausea5) Chest pain or discomfort6) Dizzy, lightheaded, unsteady, or faint7) Fear of losing control or going crazy8) Fear of dying9) Paresthesias

10) Chills or hot flashes

Sources: Institute for Clinical Systems Improvement2 and Di Giulio and Reissing.11

Journal of Midwifery & Women’s Health � www.jmwh.org

ask women with suicidal ideation about any possible con-current homicidal ideation towards their children (i.e., ‘‘Ifyou decided to kill yourself, what would happen to yourchildren? Would you take your children with you?’’).One study of 30 parents who murdered their childrenfound that 90% of mothers who were the perpetratorswere motivated by a sense of altruism—that is, by con-cerns that their children would be in acute danger ofa fate worse than death if they were allowed to live.13 Fac-tors identified in the literature that have been reported toincrease the risk that women will murder their infants in-clude being of younger age, having little or no prenatalcare, having no plans for the care of the infant, and thepresence of underlying mental illness.13,14

DEVELOP A TREATMENT PLAN

If the woman is deemed to be safe and does not require im-mediate evaluation by a psychiatric specialist, the nextstep is to determine the severity of the presentation. Majordepression can be categorized as being mild, moderate, orsevere. Women with mild major depression have the min-imum symptoms to make the diagnosis and generally haveminimal functional impairment; those with moderate de-pression have five to six symptoms and more impairment;

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those with severe presentations have seven or more symp-toms and marked interference with normal functioning.2,15

Staging the severity of depression helps in guiding treat-ment choices. Those with milder versions of depressionusually respond to whatever treatment modality is chosen.Severe presentations require more aggressive treat-ment.2,15,16 The goal for treatment is remission: a returnto normal functioning with minimal to no depressivesymptoms.

Treatment Choices: Medications, Therapy, or Both?

An adequate response rate, which is defined as a reductionof symptoms of $50%, is highly predictive of eventual re-mission.2 The initial response to treatment appears to besimilar whether medications or therapy alone is cho-sen.17,18 One study that randomly assigned moderatelyto severely depressed individuals to one of three groups(pharmacotherapy [n = 120], cognitive therapy [n = 60],or placebo [n = 60]) found that the response rates were58% for both treatment groups.18 Remission rates were re-ported to be 46% for the medication group and 40% for thecognitive therapy group after 16 weeks of follow up.18

Evidence suggests that while the initial response ratesappear to be very similar with either approach, psycholog-ical treatment seems to provide long-term protectionagainst relapse or recurrence.16,17 A meta-analysis of 16studies that included more than 1800 patients found thatcombined treatment with medications and psychotherapywas significantly more effective than medication treatmentalone (AOR, 1.86; 95% CI, 1.38%–2.52%) and even moreeffective if combined treatment was extended beyond 12weeks (AOR, 2.21; 95% CI, 1.22%–4.03%).19 In a smallstudy of 104 individuals who were in remission, Hollonet al.20 reported that individuals treated with cognitive be-havioral therapy (CBT) had lower relapse rates after treat-ment was terminated than those who were treated withmedications (30.8% versus 76.2%, respectively; P =.004). Other studies concur with these findings.21–23

Ongoing psychotherapy appears to be particularly help-ful for those who have had repeated episodes of depres-sion. One study (N = 187) found that psychotherapyreduced the risk of relapse from 72% to 46% in thosewho had five or more previous episodes of depression.24

In addition, some studies suggest that the effectivenessof pharmacotherapy declines in those who experience re-peated episodes of depression. Leykin et al.25 randomized240 individuals with a current diagnosis of moderate to se-vere depression to treatment with either antidepressanttherapy (paroxetine) or cognitive therapy. After 16 weeksof treatment, those with a history of two or more previousepisodes of depression treated with antidepressants hada significantly lower response rate to paroxetine than thosewith one previous episode.25 However, the response ratein those treated with cognitive therapy did not differ bythe number of previous depressive episodes (AOR =

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2.31 for remitting with one previous episode; AOR =1.90 with two or more previous episodes).25

Some advocate a sequential approach to treatment.26

Sequential treatment with one modality (medication ortherapy) followed by the addition of the second hasbeen shown to be as effective as combined therapystarted together at the onset of symptoms.16,17,26,27 Theultimate choice of a particular treatment plan for a specificwoman will depend on a number of factors. These in-clude insurance coverage, personal preference, accessto skilled psychotherapy, cultural considerations (suchas the availability of bilingual therapists), and conve-nience, along with the acuity of her presentation. Womenwho pose a danger to themselves or others will need anurgent evaluation in a facility offering emergency psychi-atric care and inpatient services regardless of theirwishes. Otherwise, the choice of treatment can be indi-vidualized.

