Guidelines 2016 – Emotional and Mental Issues in Women

Guidelines for Nurse Practitioners in Gynecologic Settings 2016
Care Plan – Emotional and Mental Issues

Authors’ note: Increasingly, clinicians practicing in primary care settings and gynecologic settings are finding themselves in the position of needing to prescribe and provide follow-up monitoring for women needing psychotropic medication management. This chapter provides both education and guidelines for such instances. We hope that it will prove helpful.

I. DEFINITION

An alteration in mood or behavior resulting in discomfort for a woman. These changes may place the woman in chronic or acute distress. Attempting to cope with this distress may alter her ability to function, causing family relationship or workplace disturbances, as well as somatic manifestations that may contribute to morbidity and mortality.

II. PSYCHIATRIC CONDITIONS COMMONLY SEEN IN WOMEN’S HEALTH CARE SETTINGS

In this guideline, one asterisk (*) indicates a condition appropriate for assessment by a clinician in an office setting, two asterisks (**) indicate a condition appropriate for referral for further assessment and treatment, and three asterisks (***) indicate a condition appropriate for immediate referral to a hospital emergency room or other immediate care settings. It is appropriate to suggest counseling for most situations requiring psychotropic medications. If symptoms have not improved within 6 weeks of initiating medication, referral is definitely
Mood disorders
1. Bipolar disorder**
2. Dysthymia*
3. Mild situational depression*
4. Secondary depression**
  1. Caused by underlying medical disease
  2. Caused by medication
5. Major depression**
6. Postpartum depression (PPD)* or **
7. Premenstrual dysphoric disorder (PMDD)*
8. Seasonal affective disorder (SAD)*
Anxiety disorders
1. General anxiety disorder (GAD)*
2. Obsessive-compulsive disorder (OCD)* or **
3. Panic disorder**
4. Posttraumatic stress disorder (PTSD)**
5. Social phobia*
Eating disorders
1. Anorexia**
2. Bulimia**
Personality disorders
1. Borderline personality disorder**
2. Narcissistic**
3. Avoidant**
4. Dependent**
5. OCD* or **
Cognitive disorders
1. Dementia**
2. Delirium***
Psychotic disorders
1. Schizophrenia***
2. Other psychotic disorders***
  1. Delusional thought disorders
  2. Hallucinations
  3. Disordered thought process
  4. Disorganized behaviors
Sexual dysfunction* or **
1. Sexual desire disorders
  1. Hypoactive sexual disorder
  2. Sexual aversion disorder (sexual phobia)
  3. Sex addiction
2. Sexual arousal disorders
3. Orgasmic disorders
4. Pain disorders
Sleep disturbances* or **
1. Insomnia
  1. Psychophysiologic—may occur at any time, usually time- limited condition that may begin with a stressor and become a learned Usually present for at least a month; if chronic or long term, should be assessed for other causative factors (i.e., depression/anxiety)
  2. Restless/wakeful sleep
  3. Early morning awakening with inability to resume sleep
2. Narcolepsy
  1. Excessive daytime sleepiness**
3. Obstructive sleep apnea**
  1. A patient may misinterpret this disorder as insomnia, but in fact, it is characterized by loud, irregular snoring that causes sleep interruption
4. Substance-dependent sleep disorders**
5. Restless legs syndrome—characterized by fragmented sleep and increased involuntary movements of the legs (may also involve other limbs)
6. Sleep disorders associated with medical disorders—including, but not limited to, sleep-related asthma, pain syndrome, gastroesopha- geal reflux disorder, fibromyalgia, and menopause
7. Parasomnias**
  1. Sleepwalking
  2. Night terrors, not the same as nightmares (usually only seen in children)
Substance abuse disorders**
1. Alcohol
2. Nicotine
3. Medications
  1. Antianxiety drugs such as benzodiazepines
  2. Prescribed opiates
4. Drugs of abuse, such as cocaine, heroin, hallucinogens, and mari- juana in large quantities
Suicidal threats or ideation***
1. Depressed patients should always be asked about suicidal thoughts and/or plans
  1. Are you having any thoughts that life is not worth living?
  2. Do you think about harming yourself?
  3. Have you ever thought about taking your life?
  4. Do you have a thought about killing yourself? If yes, what is your plan?
  5. Have you ever made an attempt to end your life?
2. Patients who appear to be at risk need an immediate referral to a psychiatrist/clinic or hospital emergency room
Somatoform disorders* or **
1. Body dysmorphic disorder (BDD)* or **
2. Hypochondriasis* or **
3. Conversion disorder**
4. Somatization disorder* or **
5. Factitious disorder**
6. Malingering**
7. Pain disorder**

