Patients with psychiatric disorders in gynecologic practice

Marie Bixo, MD, PhD,a Inger Sundström-Poromaa, MD, PhD,a Inger Björn, MD,a and
Monica Åström, MD, PhDb
Umeå, Sweden

OBJECTIVE: The relationship between different gynecologic complaints and somatic symptoms was studied
in a gynecologic population in which the prevalence of psychiatric disorders had been established.
STUDY DESIGN: The prevalence of depression and anxiety in the unselected population of 1013 subjects
was 27.2% and 12.1%, respectively, as assessed by the Primary Care Evaluation of Mental Disorders
(PRIME-MD). The subjects’ medical charts were reviewed after the PRIME-MD diagnosis was made.
RESULTS: Depression and anxiety disorders were significantly more common among those seeking care for
abdominal pain, those who made frequent and unscheduled visits, and those who were hospitalized for
acute care. All the physical symptoms indicated in the PRIME-MD Patient Health Questionnaire were more
common among women with a psychiatric diagnosis compared with controls.
CONCLUSIONS: The majority of cases of depression and anxiety in women are undiagnosed and un-
treated, and patients with these disorders often present with physical symptoms. Because gynecologic out-
patients with abdominal pain, frequent and unscheduled visits, and admissions due to acute illness are more
likely to have a psychiatric disorder, it is desirable that gynecologists recognize and treat these problems.
(Am J Obstet Gynecol 2001;185:396-402)

Key words: Depression, anxiety, women, gynecology

Women are diagnosed much more often with mood
and anxiety disorders than are men. The risk of experi-
encing an affective episode associated with female sex
may be surpassed only by the high risk associated with a
family history of depression. The lifetime prevalence of
major depression among women has been reported to be
between 14% and 21%.1,2 Not only is major depressive
disorder 2 to 3 times more common in women than in
men,3 but women also have more recurrent and longer
episodes.4 In addition, comorbid anxiety disorders are
more common in women.5
The reason for this difference between sexes is still ob-
scure. One important factor might be the overwhelming
reproductive events that women experience. It is well es-
tablished that women are at risk for the development of
affective disorders during the postpartum period; the
prevalence is estimated at 12%.6 Furthermore, obsessive-
compulsive disorder may first appear or may be exacer-
bated during pregnancy and the postpartum period.7
From the Department of Clinical Sciences, Obstetrics and Gynecologya
and Psychiatry,b Umeå University.
Supported by a research grant from Pfizer AB, Stockholm, Sweden, and
by grants to Inger Sundström-Poromaa from the Wallenberg Foundation,
Swedish Society of Medicine, and “Spjutspetsanslag, Umeå Sjukvård.”
Received for publication August 17, 2000; revised February 21, 2001;
accepted March 30, 2001.
Reprint requests: Marie Bixo, MD, PhD, Department of Clinical Sci-
ences, Obstetrics and Gynecology, Umeå University, S-901 85, Umeå,
Sweden.
Copyright © 2001 by Mosby, Inc.
0002-9378/2001 $35.00 + 0 6/1/116094
doi:10.1067/mob.2001.116094
Premenstrual mood disturbances are common among
women of fertile age, and 3.5% to 5% of these women are
reported to have a true premenstrual dysphoric disor-
der.8 A history of depression and postpartum depression
is common among women with premenstrual dysphoric
disorder,9 and the disorder in itself is sometimes consid-
ered a risk factor for future depressive disorder.10 Al-
though menopause is not associated with a higher inci-
dence of depression, a prolonged perimenopause is a risk
factor for depressive disorders.11
Depressive and anxiety disorders are strongly associated
with increased reporting of physical symptoms.12-14 Soma-
tization disorder, a chronic mental disorder occurring
predominantly in women, is characterized by large num-
bers of unexplained symptoms, substantial impairment,
and excessive health care utilization. Some of the physical
symptoms reported more often by women with psychiatric
disorders in primary care include dizziness, headache, fa-
tigue, joint and limb pain, palpitations, back pain, and
bowel complaints.15
The obstetrician-gynecologist is the main health care
contact for approximately 1 out of 3 women of child-
bearing age. Psychiatric disorders are bound to be com-
mon among women visiting their gynecologist, given the
high incidence of depression during these years, the re-
lationship between depression and reproductive events,
and the tendency of a woman to present a physical symp-
tom as a sign of depression. The aim of this study was to
investigate how women with psychiatric disorders pre-
sent themselves at a gynecologic clinic (eg, what kinds of