Medications

There are many antidepressants from which to choose.Each antidepressant belongs to a group based on whichneurochemical axis it affects in the brain, yet all appearto be about equally effective.28,29 Today, the most com-monly used medications in primary care are the neweragents: selective serotonin reuptake inhibitors (SSRIs),norepinephrine and dopamine reuptake inhibitors(NDRIs), and serotonin-norepinephrine reuptake inhibi-tors (SNRIs; Table 3).

Other effective medications are available, but are bestreserved for use by mental health specialists. These in-clude monoamine oxidase inhibitors, tricyclics, and sero-tonin 2 antagonists/reuptake inhibitors. These agentsrequire greater expertise to prescribe safely. For example,individuals using monoamine oxidase inhibitors mustavoid ingesting tyramine-containing foods (e.g., agedcheese, beer, and red wine) or using certain drugs (e.g.,cocaine) or medications (e.g., tricyclic antidepressants,ritalin, andamphetamines). Failure to do so can resultin a severe hypertensive crisis.30 Tricyclics, which canbe used at low doses for the treatment of neuropathicpain in addition to depression, have significant side ef-fects, frequent drug interactions, and a higher potentialfor overdose.31,32 For most people, consuminga 2-week supply at one time is lethal. Trazodone, whichis a serotonin 2 antagonist/reuptake inhibitor, is an effec-tive antidepressant, but it is difficult to use because of itsproblematic side effect profile; weight gain and sleepi-ness are much more commonly reported with use oftrazodone than other antidepressants.27,33 The secondagent in this class is nefazodone. Nefazodone is thegeneric form of serzone, which was removed from themarket because of rare fatal hepatotoxicity.34 Therefore,while nefazodone is still available, it should not beused by nonpsychiatrists.

Volume 55, No. 1, January/February 2010

Table 3. Antidepressant Medications for Use by Primary Care Providers

Generic Agent (Brand Name) Side Effect Profile Pharmacokinetic Half-life

SSRIsFluoxetine (Prozac) Weight gain common, more likely after 6 months of use43,46;

sexual side effects41,44Longer half-life of 3–4 days and long elimination of active

metabolites, making withdrawal symptoms the leastlikely of all SSRIs42

Sertraline (Zoloft) Weight gain common, more likely after 6 months of use43;sexual side effects 41,44

Half-life of 2–4 days and some minimally activemetabolites, so withdrawal symptoms are less likely42

Paroxetine (Paxil) Weight gain more likely than with other SSRIs43; sexual sideeffects may be more common in the short term41

Short half-life and no active metabolites, therefore morelikely to experience serotonin withdrawal symptoms42

Fluvoxamine (Luvox) Weight gain common, more likely after 6 months of use43 Short half-life and no active metabolites, therefore morelikely to experience withdrawal symptoms42

Citalopram (Celexa) May have fewer sexual side effects than other SSRIs41;weight gain common, more likely after 6 months of use43

35-hour half-life and few metabolites, therefore missinga dose can cause serotonin withdrawal symptoms42

Ecitalopram (Lexapro) More sexual side effects compared to Cymbalta in the shortterm, no long-term difference58; weight gain common,more likely after 6 months of use43

Short half-life of 27–32 hours, therefore missing a dose cancause serotonin withdrawal symptoms59

NDRIsBupropion (Wellbutrin or Zyban) No sexual side effects45,44; weight-neutral or minor weight

loss43; lowers seizure threshold8Half-life is 29 hours for sustained release; withdrawal

symptoms not reported60

SNRIsVenlafaxine (Effexor) Weight-neutral43; fewer sexual side effects than SSRIs44;

increases blood pressure in a dose-dependent fashion15Withdrawal symptoms reported, but frequency unknown42