III. RESPONSIBILITIES OF CLINICIANS

Knowledge of signs and symptoms indicating a psychiatric condition or a psychiatric component in a medical condition
Screening and assessment
Intervention
1. Treatment
2. Referral for further assessment
3. Emergency intervention if condition warrants

IV. HISTORY

What the patient may present with
1. Stomach pain
2. Back pain
3. Pain in arms, legs, joints
4. Mood changes associated with menses
5. Loss of libido
6. Headaches
7. Chest pain
8. Dizziness
9. Rapid/pounding heart
10. Shortness of breath
11. Gastrointestinal (GI) complaints: pain, diarrhea, constipation, nausea, vomiting
12. Fatigue and/or low energy
13. Sleeping difficulties
14. Feeling edgy or nervous
15. Excessive worry
16. Difficulty swallowing or “lump in throat”
17. Feelings of sadness without known cause
Additional information to be considered
1. Generalized feeling of sadness or hopelessness
2. Weight loss or weight gain: What was patient’s weight 6 months/ 1 year ago?
3. Alcohol consumption/use of prescription or illicit drugs
4. Has partner or close associates commented on alcohol or prescrip- tive/illicit drug consumption?
5. Does patient feel guilty about drinking?
6. Does patient avoid social situations?
7. Changes in interest in sex or responsiveness during intimacy
8. History of depression or other psychiatric problem or dementia in biological family
9. Number of visits to health care provider in the past year
10. Has patient found it difficult to concentrate or been easily dis- tracted, finding it hard to find words, forgetting things?
11. Changes in work or family environment
12. Suicidal assessment
13. Seasonal pattern
14. Prescription, over-the-counter (OTC) medicine, or herbal or other complementary and alternative medicine (CAM) used currently
15. Information on any of the problems listed in Psychiatric Conditions Commonly Seen in Women’s Health Care Settings, II if not spontaneously volunteered
Interview techniques
1. Nonverbal messages are important in obtaining a reliable psychiatric
  1. Patient and clinician should be seated at equal height with no furniture between them (i.e., desk).
  2. Establish eye contact
  3. Put pen down; give patient your full attention
  4. Ask clear, open-ended questions
  5. Allow patient to talk
  6. Be supportive
  7. Be watchful for important subtexts (i.e., changing the subject, avoidance, careless or exaggerated responses, inability to maintain eye contact)
  8. Maintain a nonjudgmental attitude; however, be open to challenge contradictory statements

V. PHYSICAL EXAMINATION

Appropriate to physical complaint or symptomatology
In addition to appropriate physical exam, clinician should be alert for the following physical manifestations of emotional distress:
1. Appearance of sadness
2. Gross anxiety
3. Elevated respiratory rate and pulse
4. Excessive perspiration
5. Coldness and dampness of hands
6. Tremor
7. Inability to make eye contact
8. Unkempt appearance
If indicated by information and observation mentioned previously, a general mental status exam or a Mini-Mental State Examination should be
1. Mini-Mental State Examination
  1. Appearance
    1. Grooming
    2. Clothing: dirty, clean, appropriate to seasonal condition, revealing
  2. Behavior
    1. Are mannerisms and gestures appropriate?
  3. Attitude
    1. Is patient aggressive, angry, guarded, or cooperative?
  4. Mood
    1. Anxious
    2. Depressed
    3. Manic or hyperactive
    4. Alternating moods
2. Speech
  1. Quantity and quality
  2. Speed, pressure
3. Cognitive functions
  1. Concentration
  2. Memory
4. Affect
  1. Normal variety of facial expression
  2. Blunted, flat, or immobilization of facial features