396
Volume 185, Number 2
Am J Obstet Gynecol
physical symptoms or diagnoses they had, whether their
appointments were scheduled or unscheduled, and
whether they made frequent visits). The study consisted
of a population of patients in which the prevalence of
psychiatric disorders had been reported earlier.16
Material and methods
Study population. From November 16, 1998, to Decem-
ber 15, 1998, all patients with scheduled appointments
and patients who made walk-in visits for medical care at
two gynecologic practices in northern Sweden (Umeå
University Hospital and a private clinic in Piteå) were ap-
proached for participation in the study. The two centers
mainly offer gynecologic expertise, whereas obstetric pa-
tients in the second or third trimester of pregnancy re-
ceive care elsewhere. Both the patients with scheduled ap-
pointments, with or without referral, and those who made
walk-in visits receive care at the clinics. Exclusion criteria
for the study were (1) age younger than 18 years, (2) se-
vere illness and/or pain, (3) inability to read and under-
stand the questionnaire because of language difficulties
or cognitive impairment, (4) previous evaluation with the
Primary Care Evaluation of Mental Disorders (PRIME-
MD; Pfizer Inc, New York, NY) at an earlier visit during the
study period, and (5) lack of informed consent.
Diagnoses of psychiatric disorders were made using the
PRIME-MD system, which was developed to help primary
care physicians to screen, evaluate, and diagnose mental
disorders. Given its utility and ease of use, PRIME-MD was
considered to be a suitable tool for assessing the preva-
lence of psychiatric disorders in a gynecologic setting, in
particular since the spectrum of psychiatric disorders
found among gynecologic patients can be expected to re-
semble that found in a primary care practice. The PRIME-
MD system was constructed to conform to criteria of the
Diagnostic and Statistical Manual of Mental Disorders, Fourth
Edition (DSM-IV), and has been validated for use in a pri-
mary care setting.17-19 The agreement between PRIME-
MD and independent psychiatric diagnoses guided by a
structured interview is generally excellent across modules,
with an overall accuracy of 88%.17 The PRIME-MD system,
which is fully described elsewhere,17 consists of two com-
ponents: a 1-page Patient Health Questionnaire (PHQ)
and a 12-page clinician evaluation guide, which is a struc-
tured interview for the clinician to use when evaluating
the responses on the PHQ. The clinician evaluation guide
contains modules for somatoform disorders, eating disor-
ders, mood disorders, anxiety, alcohol abuse, obsessive-
compulsive disorders, and social phobia and a question
about how patients perceive their general health. Clini-
cians administer only the modules that are indicated by
the patient on the PHQ. Normally, the PRIME-MD screen-
ing questionnaire contains 4 questions concerning alco-
hol abuse, but these questions were omitted in this study.
The PRIME-MD system evaluates the presence of 20 possi-
Bixo et al 397
ble mental disorders, and this study focused on 13 of those
diagnoses. Of the 13 diagnoses of interest, 8 disorders
were considered to be “threshold” diagnoses because they
correspond to the specific requirements of DSM-IV (ie,
major depressive disorder, dysthymia, partial remission of
major depressive disorder, generalized anxiety disorder,
panic disorder, obsessive-compulsive disorder, social pho-
bia, and bulimia nervosa). An additional 4 diagnoses were
considered to be “subthreshold” diagnoses (ie, minor de-
pressive disorder, anxiety not otherwise specified, eating
disorder not otherwise specified, and binge eating disor-
der). Subthreshold diagnoses have fewer symptoms than
what is required for a specific DSM-IV diagnosis but are in-
cluded because they are associated with impairment of
function. Finally, a rule-out diagnosis of bipolar disorder
was included.
All patients completed and handed in the PRIME-MD
PHQ before seeing their physician, who was often un-
aware of the ongoing study. To pursue a diagnosis, a struc-
tured telephone interview was conducted 1 to 2 weeks
later with screen-positive patients who had signed an in-
formed consent for that. Patients were considered to be
screen positive if they responded to any key question for
mental disorders on the PHQ. Screen-negative patients
were those who acknowledged no items on the PHQ or
who acknowledged only the key questions for somato-
form disorder or social phobia. Each telephone interview
lasted 10 to 15 minutes. The physical symptoms indicated
by the patient in the somatoform module of the PHQ
were registered but not followed up in the interview. The
study population and procedure are thoroughly de-
scribed elsewhere.16
In short, 1101 patients were eligible for the study, and
1013 patient questionnaires were distributed—818 at the
hospital center and 195 at the private clinic. The response
rate was 88.6%, and 784 (77.4%) patients also consented
to a telephone interview. Of those, 413 (52.7%) re-
sponded to 1 or more of the key questions about mental
disorders, and 18 (2.3%) could not be reached by tele-
phone within the stipulated 14-day period. Hence, a tele-
phone interview was conducted in 413 cases, and the study
population wherein a possible confirmation of a PRIME-
MD diagnosis could be obtained consisted of 766 subjects.
The control group consisted of patients who were screen
negative (n = 353) and those who were screen positive but
who after the follow-up telephone interview were not con-
sidered to have a psychiatric diagnosis (n = 179). The
mean age of the patients who consented to a telephone in-
terview was 43.8 ± 14.3 years. The study identified 234
(30.5%) patients with a PRIME-MD diagnosis. Full DSM-
IV diagnoses were present in 16.3%, whereas 14.2% had
only a subthreshold diagnosis. Depressive disorder was di-
agnosed in 208 (27.2%) patients and anxiety disorder in
93 (12.1%) patients. Comorbidity was common—34.6%
of the patients had 2 or more psychiatric diagnoses.16
398 Bixo et al August 2001
Am J Obstet Gynecol