Duloxetine (Cymbalta) Weight-neutral in the short term, uncertain if weight gain inthe long term43; fewer sexual side effects than someSSRI in the short term, no long-term difference61; noimpact on blood pressure

Half-life of 12 hours; withdrawal symptoms reported, butfrequency unknown62

NDRI = norepinephrine/dopamine reuptake inhibitor; SNRI = serotonin-norepinephrine reuptake inhibitor; SSRI = selective serotonin reuptake inhibitor.

Making a good choice among the antidepressants willdepend on the constellation of symptoms needing treat-ment. Some women experience primarily depression,others will have low energy levels and hypersomnia in ad-dition to depression, and still others will be anxious andsad and have difficulty sleeping. Some antidepressantsare thought to be activating and improve energy levels, re-duce fatigue, and help restore more normal sleep patterns.Others are thought to be more sedating and therefore ben-eficial for women experiencing agitation, anxiety, or in-somnia in addition to depression. Still other agents arethought to be neither activating nor sedating.

Survey data describing the prescribing patterns of pri-mary care providers and psychiatrists indicate that pre-scribers consider these symptoms when making choicesamong the various products. The majority of prescribersin a recent survey (n = 308) preferred fluoxetine for de-pression and depression associated with fatigue; paroxe-tine for anxiety, anxious depression, or panic disorder;and sertraline for the elderly and those with suicidal idea-tion.35 Expert opinion agrees: the 2004 MacArthur Initia-tive on Depression states that bupropion is more likely tobe stimulating than other antidepressants and that amongthe SSRIs, fluoxetine tends to be more stimulating andparoxetine more sedating than other products.15

However, research supporting these clinical impres-sions is limited. The impact of the various agents on en-ergy levels, anxiety, and sleep problems seems to varymost markedly by class. For example, trazadone, one of

Journal of Midwifery & Women’s Health � www.jmwh.org

the serotonin 2 antagonists/reuptake inhibitors, is rarelyused as single-agent therapy because it is so sedating.Rather, it is more commonly used as adjunctive therapyfor depressed women with insomnia.33 Benzodiazepinesare older products and were historically first-line agentsused in the treatment of anxiety.36 While women experi-encing agitation in addition to depression may benefitfrom the addition of a benzodiazepine to their antidepres-sant regimen, 61% of psychiatrists in a recent survey pre-ferred to switch to a different single drug rather thanprescribing multiple drugs.36

Unfortunately, even less evidence exists that could helpdetermine which of the newer antidepressants might bea more appropriate choice for depressed women with in-somnia, hypersomnia, fatigue, or nervousness. The re-search to date has not found any significant differencesin the impact of the newer antidepressants on the preva-lence of symptoms suggestive of activation or sedation.However, this conclusion must be tempered by the under-standing that most studies are small (N # 100 per treat-ment arm) and few directly compare multiple agents.37–40

Understanding the pharmacokinetics of the various an-tidepressants is critical to choosing the appropriate drug.Women who have difficulty adhering to an oral medica-tion regimen and are therefore more likely to miss dosesshould not be prescribed a SSRI with a short half-life.41

Antidepressants with short half-lives are more likely totrigger withdrawal symptoms if they are abruptly discon-tinued.42 This reaction is not related to addiction to the

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drug; rather, it is a result of a rapid decline in neurochem-ical levels that had been supported by antidepressant use.Women on any antidepressant should be counseled thatthe dose needs to be tapered slowly downward if the deci-sion is made to stop pharmacotherapy. Abrupt discontinu-ation of a SSRI with a short half-life is particularlyproblematic, because it can lead to dizziness, nausea, leth-argy, headache, anxiety, and agitation.41