VI. DIFFERENTIAL DIAGNOSIS

Mental and physical disorders frequently overlap; the challenge pre- sented in diagnosis is consideration of both dimensions at the same time and ability to differentiate between the two by the way in which both entities may be present and contributing to the symptomatology
1. Hypothyroidism
2. Hyperthyroidism
3. Hypoglycemia
4. Mitral valve prolapse
5. Ménière syndrome/vestibular neuronitis
6. Esophageal tumors or other obstructions
7. Asthma
8. Caffeine abuse
9. Coronary artery disease
10. Alzheimer’s disease or senile dementia
11. Irritable bowel syndrome
12. Crohn’s disease
13. Brain tumors
14. Valvular diseases
15. Cardiac arrhythmias
Signs and symptoms of conditions indicated in Psychiatric Conditions Commonly Seen in Women’s Health Care Settings, II as suitable for diagno- sis and treatment in a primary women’s health care setting
1. Dysthymia: A milder form of depression; symptoms are not disabling but chronic, typically lasting for many years. These symptoms may be so much a part of an individual’s life that they are taken for granted, and patient does not complain to
  1. Depressed mood/chronic sadness lasting more than a year
  2. Poor appetite
  3. Insomnia
  4. Hypersomnia
  5. Low energy/fatigue
  6. Low self-esteem
  7. Poor concentration
  8. Difficulty making decisions
  9. Feelings of hopelessness
2. Mild situational depression: Symptoms present for not more than 2 months after the event; generally associated with loss of a loved May also be associated with loss of a job.
  1. Functional impairment—inability to carry on with life
  2. Exaggerated guilt (i.e., “It should have been ” “I should have done more.”)
  3. Preoccupation with feelings of worthlessness
  4. Psychomotor retardation
3. PPD: A self-limiting period of affective lability occurring within a few days to a week or so after childbirth. Many times, PPD goes without diagnosis, which may leave the woman with lifelong feelings of guilt, fear, and Symptoms (a) through (d) indicate nonpsychotic PPD and (e) through (i) may indicate a psychotic illness. The psychotic and/or delusional mother may be at risk to herself and/or her child. Evaluation by a mental health professional is indicated. Women who have experienced one episode of PPD are at greater risk for another. Women with inadequately treated psychotic symptoms are at greater risk for future mental health illness. If there is little to no improvement after 4 weeks of start- ing medication, woman should be referred for immediate eval- uation. If condition worsens at any time, immediate referral is indicated.

1. 1. Sleeplessness
  2. Weeping
  3. Sadness
  4. Guilt
  5. Agitation
  6. Prolonged sleeplessness
  7. Lack of personal hygiene
  8. Anorexia
  9. Preoccupation with concerns or delusions about the infant
  10. If left untreated, the preceding symptoms may contribute to lack of bonding and have been implicated in lifelong problems for mother and infant.