Table I. Number of patients with or without psychiatric diagnosis with respect to their primary gynecologic diagnosis

Controls Patients with any psychiatric diagnosis

Diagnosis No. % No. %

Abdominal pain 29 53.7 25 46.3

Climacteric symptoms 98 73.7 35 26.3
Cervical dysplasia 58 78.4 16 21.6
Vulva diseases 58 73.4 21 26.6
Legal abortion 12 50.0 12 50.0
Menometrorrhagia 83 74.1 29 25.9
Urogynecologic problems 17 53.1 15 46.9
Infertility 34 72.3 13 27.7
Family planning 24 66.7 12 33.3
Pregnancy-related problems 20 76.9 6 23.1
Infection 7 70.0 3 30.0
Others 78 66.7 39 33.3

Table II. Risk factors influencing the probability of having any depression diagnosis (n = 199)

Cases Controls
Odds ratio (95% confidence interval,
Variable No. % No. % bivariate analysis) P

Diagnosis
Abdominal pain 23 11.6 29 5.6 2.17 (1.22-3.84) .0081
Legal abortion 10 5.0 12 2.3 2.20 (0.93-5.17)
Menometrorrhagia 23 11.6 83 16.0 0.70 (0.42-1.14)
Cervical dysplasia 14 7.0 58 11.2 0.62 (0.33-1.33)
Endocrinology/infertility 11 5.5 30 5.8 0.88 (0.42-1.84)
Pregnancy-related problems 4 2.0 20 3.9 0.50 (0.17-1.49)
Infections 3 1.5 7 1.4 1.10 (0.28-4.31)
Climacteric symptoms 34 17.1 98 18.9 0.87 (0.57-1.33)
Family planning 12 6.0 24 4.6 1.30 (0.64-2.66)
Urogynecologic problems 14 7.0 21 4.1 1.76 (0.88-3.54)
Vulva diseases 17 8.5 58 11.2 0.68 (0.38-1.22)
Others 34 17.1 78 15.1 1.14 (0.73-1.77)
No. of visits
1 1
2-3 55 27.6 138 26.6 1.13 (0.77-1.64)
≥4 23 11.6 41 7.9 1.58 (0.91-2.75)
Hospitalization for acute care
0 1
≥1 9 4.5 9 1.7 2.64 (1.03-6.75) .0425
Surgery planned
No 1
Yes 15 7.5 34 6.4 1.14(0.61-2.15)
Appointment
Scheduled 1
Unscheduled 37 18 52 14.7 1.14 (0.71-1.84)