Minimizing side effects is also important. For women,the two most common concerns are weight gain and sexualside effects. The frequency and severity of these side effectsvaries by class. For example, tricyclics seem to cause moreweight gain than SSRIs.43,44 Sexual side effects are morecommon with use of a SSRI than a NDRI.44,45 Differencescan also occur within a class. For example, while all SSRIscan cause weight gain, paroxetine is associated with signif-icantly more weight gain than other SSRIs.44,46 If a womanexperiences side effects, the dose of her antidepressant canbe lowered, treatment continued, and dosages slowly raisedas side effects abate over time.15 Other strategies that havebeen reported in the literature that may be helpful in themanagement of SSRI-induced side effects include using ad-junctive therapy with buproprion for sexual dysfunctionand trazadone for insomnia or switching to a different agentif agitation or weight gain is problematic.36 However, itshould be remembered that sexual side effects or weightgain associated with the use of some antidepressants maynot be problematic for all women, especially for womenwho are not sexually active, who have a poor appetite, orwho have a desire to gain weight.

Once the decision is made to start an antidepressant,providers should adhere to basic management principles.In order to increase tolerability, doses should be startedat the minimum starting dose and then slowly titrated up-wards until the symptoms resolve almost completely. Thestarting dose and the rate and magnitude of dose increasesvary by both product and presentation. However, in gen-eral, dosages are maintained at the same level for 4 weeksbefore they are increased.15,44 Relief from depressivesymptoms is gradual; women with an appropriate thera-peutic response to antidepressants report a 50% reductionin symptoms in 8 to 10 weeks and a 90% reduction in 3months.15 Patients with a partial response will reporta 25% reduction in symptoms over the previous 4 weeks.They should have their medication dose increased until ei-ther the maximum therapeutic level is reached or remis-sion is achieved.2,15 Increasing the dose to the maximumrecommended level is the preferred initial approach forthose with a partial response, rather than switching toanother antidepressant.15 Women with no response at 4to 6 weeks should be switched to another drug or startpsychotherapy.

In addition, those with no response or an inadequate oneshould be reevaluated to confirm the diagnosis. One com-monly missed diagnosis is bipolar disorder. Women withbipolar disorder who are given antidepressants alone with-

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out a mood stabilizer may report increased insomnia ormania with antidepressant use.

Women should continue pharmacotherapy for a mini-mum of 4 to 9 months after remission.15 Women with re-peated episodes of depression need a minimum of 9months, if not lifelong, pharmacotherapy. Discontinuingmedications too early can significantly increase the riskof relapse.15

Therapy

Psychotherapy appears to help individuals learn and ap-ply coping skills and healthier thinking patterns thatcan promote recovery and help prevent relapse. Thereare a vast number of therapeutic approaches within thefield of psychology that can do this. Some of the com-mon approaches include psychodynamic therapy, CBT,group therapy, family therapy, interpersonal therapy,and psychoeducation. For many years, researchers andclinicians have attempted to identify the important ele-ment of a modality-specific therapy that contributes tothe patient ‘‘getting better.’’ Among the common ele-ments of psychotherapy, the collaborative relationshipbetween patient and therapist known as the ‘‘therapeuticalliance’’ has long been considered one of the most im-portant, but its importance relative to the type of treat-ment remains uncertain.47

Of the various psychotherapeutic approaches, CBT hasbeen the most extensively studied and has been found to beuseful in the prevention and treatment of both depressiveand anxiety disorders.48–51 The goal of CBT is to reducesymptoms by targeting and modifying negative patternsof thinking and behavior. It is a symptom-based therapythat is time-limited (4–20 sessions, classically 16) andstructured. Some of the major components of such a ther-apy include analyzing thought schemas (usually the nega-tive underlying attitudes that individuals have of oneselfand of the world), developing strategies to reduce negativethinking, promoting relaxation (deep muscle and breath-ing relaxation, meditation, and mindfulness), encouragingself-care activities (diet, exercise, and sleep hygiene), andteaching problem-solving skills.

Another approach to treating mental health problems is‘‘supportive therapy.’’ Supportive therapy techniques in-clude advice giving and providing perspective onproblems.15 While it is devoid of insight-oriented inter-vention, it does incorporate active listening, which in-volves the provider acknowledging the feelings thepatient is experiencing, creating a feeling of ‘‘beingheard’’ for the patient. It has been found to be beneficialin reducing relapse rates of mental disorders; it increasesself-confidence and socialization. It is effective in treatingsuch ailments as grieving the death of a loved one, medi-cal/psychological illness of family member or oneself, ordomestic violence in the home. Most importantly, it pro-vides a support network for the individual in therapy.