1. PMDD: A cluster of symptoms regularly presenting during the last week of the luteal phase, beginning to remit within a few days of the follicular Symptoms are always absent in the week following the menses. Symptoms are not present prior to the last week of the luteal phase. Symptoms are of comparable severity, but not duration, to those displayed in a major depressive episode, including
  1. Sadness
  2. Hopelessness
  3. Anxiety/tension/feeling on edge
  4. Mood instability with tearfulness
  5. Persistent irritability
  6. Increased anger
  7. Increased interpersonal conflicts
  8. Binge eating
  9. Insomnia
  10. It is helpful in making a diagnosis if the patient maintains a daily diary, charting symptoms over a 2-month
2. Seasonal affective disorder
  1. Essential feature is that symptoms of a depressive episode occur seasonally, during fall or winter, remitting during spring
3. GAD: An essential feature is excessive anxiety and worry occur- ring more days than not during a period of 6 Other symptoms include
  1. Restlessness
  2. Easy fatigue
  3. Difficulty concentrating
  4. Irritability
  5. Muscle tension
  6. Disturbed sleep patterns
  7. Fearfulness
  8. Somatic complaints (i.e., cold hands, lump in throat, )
  9. Social phobia
4. BDD: An essential feature of BDD is preoccupation with a defect in This preoccupation must cause significant distress or impairment in lifestyle and in other areas of function. Complaints commonly include
  1. Hair thinning
  2. Acne
  3. Wrinkles
  4. Scars
  5. Vascular markings
  6. Paleness or redness of complexion
  7. Facial asymmetry or disproportion
  8. Excessive hair on face
  9. Preoccupation with a bodily part
5. Panic disorder: A discrete period of intense fear and/or discomfort. Onset is rapid, without warning; symptoms are mild, then rapidly crescendo, generally within 10 Symptoms include
  1. Fear that something terrible is about to happen, maybe as intense as feeling death is imminent
  2. Patient may feel that she is detached from
  3. Somatic symptoms may include palpitations, diaphoresis, respiratory distress, chest discomfort, nausea, and
6. OCD: Characterized by recurrent, unbidden thoughts or images (obsessive). To control this, the patient begins a pattern of com- pulsive, repetitive behaviors, which serve to control the obsessive thoughts. Symptoms include
  1. Unreasonable fear of something
  2. Unreasonable fear of losing control and doing something violent or harmful
  3. Waxing and waning of obsessions and compulsions
  4. Phobic avoidant behaviors
7. PTSD: Exposure to an event or events that involved threatened death or life-altering loss resulting in intense fear or The patient then goes on to reexperience the event by thinking, dreaming, or imagining that is recurring (flashback). Symptoms may occur at any time, although often shortly after the events. Symptoms may include

1. 1. Intrusive thinking
  2. Nightmares
  3. Hypervigilance
  4. Excessive startle response
  5. Avoidance of people, situations that may serve as a reminder

VII. LABORATORY EXAMINATION

The following may be considered according to presenting complaint and symptomatology
1. Complete blood cell count (CBC)
2. Urinalysis
3. Electrolytes
4. Blood glucose levels
5. Thyroid function tests
6. Liver enzymes
7. Hormone levels
8. Electrocardiogram (ECG)
9. Electroencephalogram (EEG)
10. Drug screen if indicated