The study was approved by the Ethics Committee,
Umeå University, Sweden.
Review of medical charts. When all the telephone in-
terviews were completed and the PRIME-MD diagnoses
were obtained, the medical charts of all the patients were
thoroughly reviewed. Apart from the gynecologic diagno-
sis registered at the patient’s visit during the study period,
data regarding type of appointment, number of visits and
acute hospitalizations during the last year, and whether
surgery was planned for the patient were noted. In addi-
tion, information in the gynecologic medical records re-
garding psychiatric history and treatment was obtained.
Statistics. Continuous variables were compared by
using the t test and are displayed as mean ± SD. Logistic
regression was used for estimating association between
PRIME-MD diagnoses, gynecologic diagnoses, type of ap-
pointment, number of visits and hospitalizations for
acute care, and whether surgery was planned for the pa-
tient. All statistical analyses were performed using SPSS
7.5 for Windows (SPSS, Inc, Chicago, Ill). A P value < .05
was considered significant.
Results
Gynecologic diagnoses in relation to PRIME-MD diag-
noses. Factors influencing the risk of having any depres-
sive, anxiety, or full DSM-IV disorder, according to gyne-
Volume 185, Number 2 Bixo et al 399
Am J Obstet Gynecol

Table III. Risk factors influencing the probability of having any anxiety diagnosis (n = 90)

Cases Controls
Odds ratio (95% confidence interval,
Variable No. % No. % bivariate analysis) P

Diagnosis
Abdominal pain 15 16.7 29 5.6 3.34 (1.71-6.50) .0004
Legal abortion 3 3.3 12 2.3 1.44 (0.40-5.22)
Menometrorrhagia 9 10.0 83 16.0 0.60 (0.29-1.23)
Cervical dysplasia 7 7.8 58 11.2 0.70 (0.31-1.57)
Endocrinology/infertility 4 4.4 30 5.8 0.58 (0.17-1.94)
Pregnancy-related problems 5 5.5 20 3.9 1.45 (0.53-3.98)
Infections 2 2.2 7 1.4 1.65 (0.34-8.06)
Climacteric symptoms 15 16.7 98 18.9 0.85 (0.47-1.54)
Family planning 2 2.2 24 4.6 0.46 (0.11-2.00)
Urogynecologic problems 6 6.7 21 4.1 1.68 (0.66-4.28)
Vulva diseases 8 8.9 58 11.2 0.77 (0.35-1.67)
Others 14 15.6 78 15.1 1.03 (0.56-1.91)
No. of visits
1 1
2-3 28 31.1 138 26.6 1.59 (0.95-2.66)
≥4 16 17.8 41 7.9 3.06 (1.58-5.92) .0013
No. of acute hospitalizations
0 1
≥1 6 6.7 9 1.7 4.01 (1.39-11.54) .01
Surgery planned
No 1
Yes 7 7.8 34 6.4 1.19 (0.51-2.78)
Appointment
Scheduled 1
Unscheduled 24 26 52 14.7 1.86 (1.08-3.21) .024

Table IV. Risk factors influencing the probability of having a full DSM-IV diagnosis (n = 122)

Cases Controls
Odds ratio (95% confidence interval,
Variable No. % No. % bivariate analysis) P

