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Serotonin plays a role in many brain processes, including regulation of mood. It is produced in the raphe nuclei by neurons that carry it to most of the brain and the spinal cord. Administration of a selective serotonin reuptake inhibitor often increases serotonin levels and ameliorates symptoms of postpartum .

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44_OBGM0609 44 5/21/09 2:40:53 PM LIFE ON CALL Does your OB patient have a psychiatric complaint? And can you manage it?

Here’s how to handle 5 challenges, including , an attempt to leave the hospital against advice, and denial of

here’s a full moon tonight—and you’re the ob- Susan Hatters Friedman, MD stetrician on call. Not that you should expect any more funny business than usual. Despite stories of Dr. Friedman is Senior Instructor, T Departments of and werewolves and other deviants coming out of the wood- Pediatrics, Case Western Reserve work, there is no “full moon eff ect”—at least not one that IN THIS University School of Medicine, ARTICLE Cleveland, Ohio. She is on sabbatical can be documented. Nevertheless, chances are good that at the Mason Clinic, Waitemata you will encounter at least one of the following psychiatric District Health Board, Auckland, 5 steps to New Zealand. challenges as you end your day in the clinic and move on take when to an extended vigil: Jaina Amin, MD, BSN a patient wants • postpartum depression to leave against Dr. Amin is affi liated with the • leaving against medical advice Department of Psychiatry, Case your advice • agitation Western Reserve University School of page 48 Medicine, Cleveland, Ohio. • antenatal illicit drug use • denial or concealment of pregnancy. The authors report no fi nancial Here are some relationships relevant to this article. In this article, we describe the management of these challenges and make recommendations to help increase causes of agitation your comfort level with patients who exhibit psychiatric page 49 problems. In some situations, our suggestions may help you manage the problem without a psychiatric consult. Commonly abused drugs and their effects Postpartum depression page 51 ›› SHARE YOUR COMMENTS What is the most challenging OB Is it just the blues? psychiatric complaint you have It is the end of your day in the clinic, and your last patient had to manage? Let us know and we may publish your case in a is a 30-year-old G3P3 who is 6 weeks postpartum. She future issue. describes repeated tearful episodes over the course of E-MAIL [email protected] several weeks, decreased concentration, and poor appe- FAX 201-391-2778

MOLLY BORMAN FOR OBG MANAGEMENT MOLLY tite. She feels guilty because she is tired all the time and not bonding with her baby. She denies having suicidal or