VIII. TREATMENT

Medication: All of the conditions listed as suitable for office treatment usually respond well to the use of an antidepressant or antianxiety medication. Most antidepressants are effective in treating anxiety as well as Included subsequently are those medications that can be most effectively and safely used in a general practice setting. When a patient does not respond well to one choice, she or he may do better with another. When switching medications, do not stop initial drug abruptly prior to starting a new one; instead, cross taper over a few weeks. For pregnant women, only Prozac, Zoloft, and Wellbutrin are currently recommended. Only Paxil has specific warnings against use in pregnancy.
1. Antidepressant/antianxiety medications (most commonly used)
  1. Selective serotonin reuptake inhibitors (SSRIs)
    1. Citalopram hydrobromide (Celexa)—starting dose 10 to 20 mg/d; usual daily dose 20 to 60 mg
    2. Fluoxetine hydrochloride (Prozac/Sarafem)—starting dose 10 to 20 mg/d; usual daily dose 20 to 60 Sarafem is used for PMDD and is generally given for 2 weeks prior to men- ses. Usual dose 20 to 40 mg/d.
    3. Paroxetine hydrochloride (Paxil)—starting dose 10 to 20 mg/d; usual daily dose 20 to 60 mg
    4. Sertraline hydrochloride (Zoloft)—starting dose 25 to 50 mg/d; usual daily dose 50 to 200 mg
    5. Escitalopram oxalate (Lexapro)—starting dose 10 mg/d; usual daily dose 10 to 20 mg
    6. Vilazodone (Viibryd)—starting dose 10 mg/d for 7 days, then 20 mg/d for 7 days; then increase to 40 mg/d. For adequate absorption, this medication must be taken with food
2. Major side effects of SSRIs include
  1. GI disturbances
  2. Sexual side effects
  3. Restlessness
  4. Insomnia
  5. Headaches
  6. Orgasmic dysfunction
  7. Activation of mania in patients with bipolar disorder
  8. Avoid use of paroxetine, fluoxetine, and sertraline in women on tamoxifen because of CYP2D6 metabolizing in the liver— resulting in decreased absorption of
3. Norepinephrine–dopamine reuptake inhibitors (NDRIs)
  1. Bupropion hydrochloride (Wellbutrin)—starting dose 100 mg/d; usual dose 100 mg three times a day
  2. Bupropion hydrochloride sustained release (Wellbutrin SR)— starting dose 100 mg or 150 mg/d; usual daily dose 300 mg (150 mg twice a day)
  3. Bupropion hydrochloride extended release (Wellbutrin XL), 150 to 300 mg—starting dose 150 mg daily for 7 days; usual daily dose 300 mg in the morning. Useful in SAD—start in autumn, taper, and stop in early
  4. Desvenlafaxine (Pristiq) extended release—starting dose 50 mg/d
  5. Major side effects of DNRIs
    1. Seizures possible with high dose (450 mg/d and history of eating disorder or seizure disorder)
    2. Nausea and vomiting with SR formulation
    3. Headaches
    4. Psychosis (use cautiously in psychotic disorders)
4. Serotonin–norepinephrine reuptake inhibitors (SNRIs)
  1. Venlafaxine (Effexor)—starting dose 5 mg/d; usual dose
  2. 7.5 mg twice a day
  3. Venlafaxine extended release (Effexor XR)—starting dose
  4. 37.5 mg/d; usual daily dose 75 to 225 mg
  5. Duloxetine hydrochloride (Cymbalta)—20 mg, 30 mg, or 60 mg
  6. Major side effects with SNRIs
    1. Hypertension
    2. Nausea
    3. Activation
    4. Sexual dysfunction
    5. Not recommended for women with increased daily alcohol ingestion
5. Serotonin modulators (SMs)
  1. Nefazodone (Serzone)—starting dose 50 mg daily; usual dose 150 to 300 mg
  2. Trazodone (Desyrel)—starting dose 50 mg daily; usual dose 75 to 300 mg in divided doses twice a day
  3. Major side effects of SMs
    1. Orthostatic hypotension
    2. Anticholinergic symptoms
    3. Sedation
    4. Priapism (trazodone in males)
6. Norepinephrine–serotonin modulators (NSMs)
  1. Mirtazapine (Remeron)—starting dose 15 mg daily; usual dose 15 to 45 mg
  2. Major side effects of NSMs
    1. Anticholinergic symptoms
    2. Weight gain
    3. Sedation
    4. Increase in cholesterol levels
    5. Agranulocytosis (discontinue medication)
Antianxiety medications
1. Benzodiazepines should be used for short term only (i.e., specific situation known to cause anxiety/panic or sleepless- ness, plane flights, recent loss). This category of drugs is habit forming and can quickly lead to dependence. Use with caution, if at all, in patients with past or present alcohol dependence or abuse. Because of the addictive quality of these medications, they should be prescribed sparingly, if at all, and with great cau- tion in the If benzodiazepines are needed for more than 2 weeks, referral is appropriate.
  1. Alprazolam (Xanax)—usual dose 0.5 mg up to three times a day for no longer than 2 weeks
  2. Clonazepam (Klonopin)—usual dose 0.5 mg up to twice a day for no longer than 2 weeks
  3. Lorazepam (Ativan)—usual dose 5 to 1 mg up to three times a day for no longer than 2 weeks
  4. Most common side effects of benzodiazepines
    1. Frequent: drowsiness, ataxia
    2. Occasional: confusion, amnesia, disinhibition, depression, dizziness
    3. Withdrawal symptoms: delirium/convulsions (with abrupt discontinuation), rebound insomnia, or excitement
    4. Discontinue by tapering dose; no more than 25% per week decrease in dose
2. Other treatment
  1. Psychotherapy
    1. Cognitive therapy
    2. Interpersonal therapy
    3. Behavioral therapy
    4. Exposure therapy
    5. Biofeedback therapy
3. Other medications
  1. Buspirone hydrochloride—starting dose 5 or 10 mg daily; usual dose 10, 15, or 30 mg twice a day
  2. Most common side effects
    1. Frequent: headaches, dizziness, nausea
    2. Occasional: nausea, paresthesias, diarrhea
    3. Rare: psychosis, mania
4. Insomnia medication/interventions
  1. Sleep hygiene should first be used
    1. Avoid caffeine, tobacco, and alcohol in the evening
    2. Establish consistent pattern for bedtime and waking
    3. Establish regular exercise program but do not exercise in late evening
    4. Avoid daytime napping or limit to no more than 20 minutes in the morning and afternoon
    5. Establish a good sleep environment: comfortable bed, pillow, and covering; consistent, comfortable temperature with good ventilation
    6. Avoid eating or watching TV in bed
    7. If you cannot fall asleep, get up and do something in another room
  2. Medications listed next are a few of the nonbenzodiazepine hypnotics; before prescribing these medications, be aware of the new S. Food and Drug Administration (FDA) warning regarding rare allergic reactions and complex sleep-related behaviors, including sleepwalking and sleep driving.
    1. Zalepion (Sonata)—usual dose 5 to 10 mg at bedtime, 5 mg in the elderly
    2. Zolpidem (Ambien)—usual dose 5 to 10 mg at bedtime, 5 mg in the elderly
    3. Zolpidem controlled release (Ambien CR)—usual dose 6.25 to 12.5 mg at bedtime, 6.25 mg in the elderly
    4. Eszopiclone (Lunesta)—usual dose 2 to 3 mg at bedtime, 1 to 2 mg in the elderly
    5. Medications listed previously should be used for short term or episodically only, ideally 6 to 8 Persistent insomnia after short-term treatment should be referred for psychiatric evaluation.
    6. Side effects of medications listed previously include
      1. Unpleasant taste
      2. Central nervous system (CNS) effects
      3. Complex sleep-related behaviors such as sleepwalking
      4. Dry mouth
      5. GI upsets
      6. Use with caution in patients with alcohol or other CNS- dependent use
5. Complementary therapy
  1. John’s wort (Hypericum perforatum)—usual dosage 300 mg three times a day or 450 mg twice a day for use in depression. Interaction with all medications listed previously. Serotonin syndrome of nausea, diarrhea, and headache may occur if used simultaneously.
  2. Essential fatty acids are increasingly used for mood
  3. Meditation/relaxation therapy
  4. Regular exercise program
  5. Regulation of sleep/wake patterns
  6. Dietary changes, including decrease or elimination of caffeine
  7. Light therapy with SAD
  8. Yoga