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Several studies have found that various therapies (briefCBT, supportive therapy, brief interpersonal therapy, andproblem-solving therapy [PST]) conducted by primarycare providers are effective in the treatment of depres-sion.52,53 Of therapies conducted by primary care pro-viders, PST has the strongest evidence foreffectiveness.54 It consists of a series of six to eight ses-sions that help an individual focus on sequential stepsneeded to rectify problems. These steps include the fol-lowing: 1) clarifying and prioritizing the problems; 2) de-veloping a list of achievable goals and solutions; 3)choosing the preferred solution; 4) implementing the solu-tion; and 5) evaluating this solution. Mynors-Walliset al.53 randomly assigned 154 individuals with depressioninto four treatment arms (PST conducted by nurses, PSTconducted by physicians, medication alone, or a combina-tion of medication and PST).53 All approaches wereequally effective in alleviating depression.53 Responseand remission rates at 12 weeks ranged from 64% to 78%.

Providers can incorporate elements from the varioustherapies described above into their counseling and focuson problem-solving, coping strategies, negative thinkingpatterns, and promoting pleasurable activities.15 Whilewomen’s health care providers may have had little trainingin specific counseling strategies, they are skilled in coun-seling and may already have developed a therapeutic alli-ance with the patient, which is critical to the success of alltherapies. In order to improve treatment success, providersmay benefit from additional formal training in counselingor on-site ‘‘supervision.’’ Supervision is a common strat-egy used in the fields of social work and psychology to en-sure clinical competency. In these fields, supervisionrefers to time spent with another therapist to review casesand approaches to care. Supervision can also help pro-viders set reasonable time-limited goals that they can ac-complish with patients. Providers in busy clinicalpractices will need to employ time-limited strategies,such as PST, in order to manage the demands of the prac-tice and the needs of their patients.

A CASE EXAMPLE: A TEAM APPROACH TO CARE

Montefiore South Bronx Health Center serves one of themost disadvantaged communities in New York City.Forty-five percent of residents in the surrounding com-munity live below the poverty line; 73% are Hispanicand 24% are black. Rates of diabetes, cardiovasculardisease, and premature death are higher than that forNew York as a whole, and 9% of residents report severepsychological distress compared to 6% of New Yorkresidents.55 In busy clinical settings, particularly inthose serving disadvantaged communities such asours, meeting the mental health needs of women canseem overwhelming. Over the course of the last severalyears, we developed a team approach to care in order toimprove the management of women with depression.

Journal of Midwifery & Women’s Health � www.jmwh.org

Each member of the team (providers, social workers,and mental health specialists) contributes to the effort.

Screening

A common approach in obstetric and gynecologic prac-tices is to send all women with identified risk factors tothe social worker for evaluation. However, in our practice,the provider completes the initial psychosocial assess-ment. The advantage of this approach is that it protectsthe time of the mental health team, allowing the mentalhealth team to focus on the few who need care, not on gen-eral screening for the many with risk factors.

Providers verbally screen using the two questions foundin Table 1. A positive response to either question promptsthe clinician to rescreen using the PHQ-9 or a verbalequivalent. The PHQ-9, which mirrors the Diagnosticand Statistical Manual of Mental Disorders, 4th editioncriteria, can be used for screening and to monitor treatmentsuccess.15,56 It can also be used to gauge severity: scores of5 to 9 are associated with mild depression, 10 to 14 withmoderate depression, and 15 or greater with severe depres-sion.2 Adequate response to treatment can be documentedby seeing a significant drop in the score of the PHQ-9 overtime.15,56 For example, serial administration of the PHQ-9should demonstrate a minimal drop of five points in thefirst 4 to 6 weeks after initiation of pharmacotherapy.15

The use of this instrument is very useful in practicessuch as ours where providers engage in counseling andmedication management of depression and screening.