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TABLE 1 SIG: E CAPS—a mnemonic One useful question is whether the mother to assess for depression1 is able to sleep when the baby sleeps. If she isn’t, this wakefulness may be a symptom of Decreased (sometimes increased) Sleep depression. Decreased Interests Th e Edinburgh Postnatal Depression Feelings of Guilt Scale is an easy, 10-question screening tool that is completed by the patient; it can be Decreased Energy used both during pregnancy and postpar- Decreased Concentration tum. It is available on the Web at a number of Decreased (sometimes increased) Appetite sites, including www.fresno.ucsf.edu/pediat- rics/downloads/edinburghscale.pdf. , slowness Suicidal thoughts, plans, or intent Differential diagnosis Besides postpartum depression, the diff er- homicidal thoughts, or any . She ential diagnosis for altered mood in the post- had expected her energy to return to normal partum period includes several entities. over the fi rst few postpartum weeks, but it has Baby blues generally occurs quite soon after not. She is worried because she will soon be birth and resolves within 2 weeks. It involves returning to work as a medical resident. crying, emotional lability, and irritability.2 It Does this patient have postpartum depres- occurs in around 50% to 75% of new moth- sion? Or is it another condition with overlap- ers (compared with postpartum depression, ping symptoms? which aff ects 10% to 20%).3–5 Postpartum often involves the If a mother tells you that she is suicidal onset of psychotic symptoms within 1 week or having thoughts of harming her child or after delivery. Th e patient may exhibit both others, she should be sent immediately to mood symptoms and psychosis. For exam- The differential the nearest emergency department for psy- ple, she may believe that the baby is not hers diagnosis for chiatric evaluation. Short of such a dramatic or hear voices commanding her to kill the altered mood in situation, how do you know when you should baby or warning her not to trust her health- 6 the postpartum manage a patient’s depression on your own care providers. Postpartum psychosis has a 3–6 period includes and when she should see a psychiatrist? prevalence of about 0.2%. Th orough assessment is the key. Th is psychosis can be organic in nature depression, baby or can arise from a preexisting mood dis- blues, postpartum Don’t mistake transient feelings for order or . Because treatment psychosis, and depression varies, depending on the cause, a thorough Transient feelings of sadness, bereavement, medical workup is needed. and grief are not the same as depression, Bipolar disorder may present as depression, which must last 2 weeks or longer to confi rm but it also consists of manic periods of ele- the diagnosis. vated, expansive, or irritable mood that last A quick mnemonic for symptoms of de- several days to weeks. Many symptoms ap- pression is SIG: E CAPS (as if writing a pre- pear to be the opposite of depression, such as scription for energy capsules) (TABLE 1).1 Th is increased energy and elevated self-esteem.7,8 mnemonic helps remind you to assess the It is important to consider bipolar disor- patient’s sleep, interest, guilt, energy, con- der in the diff erential diagnosis. If a woman centration, appetite, and psychomotor func- who has unrecognized bipolar disorder is giv- tion, as well as identify any suicidal ideation. en an , a manic state could be It is important to assess a woman’s sleep precipitated. Women who have bipolar disor- and appetite in addition to mood. However, der require diff erent drugs than women who diff erences may be diffi cult to ascertain due have depression only, and they should be to normal changes in the . evaluated by a psychiatrist, at least initially.

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46_r1_OBGM0609 46 5/27/09 12:03:44 PM Start treatment as soon as possible CASE 1 RESOLVED Once you confi rm that the patient has A comprehensive discussion with the mother postpartum depression—and not another reveals that she is suffering from postpartum psychiatric disorder—prescribing an antide- depression. No history of bipolar or psychotic pressant may be the next step. Keep in mind symptoms is discovered. After discussing that these drugs take several weeks before treatment options, you prescribe sertraline. their benefi ts are felt. Th erefore, it is best to Over the next 2 months, the patient’s symp- start an antidepressant before depression toms improve, and she bonds with her infant becomes severe. Th e mother may also ben- and successfully returns to work. She is also efi t from psychotherapy. referred to a psychologist to work through Th e selective serotonin reuptake inhib- some underlying issues. itor sertraline (Zoloft) is a reasonable fi rst choice in pregnancy and when the depression is of new onset.9,10 Start it gradu- Leaving against medical advice ally (e.g., 25 mg for sertraline, which can cause nausea if it is initiated too rapidly) and Patient threatens to leave the hospital titrate it over time, if necessary. When there At midnight, you are paged to attend to a 32- is comorbid anxiety, it sometimes is helpful year-old G1P0 at 27 weeks’ gestation who is to prescribe low dosages of lorazepam (Ati- threatening to leave against medical advice. van, Temesta) on an as-needed basis, while She was admitted earlier in the day with uncon- the patient is waiting for the antidepressant trolled and is refusing her to “kick in.” Also consider follow-up—do insulin. you plan to follow her frequently or refer her How do you respond? to psychiatry? Remember to discuss the risks, benefi ts, Use the relationship that you have estab- side eff ects, and alternatives of antidepres- lished with this patient to the best of your abil- sant medication—and document that you ity. Make sure that you have explained fully, Untreated have done so. In addition, discuss medica- and in language she can easily comprehend, depression tion specifi cally in regard to lactation. Con- the reasons she needs to stay for treatment. can become so sultation with pediatrics is optimal. Don’t overlook the obvious, either: Why severe that Adjunctive or alternative options in- does she want to leave? Sometimes the rea- a woman begins clude psychotherapy, group therapy, and son makes sense (e.g., one mother wanted to to experience music therapy. Referral to a psychiatrist is leave to protect her daughter from an abu- psychosis or warranted if the patient does not respond to sive husband). Other reasons may be related suicidality the initial antidepressant agent. to psychosis, addiction, lack of sleep in the Also be aware that untreated depres- hospital, or a desire to smoke, drink, or use sion can become so severe that a woman drugs. Can you convince her to postpone her can begin to experience psychosis, war- decision until morning, when her physician ranting rapid referral. Also refer any woman will be available? who reports a complex history of previous It is important to document in the medical depression—unless the previous episode record your explanations and her reasoning. was easily controlled with a medicine safe Can she coherently verbalize an understand- for use during pregnancy and lactation. ing of the consequences of her decision to If the patient is not lactating, a greater leave, including the risks and implications to range of agents may be considered. (A full herself and the ?12 Can she describe alter- discussion of the risks and benefi ts of anti- natives and the reasoning against them? depressant use in pregnancy is outside the If she is able to do these things, and you scope of this article. Th e interested reader is fi nd her thought processing and reasoning referred to an article on the subject by Wis- to be lucid, then she may have the capac- ner and colleagues.11) ity to leave against medical advice. Keep in