Diagnosis
Abdominal pain 16 13.1 29 5.6 2.55 (1.34-4.85) .045
Legal abortion 8 6.6 12 2.3 2.96 (1.18-7.41) .020
Menometrorrhagia 18 14.8 83 16.0 0.94 (0.54-1.63)
Cervical dysplasia 5 4.1 58 11.2 0.35 (0.14-0.90) .03
Endocrinology/infertility 10 8.2 30 5.8 1.35 (0.62-2.92)
Pregnancy-related problems 4 3.3 20 3.9 0.85 (0.28-2.52)
Infections 2 1.6 7 1.4 1.22 (0.25-5.94)
Climacteric symptoms 16 13.1 98 18.9 0.65 (0.37-1.15)
Family planning 6 4.9 24 4.6 1.07 (0.43-2.67)
Urogynecologic problems 9 7.4 21 4.1 1.89 (0.84-4.23)
Vulva diseases 8 6.6 58 11.2 0.56 (0.26-1.20)
Other causes 20 16.4 78 15.1 1.10 (0.65-1.89)
No. of visits
1 1
2-3 33 27.0 138 26.6 1.17 (0.74-1.86)
≥4 17 13.9 41 7.9 2.04 (1.09-3.81) .024
No. of acute hospitalizations
0 1
≥1 6 4.9 9 1.7 2.93 (1.02-8.39) .0452
Surgery planned
No 1
Yes 8 6.6 34 6.4 1.00 (0.45-2.22)
Appointment
Scheduled 1
Unscheduled 30 24 52 14.7 1.83 (1.10-3.02) .019
400 Bixo et al
Table V. Frequency of physical symptoms by prevalence of any PRIME-MD diagnosis
Percentage of patients reporting symptoms
All physical symptoms Diagnosed PRIME-MD (n = 234)
Abdominal pain 44.9
Back pain 56.4
Bowel complaints 41.6
Chest pain 26.8
Dizziness 39.7
Dyspnea 12.4
Headache 52.8
Fatigue 89.7
Insomnia 48.7
Joint or limb pain 52.4
Nausea 57.8
Palpitations 31.2
Fainting 3.9
Menstrual problems 42.5
Sexual problems 23.4
cologic diagnosis, are presented in Tables I through IV.
Patients with any mood disorder, including those with
minor depression, were identified more often among pa-
tients seeking treatment for abdominal or pelvic pain
(see Table II). These patients made 1.86 visits to gyneco-
logic clinics during 1998 compared with 1.68 visits made
by patients with no psychiatric diagnosis. Furthermore,
patients presenting with abdominal or pelvic pain had a
more than 3-fold increased risk of having an anxiety dis-
order (see Table III). Patients with abdominal or pelvic
pain and patients undergoing legal abortion had 2 to 3
times increased risk of fulfilling full DSM-IV criteria for
any psychiatric disorder at the time of the interview (see
Table IV). Patients within the screening program for cer-
vical dysplasia or with cervical dysplasia were less often di-
agnosed with a full DSM-IV diagnosis than other gyneco-
logic patients (see Table IV).
Patients with anxiety disorders made more visits to the
gynecologic center during 1998 than patients without
psychiatric diseases (2.31 visits vs 1.68 visits, P < .0001).
Patients with a full DSM-IV diagnosis were also frequent
visitors, with a mean number of visits during 1998 of
2.03, which differed significantly from the control
group, P < .05. Within the study group, 19 patients at
some time during 1998 had been hospitalized for acute
care. Women with any mood or anxiety disorder or any
full DSM-IV diagnosis were more likely to have a history
of hospitalization for acute care, whatever the gyneco-
logic cause was, than control subjects (see Tables II
through IV). However, patients who had planned for
surgery during the study period, regardless whether the
operation was performed during or after the study pe-
riod, did not display an increased risk for having any
mood or anxiety disorder.
Psychiatric history in the gynecologic records. Very little
on psychiatric history and treatment was found in the
medical records at the gynecologic centers. Among pa-
August 2001
Am J Obstet Gynecol
Nondiagnosed PRIME-MD (n = 532) P
25.0 .0001
36.6 .0001
22.0 .0001
12.5 .0001
16.3 .0001
4.4 .0001
35.7 .0001
48.5 .0001
21.6 .0001
40.3 .002
29.4 .0001
12.7 .0001
0.9 .017
30.9 .003
14.8 .005
tients with any psychiatric PRIME-MD diagnosis, 23
(9.8%) had a notation regarding psychiatric history in
their medical record, and 38 patients (16.2%) presented
with psychiatric symptoms in addition to their gyneco-
logic problems. Thirty-five patients (15.0%) with any psy-
chiatric PRIME-MD diagnosis had been prescribed anti-
depressant medications; the majority of these cases were
discovered during the telephone interviews. In addition,
a number of patients not detected by PRIME-MD as hav-
ing any psychiatric disorder had evidence of ongoing or
prior psychiatric diseases. Among these, 18 patients
(3.3%) had a psychiatric history in their gynecologic
