Behavioral Health Care Integration in Obstetrics and Gynecology

Jean M. Cassidy, LCSW, BCD, Virginia A. Boyle, PhD, Hal C. Lawrence, MD

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In This Article

Relevancy of Behavioral Healthcare to Women's Healthcare

There has long been a conceptual separation of mind and body in the general practice of medicine as well as in the practice of obstetrics and gynecology. This is true despite a history of research, experience, and opinion about the influence and interplay between the mind and body in illness and in healthcare maintenance. We can attribute the initial idea of the separation of mind and body to those Greek philosophers who argued that mind and body are distinct and mutually exclusive components. However, since the work of Descartes in the 17th century, research and experience have shown us that indeed an individual's emotional state, coping style, and functional ability directly affect overall well-being and physical health.[7] Today, behavioral healthcare maintenance should be seen as a basic and key component of health and should be intrinsic to every diagnostic, treatment, medical management and referral decision made by healthcare providers.

There is a considerable body of research that clearly shows the impact of mental health on physical health. For example, patients with depressive disorder are more likely to have somatic complaints, including chronic pain and gastrointestinal conditions, and they make more frequent visits to their doctor.[7,8,9] Medical prognosis tends to worsen in patients who have an untreated depressive disorder.[8,9] Patients with only mild depression can have functional impairment equal to or greater than the functional impairment seen in those patients with major chronic medical conditions, including diabetes, arthritis, gastrointestinal disorders, back problems, and hypertension.[8] Wells and colleagues[9] studied 11,242 outpatients and found that the effects of depression and medical conditions were "additive": the combination of depression along with a medical condition was associated with about twice the reduction in social functioning that would be present with either condition by itself.

Studies indicate that the lifetime risk of depressive disorder for women is 20% to 25%.[10,11] Women are at 2 to 3 times greater risk than men for anxiety disorder.[10,12] The Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV)[12] reports that twice as many adolescent and adult women as men in the United States have major depressive disorder, 3 times as many have panic disorder, and 3 times as many have generalized anxiety disorder. Many more women than men have somatoform disorders and panic disorder, although a more exact ratio is unclear because of such intervening factors as the influence of cultural differences in defining what is considered an appropriate emotive and behavioral response to a particular situation.[12]

In a primary care study by Kroenke and colleagues,[13] only 16% of patients presenting with the most common physical symptoms, such as backache, headache, insomnia, or fatigue, were given an organic diagnosis, even after extensive testing. In an analysis of 5 studies having to do with primary care published between 1985 and 1993, Higgins[14] found that psychiatric disorders went unrecognized between 33% and 79% of the time, even when patients presented with classic symptoms. He proposed that primary care physicians could provide better service to their patients and society by improving their recognition of what Goldberg[15] dubbed the "hidden psychiatric morbidity." Despite this, in the United States, medical management of mental and emotional disorders without any other intervention by a mental health specialist has been the norm rather than the exception, particularly for mood and anxiety disorders.[16] The impact of this on medical care is huge in terms of time, healthcare dollars, and human suffering.[9] In 1993, Greenberg[17] estimated that the economic burden of depression alone in the United States was $44 billion. Better diagnosis, intervention, medical management, and appropriate referral of women with comorbid mental illness need to be occurring in the offices and clinics of obstetrician-gynecologists.

From a random survey of 4075 residents of Luebeck, Germany, Lucht and colleagues[4] reported that the rate of depression in women prior to pregnancy is not higher than in men. They found that there was a higher risk for depression for women associated with having children. In our experience on interviewing young, pregnant women at a US women's health center, we frequently hear women express a fear that pregnancy will require their life and career plans to be either put on hold or disregarded altogether. The fruition of this scenario could foster a cycle of dependency (and depression) for many women and impede their professional and financial progress during adulthood, a life situation that can contribute to or even precipitate a mood disorder or anxiety disorder.

Medical literature over the past 40 years has described the detrimental effects of childhood sexual abuse; socioeconomic deprivation; physical, emotional, and sexual violence; emotional and mental disorders; and substance dependency/abuse on women's health.[5,6,7,18,19] Yonkers and colleagues,[10] for example, cite epidemiologic studies that describe several influences that place women at risk for depression:

Gender-specific risk factors for depression in women include absence of a confidant, less than a high school education, presence of young children at home, lack of work outside the home, unstable marital history, personal feelings of helplessness (low mastery), and comorbid anxiety or somatization disorder.

Childhood sexual abuse is directly connected to a greater incidence of depression in women.[11,18] Data presented from a study by Dr. Harriet McMillan[18] at the Canadian Centre for Studies of Children at Risk in Ontario, suggest that some of the mental health problems arising in women may be explained by the greater frequency of childhood sexual abuse experienced by girls. The study reports that the exposure to physical abuse in childhood predisposes women to major depressive disorder more than men who have been exposed to similar abuse. So, it seems that girls experience more sexual violence than boys and that they are more susceptible to the negative psychological effects of abuse generally. Data from this study further indicate that as a result of a person's experience of childhood sexual abuse, both men and women have increased risk for externalized disorders (eg, alcohol/drug abuse and dependency, antisocial behavior) as well as internalized disorders (eg, depression and anxiety).

These findings are only a small part of a large body of research that recognizes the impact of psychosocial issues on healthcare in general and women's healthcare in particular. Behavioral healthcare cannot be disregarded in women's healthcare any more than cardiology, neurology, gastroenterology, or endocrinology could be excluded from diagnostic consideration.

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