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TABLE 2 5 steps to sound management of a patient A urine toxicology screen would also be who wants to leave against medical advice prudent. If the patient is irrational and lacks the 1. Ask the patient why she wants to leave now capacity to decide whether to stay or leave, 2. Inform her of the risks to herself and to her fetus document your conversation with her, as 3. Ask her to verbalize the risks to herself and to her fetus well as the reasoning behind your decision to intervene further. Other steps include: 4. Determine whether the patient’s request is rational • If it is, call the hospital’s attorney at once; forms may need to be • contacting the hospital’s attorney signed • completing an emergency detention form • If it isn’t, and she is not convinced to stay, complete an emergency • calling security detention form; in addition, you may need to contact psychiatry, • ensuring that the patient’s environment security, and the hospital’s attorney is safe for her and others (TABLE 2).13 5. Document the medical explanation and reasoning in the chart If the patient is psychotic or delirious, look for organic causes and treat her to main- tain her safety (see Case 3). mind that rational persons do have the right, constitutionally, to refuse treatment, even if CASE 2 RESOLVED doing so will lead to morbidity. (A Jehovah’s After building some rapport with the patient, Witness who refuses treatment is the typical you ask why she wants to leave right now. Dur- example.12) Contact the hospital’s attorney— ing this conversation, the patient reveals that tonight—and document that you did so. Th e she has not slept in three nights, and says she attorney may recommend that the patient believes that the insulin is keeping her up. You sign a letter stating that she recognizes the are able to assure her that this is not the case maternal and fetal risks of leaving. and offer her something to help her sleep. She decides not to leave against medical advice. Sometimes a patient must be held If a patient is against her will irrational, wants to Some mothers lack the capacity to refuse Unexplained agitation leave the hospital, treatment. Th ey may be unable to verbal- and lacks the capa- ize an understanding of the situation and its Patient becomes abusive city to make such a risks. Th eir reasoning may be abnormal, with At 1 AM, you are called to the seventh fl oor, disorganized or delusional thinking, or both. where a 20-year-old G2P1 at 26 weeks’ gesta- decision, you may Th e patient may be tangential or talk “in cir- tion is yelling at staff and hitting anyone who need to contact the cles” rather than answer your questions. comes near. She was admitted earlier in the hospital’s attorney Try to ascertain whether mood symp- day for management of threatened and complete toms are contributing to her irrational think- and a dilated cervix. She has no documented an emergency ing. For example, is her rationale for going psychiatric history, but is fl ushed, disheveled, detention form home—“just to be with my husband because and hostile, accusing the staff of sabotaging I don’t want to be alone”—due to her depres- her life, and is seen picking at imaginary things. sion, despite the risk to herself and the fetus? You notify psychiatry, but no one is available. Try to be fl exible and creative. For example, What do you do? you could call the husband and ask him to come to the hospital to sit with the patient. Determining the origin of these symp- Is the patient psychotic? For example, toms will help determine the appropriate does she believe she has to leave now be- course of action. Among the possibilities are: cause the staff has been replaced by aliens • drug intoxication or withdrawal who plan to kill her and her fetus? If so, you • have the authority to continue her hospital- • psychosis ization—but contact the psychiatry depart- • a chronic problem such as a personality ment for medication recommendations. disorder (TABLE 3).