IX. COMPLICATIONS

Untreated
1. Increased risk for suicide or harm to others
2. Increased risk for other impulsive and acting-out behavior
3. Loss of friends or job
4. Decrease in family harmony
5. Exacerbation of any of the symptoms previously mentioned
Treated
1. Behaviors and somatic problems listed previously
SSRI/SNRI discontinuation syndrome
1. Abrupt discontinuation of an SSRI/SNRI antidepressant has the potential for a withdrawal effect known as antidepressant discontinuation syndrome.
2. Discontinuation syndrome has been linked to all SSRI/SNRI anti- depressants, especially those with the shortest half-life elimination. Discontinuation syndromes are variable in their incidence and Onset of symptoms generally occurs within hours to a day.
3. Common symptoms include a range of somatic complaints. Included are headache, restlessness, dizziness, anxiety, irritability, mood lability, decreased concentration, insomnia, and panic attacks. The GI system may also become Common symptoms include nausea, cramping, and occasional vomiting.
4. The causative factor is considered to be the sudden removal of excess serotonin after neuronal Other issues are related to the removal of inhibitor serotonin effect on noradrenergic and cholinergic neurons; this may lead to transient hypotension, which may account for the headaches associated with the discontinuation syndrome.
5. Dosage tapering or substitution may minimize the discontinuation syndrome. Patients should be advised to wean off medication by pill splitting or capsule opening, in a minimum of 1-week Patients should be urged to taper in steps of one-half to one-fourth dosage per week over a week period. If symptoms reoccur, the patient should be directed to go back to the last step on alternating days for a week or two.
6. An alternative method requires having the patient go to the end of the second week of weaning and then take two 10-mg Prozac daily for 2 days, then one 10-mg Prozac daily if the symptoms reoccur
7. There are rare patients who continue to exhibit symptoms. These ongoing symptoms most frequently occur with Paxil and Patients who continue to experience uncomfortable somatic complaints should be referred for a psychiatric evaluation.