Making the Diagnosis

Once depression is suspected, other possibilities need to beexcluded. Hypothyroidism is the most likely clinical con-dition that could mimic depression in women of reproduc-tive age. Fatigue associated with this condition cansometimes be mistaken for depression. Although anemiais often suspected by women in our practice to be the un-derlying cause of feelings of fatigue and depression, it israrely found on screening. Therefore, the only standardlaboratory test ordered in our practice is a thyroid-stimulat-ing hormone (TSH) test. TSH levels have been found to bea cost-effective screening test; additional thyroid functiontests are only necessary if the initial TSH level isabnormal.57

Women may be concerned that they have an underlyingmedical condition that is responsible for their feeling ofanxiousness, depression, and insomnia. Women, particu-larly those who experience panic attacks, have difficultybelieving that such distressing physical symptoms can becaused solely by depression, anxiety, or panic attacks. Inthese cases, a consultation with an internist or family phy-sician can be helpful. The medical provider is apprised thatthe woman is thought to have only depression or anxietybut is requesting a second opinion. In our experience of

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more than 7 years, no woman who had been initiallythought to be medically healthy was later found to havean unrecognized medical problem that accounted for hersymptoms. Three clinical scenarios should prompt a clini-cian to consider that an individual may be experiencing de-pressive symptoms secondary to a medical condition, notmajor depression if the individual is: 1) older, 2) experi-encing a first episode of depression after 40 years of age,or 3) not responding fully to treatment.2

Generally in our practice, the woman’s provider (whichcan be either the midwife, obstetrician, or primary carephysician) establishes the diagnosis. However, if the diag-nosis is in question, other psychiatric comorbidities aresuspected, or if the woman’s personal life is affected byother stressors—such as inadequate housing—women inour practice are referred to the social worker for a morein-depth evaluation and/or practical support. Womenwith substance abuse, psychosis, bipolar disorder, schizo-phrenia, eating disorders, personality disorders, and thosewith a history of cutting or other self-injurious behaviorsrequire referral to the mental health team. Women withthese conditions need expert care.

Safety

Suicidality and homicidality are psychiatric emergenciesand need to be treated as such. In our practice, we have de-veloped a set of guidelines on how to safely manage thesesituations. If active suicidal or homicidal thoughts arepresent, an arrangement is made for emergency transport.Calling 911 is a better option than sending a patient toa psychiatric facility via ambulette, cab, or private trans-port, because it minimizes the chance that the patientwill decide not to go. In addition, the medical director isnotified immediately and a security guard is requested toremain nearby in the event that backup support is needed.Patients are informed that evaluation in a psychiatric emer-gency room does not necessarily mean they will be hospi-talized; rather, it allows them access to a psychiatrist andtimely follow-up care. This process allows an individualto not only be evaluated immediately in the emergencyroom by a psychiatrist, but also to receive a follow up ap-pointment in 2 weeks. In our community, wait times to seean outpatient psychiatrist can be up to 8 to 12 weeks. Be-cause fear of psychiatric facilities is so pervasive, inform-ing the patient of the evaluation procedures used at thefacility where they will be sent can help relieve some oftheir distress.

Treatment

Some women prefer therapy as a first approach; others pre-fer medication. Because both of these approaches have beenshown to be equally effective, either is acceptable. Whilecombination therapy with both medication and therapy isanother alternative, few women in our practice request

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this unless they have had previous episodes of depression.However, it should be remembered that therapy should berecommended to all women who have no response to med-ications after 6 weeks or only a partial response after 12weeks. Similarly, women who choose therapy should be of-fered medication if they have no improvement after 6 to 8weeks or only partial improvement after 12 weeks.15

One of the most important considerations in choosingamong the options is time. Women may not be able tomake the time commitment to go to therapy, and waittimes to get an appointment for a therapist, even withinour center, can be long. Therefore, medication is oftenused as the first approach to treatment. Initial treatmentwith pharmacotherapy is cost-effective and is easy to im-plement in primary care. In addition, individuals generallyrespond more quickly to pharmacotherapy than psycho-therapy.15 Adding on psychotherapy after the worst ofthe symptoms have abated with medication use may alsohasten recovery: it has been theorized, but not yet studied,to improve an individual’s ability to implement sugges-tions made in therapy.