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48_r2_OBGM0609 48 5/27/09 12:03:19 PM PRODUCT UPDATE

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Vol. 21 No. 6 | June 2009 | OBG Management 49 INFORMATION PROVIDED BY THE MANUFACTURERS OF THESE PRODUCTS

49_r1_OBGM0609 49 5/27/09 9:54:07 AM Advertisement Psychiatric challenges in OB

IN THE UNITED STATES, THE PRESS CANNOT BE CENSORED. sire for instant gratifi cation. Th ey may also misinterpret the behavior of other people and take off ense easily as a result. Lacking stress-management skills, they regress to THE INTERNET CANNOT BE CENSORED. unhealthy defense mechanisms such as act- ing out, complaining, passive aggressiveness, POLITICAL ADVERTISING and splitting of the staff (thinking that people are all good or all bad). CANNOT BE CENSORED. Dementia may also be on the diff erential diagnosis, but this chronic condition is un- likely in such a young patient (unless she WHY ARE SOME MEMBERS OF were in the late stages of HIV/AIDS, for ex- CONGRESS & ACADEMIA TRYING TO ample). Dementia has a gradual onset and CENSOR MEDICAL COMMUNICATIONS? is irreversible.

Workup for the agitated patient Assess vital signs and basic laboratory stud- Diabetes. Cancer. Obesity. Respiratory disease. ies, particularly a complete count, America’s medical professionals are busier testing, metabolic screens, glucose, than ever. How can they stay current with serum chemistry panel, and urine toxicol- ogy, to rule out causes of delirium and detect medical advances and still improve their any substances the patient may have used. patients’ well-being? Also consider that the patient may have initi- ated a new medication recently. Information is part of quality care. Yet Imaging of the brain or chest or electro- government controls threaten to keep doctors encephalography may be necessary, such as in the dark about current medical advances. in the setting of infection or concerns regard- ing seizure activity. Restrictions on how much information Gather collateral information about the consumers and doctors can know about current patient from her relatives, friends, and the and new treatments reduce their ability to support staff . Search her chart for recent advocate for care. contacts. Did she have a visitor or phone call that may have upset her? Explore whether Using censorship as a policy tool to control she is having problems with her partner or healthcare costs is a bad idea! Yet that’s what family and friends. Also confi rm that her agi- vocal pockets of academic medicine and tated behavior is an acute change. Congress have in mind. Investigate the patient’s . Why does she believe that the staff is against her? We are concerned that some members of Does she believe they are trying to harm, kill, Congress and academia are seeking to restrict or poison her? Assess her reasoning to deter- the content of CME and other industry-sponsored mine whether her behavior is psychotic or a communications without input from personality problem. practicing physicians. Ask her about hallucinations, keeping in mind that hallucinations are diff erent from il- lusions, in which a patient misinterprets what Information is the fi rst step to care. she sees. What are the voices saying to her? To learn more, visit cohealthcom.org. Also ask about any suicidal or homicidal commands. If she acknowledges that she is hearing them, get a sitter for her immediately Th is message brought to you as a public service by the and make her environment safe so that she Coalition for Healthcare Communication.

50 OBG Management | June 2009

50_r1_OBGM0609 50 5/27/09 9:54:11 AM TABLE 4 Commonly abused drugs and their potential effects

Drug Withdrawal effects on mother Drug effects on fetus or infant Alcohol Sweating, increased heart rate, hand Fetal alcohol syndrome. tremor, nausea/vomiting, physical Withdrawal symptoms similar to those of the mother agitation, (tactile, visual, auditory), illusions, grand mal seizures25 Agitation, anxiety, anger, nausea/ Risk of abruptio placenta, small-for-gestational-age infant, vomiting, muscle pain, disturbed sleep, microcephaly, congenital anomaly (cardiac and genitourinary depression, intense cravings for the abnormality, necrotizing enterocolitis), central nervous drug, irritability25 system stroke or hemorrhage. Withdrawal effects include hypertonia, jitteriness, and seizures.26 Crystal Anxiety, psychotic reaction, intense Premature birth, abruptio placenta, small-for-gestational methamphetamine hunger, irritability, restlessness, fatigue, age, hypertonia, tremors, poor feeding, abnormal sleep depression, sleep disturbance, cravings25 patterns26 Marijuana Irritability, anxiety, physical tension, Irritability, increase in bodily motility, tremors, startles, decreased appetite and mood25 poor habituation to visual stimuli, abnormal refl exes, symptoms similar to mild withdrawal27 Opioids Dilated pupils, watery eyes, runny nose, Risk of prematurity, small-for-gestational age, adult (Heroin, diarrhea, nausea/vomiting, muscle withdrawal symptoms, irritability, hypertonia, wakefulness, methadone) cramps, piloerection, chills or profuse jitteriness, diarrhea, increased hiccups, yawning and sweating, yawning, loss of appetite, sneezing, excessive sucking and seizures. Withdrawal tremor, jitteriness, panic, , effects occur earlier in heroin-exposed babies than in stomach ache, irritability26 methadone-exposed infants.26

is unable to harm herself. Th en contact the about 3 days earlier. They also report that, psychiatry department again. before she quit, she drank approximately 25 oz of vodka and a sixpack of beer nightly. They How to intervene deny knowledge of any other illicit drug use. Talk gently and quietly in an attempt to calm Because her vital signs suggest alcohol with- the situation. Try to make yourself “small”: drawal, you offer oral lorazepam and treat her Stand back and stay at the patient’s eye level, according to the hospital’s alcohol withdrawal not in her personal space or towering over her. protocol. She recovers without any further Also, protect yourself. Don’t challenge complications and is referred to the chemical her complaints immediately or you will dependency service for evaluation. alienate her. Medically evaluate and treat the cause of her agitation, and, if medica- tions are necessary for psychosis or seda- Drug abuse during pregnancy tion, contact psychiatry for assistance. Patient skips CASE 3 RESOLVED It is 2 AM, and you are about to get some rest The patient does not respond to your attempts when you are paged by the emergency room to reason and refuses to allow the nurses to about a 26-year-old G5P4, who is in active labor check her vital signs. Security is called to with no dates. You check the database and dis- stand by while her vital signs are reassessed. cover that her previous were com- The nurses inform you that the patient’s family plicated by chronic . is in the waiting room. Though you fi nd no doc- How do you respond? umented history of substance use or abnormal labs, the family reports that the patient had You might feel frustrated and angry with a history of alcohol abuse but quit drinking this patient. Considering that you have not