Providers in our practice prescribe from only three med-ication categories: SSRIs, NDRIs, and SNRIs. These pro-viders have a small personal formulary of four to fivemedications drawn from these three categories and pre-scribe only one medication at a time. With long-termuse, antidepressants generally correct sleep problems,but for some women the additional short-term support ofa sleep aid, such as zolpidem tartrate (Ambien) or diphen-hydramine hydrochloride (Benadryl) may be beneficial.Patients who experience significant side effects, who re-quire multidrug regimens, who fail to respond to antide-pressants after an appropriate trial, or who have mixedsymptoms (anxiety or insomnia in addition to depressionthat does not resolve with antidepressant use) are referredto a psychiatrist for medication management. Women whofail to respond to antidepressants may also be referred tothe social worker or psychologist for counseling, depend-ing on the woman’s preference.

Because of the risks of untoward medication interac-tions, women’s health providers defer medication manage-ment of depression in women with significant comorbidmedical conditions to a psychiatrist or the primary careclinician who is managing these conditions.

Psychotherapy provided by providers in our setting isminimal because of time constraints. Patients generally re-spond well to supportive therapy, advice giving, and activelistening.15 In our center, each provider has his or her ownskill and comfort levels for providing counseling, but noneprovide more than four counseling sessions to a woman asshort-term crisis intervention or supportive counseling.These are generally provided only during the transitionto a mental health expert for long-term care.

Transitioning women from the primary provider to themental health team or from the mental health team to anoutside facility can be difficult for some women. In order

Volume 55, No. 1, January/February 2010

to ensure that women do not discontinue care during thetransfer of care, providers continue to see a woman untilshe is settled comfortably into care with a mental healthprovider on-site or has been seen in another setting. Theadvantages of transitioning are reinforced at each visit;drop-in introductions to the psychiatrists or psychologistduring the woman’s visit with the provider are encouragedand seem to demystify mental health care. Mental healthcare is destigmatized by stressing that depression isa chronic condition like hypertension or diabetes and,like hypertension or diabetes, depression requires life-long care.

While our center has the advantage of an on-site mentalhealth team, our resources are not inexhaustible. There-fore, mental health services are only provided to patientsreceiving medical care at the center. In addition, womenwith significant psychiatric problems, such as eating disor-ders, schizophrenia, bipolar disorder, and substance abuse,are referred to off-site psychiatric treatment facilities.Mental health counseling provided by the mental healthteam is relatively short-term, generally of 6 months’ dura-tion. Women needing more intensive psychotherapy orwho are anticipated to need longer-term care are referredto an outside therapist.

CONCLUSION

Because depression is so common and resources so lim-ited, meeting the need for care for everyone with depres-sion, not just the few with insurance coverage and accessto a mental health specialist, will require professionals towork cooperatively together in a systematic fashion. Onechoice is to integrate mental health services into a healthcare center, such as we have done. In our center, counselingrooms are interspersed in the same clinical space as themedical examination rooms, making mental health andmedical care seamless and communication easy. Consulta-tions can occur formally or informally as need dictates, andclinicians have ready access to both expertise and mentor-ing. Because communication is so easy, both groups ofprofessionals have the support of each other. Having readyaccess to a mental health team makes addressing these is-sues less overwhelming for the medical providers andgives extra support to the mental health team.

Our system of coordinated collaborative care is repro-ducible. Those working in large medical systems such asours could approach their social work and psychiatriccolleagues to see if care could be decentralized and men-tal health specialists could be assigned to work in outpa-tient settings. Women’s health care providers working inprivate practice could easily reproduce the same systemby offering private therapists and psychiatrists low- orno-cost space on evenings or weekends in exchangefor providing some level of mental health care forwomen enrolled in care in the practice. Only creative so-lutions and a commitment to quality care will ensure

Journal of Midwifery & Women’s Health � www.jmwh.org

that women will receive the treatment needed to mini-mize the personal and societal costs associated withdepression.

Supported in part by the Children’s Health Fund.

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