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met her, these feelings would be based on pre- tody of their child—sometimes to foster care, vious contacts with patients who had a simi- sometimes to other family members.20,21 lar history. Th is is countertransference. We Some states use positive serum and all experience it. It can be helpful or harm- urine toxicology as evidence to remove a ful, but you cannot control it unless you are child from the mother’s custody.19 aware of it. Pay attention to the anger, hap- It is important to attempt to build a doc- piness, or pride that a patient triggers in you, tor–patient relationship. You cannot solve the and acknowledge that it is your issue. patient’s problem in Your frustration may also stem from per- one night, but you can refer her to drug treat- sonal feelings about mothers who repeatedly ment. A urine toxicology screen can help you expose their to drugs and neglect pre- and the pediatricians know what the patient natal care, as well as anxiety about what you has been exposed to (TABLE 4, page 51). are legally and ethically bound to do. In Ferguson v City of Charleston, the CASE 4 RESOLVED Supreme Court found that drug testing of a After delivery, a test indicates that the newborn pregnant woman for the purpose of criminal has been exposed to cocaine. The mother prosecution is a violation of Fourth Amend- admits to cocaine use during pregnancy. She ment rights.14 However, there have been cas- says she did not seek prenatal care because es in which a state prosecuted a woman for she was afraid of being prosecuted and sent to using an illegal substance during pregnancy. jail. A social work consult is requested, and the Th ese cases involved: mother is referred to a substance abuse treat- • child neglect15 ment program. State law requires the case to • delivery of a stillborn fetus whose be reported to child protective services. Upon revealed traces of cocaine by-products16 hospital discharge, the newborn is initially • reckless endangerment after a newborn placed with the paternal grandmother. tested positive for cocaine.17 Among the criteria In 2006, a California appeals court deter- for substance mined that “the crime of reckless endanger- Denial of pregnancy dependence are ment does not apply to a pregnant woman’s tolerance to the conduct with respect to the child she is carry- Patient’s labor takes her by surprise 18 drug, withdrawal ing.” Other states have their own reporting The night is nearing its end, but it isn’t over criteria, as well as criteria for prosecution. It yet. At 5:30 AM, you are called to a precipitous when the drug is cut is important to know the reporting criteria delivery involving a 17-year-old who has had back or stopped, and for the state in which you practice. no prenatal care. She denies knowing that she continued use of was pregnant, and says she thought her labor the drug despite What is drug abuse? pains were a bowel movement. Her parents evidence of its According to the 4th edition of the Diagnos- were similarly unaware that their daughter was dangers tic and Statistical Manual of pregnant, and are threatening to disown her. Disorders, it is a “maladaptive pattern of How do you defuse the situation? substance use manifested by recurrent and signifi cant adverse consequences related to In a study of women who denied or con- the repeated use of substances” within a 12- cealed pregnancy, patients presented to the month period, or persistently.7 To meet cri- hospital for various reasons.22 For example, teria for substance dependence, in addition one woman went to the ER because she was to the criteria just mentioned, the individual seizing and her workup revealed that she must be tolerant to the drug, experience with- had . A number of women did not drawal when the drug is cut back or stopped, even recognize when they were in labor. Th e continue to use the drug despite knowledge infants born to these women are at risk for a of its dangers, or all of the above. Mothers poor neonatal outcome.21,22 who match this description often lose cus- How can psychiatry help in such a case?

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52_r1_OBGM0609 52 5/27/09 9:54:19 AM By determining whether the patient denied Consider how well this young woman her pregnancy—even to herself—or actively can be a mother. When she did not even rec- concealed it from others. Obviously, these ognize that she was pregnant for 9 months, circumstances have diff ering implications. how well will she be able to attend to her Denial is not a simple entity. It may in- baby’s needs? Psychiatry can evaluate the volve a psychotic schizophrenic woman who patient to help determine her capacity for is out of touch with the reality of her preg- parenting and whether child protective ser- nancy; a woman who “aff ectively” denies vices should be alerted. Of additional con- her pregnancy, keeping the signifi cance of cern is the distress of the patient’s parents. her condition from herself and behaving as Family support will be extremely important. though she is not gravid (perhaps because she Be sure to conduct thorough contracep- plans to give the baby up for adoption); or a tive education and planning at the time of woman who has pervasive denial and does discharge because this patient is at risk for not know that she is pregnant.22,23 In contrast, future denied or concealed pregnancies.22 a woman who conceals her pregnancy is quite aware that she is gravid but consciously hides CASE 5 RESOLVED the gestation from others, begging the ques- The patient is seen by psychiatry. She has no tion of what she had planned for the future.22 major mental illness, but her denial appears to Psychological issues abound, and may be related to problems with her boyfriend, her include a history of sexual and psychological attempts to be the perfect daughter, and fear trauma, an attempt to avoid religious prohibi- of being disowned. After the initial shock, the tions against unwed intercourse, anger at the patient’s parents become more supportive and father of the infant, and even homicidal urges begin to bond with their new grandchild. The toward the baby.24 Th ere may be more going new mom is educated about birth control and on under the surface than “only” a failure to agrees to follow up with a counselor and take recognize the pregnancy, and the patient may parenting classes. The baby is discharged to need further mental health treatment. his mother and grandparents.

References

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