records, 10 (1.9%) were taking antidepressant medica-
tion, and 30 (5.6%) presented with psychiatric symptoms
in addition to their gynecologic problems. A number of
patients received a psychiatric diagnosis by their gynecol-
ogist: 7 patients were diagnosed with premenstrual dys-
phoric disorder, 6 patients were diagnosed with major de-
pression, and 1 patient was diagnosed with panic
disorder. Among patients diagnosed with major depres-
sion, 3 received only a psychiatric diagnosis. Of the pa-
tients with premenstrual dysphoric disorder, 6 had an ad-
ditional psychiatric diagnosis according to PRIME-MD.
Four patients reported prior eating disorders from which
they most likely had recovered, as PRIME-MD was unable
to recognize any present eating disorder. However, 2 of
these patients still suffered from endocrine aberrations
due to their eating disorder (eg, amenorrhea and men-
strual disturbances).
Physical symptoms. Table V summarizes the frequency
of physical symptoms reported by the patients on the PHQ
with respect to prevalence of any PRIME-MD diagnosis. Vir-
tually all somatic symptoms were significantly more com-
monly reported by patients with a PRIME-MD diagnosis.
Among diagnosed patients, the prevalence of sexual prob-
lems was 23.4%, whereas menstrual problems and abdomi-
nal pain were reported to be 42.5% and 44.9%, respectively.
Volume 185, Number 2
Am J Obstet Gynecol
Comment
The results of this study suggest that women attending
a gynecologic clinic with abdominal pain as their main
problem are more likely to have a psychiatric disorder
than those seeking care for other reasons. Both depres-
sion and anxiety are more common in this group than
among those seeking care for other reasons, but this is not
surprising considering the high frequency of this kind of
comorbidity among women. A higher prevalence of psy-
chiatric disorders among women seeking care for pelvic
pain at a gynecologic clinic has been reported earlier.20
However, even though chronic physical illness is a risk fac-
tor for psychiatric disease, it is impossible to know the
exact nature of the relationship in an individual patient.
Because the current opinion among psychiatrists is that
secondary psychiatric disorders should be treated, it is im-
portant to identify patients with these types of disorders.
It is well established that women are more prone to de-
velop somatoform disorders than men21 and that physical
symptoms overall are more common in women, regardless
of psychiatric disease, as assessed in primary care.15 In
women, physical symptoms such as headache, chronic fa-
tigue, pain, and bleeding irregularities are often associ-
ated with psychiatric disorders.22 Depressive symptoms are
often not recognized in clinical gynecologic practice.23 In
this study, gynecologists did not recognize the psychiatric
diagnosis in most patients and therefore those patients
were not treated. Only 10% of the patients were adminis-
tered antidepressant therapy.16 Epidemiologic data indi-
cate that two thirds of depressed subjects had not been
prescribed any treatment.19 It is evident from our results
that gynecologic patients with psychiatric disorders are
prone to seek medical care more frequently and at un-
scheduled times and are also hospitalized for acute care
more often. The consequences of not identifying and
treating these women properly is, apart from the pro-
longed suffering for the patients, an unnecessary burden
on medical units. Given the high rates of mental disorders
among gynecologic patients, it is desirable that gynecolo-
gists become familiar with these conditions and become
more willing to treat and refer for treatment women with
depression and other common mental disorders.
In this study, women applying for induced abortion had
an almost 3-fold risk of having a full DSM-IV diagnosis. On
the other hand, studies focused more on social and psy-
chologic factors have found that abortion is unlikely to be
followed by severe psychologic responses.24,25 Rather, psy-
chologic aspects were considered to be best understood as
normal reactions of stress and coping. However, one ex-
planation for our results might be that at the time of the
telephone interview the women were in the midst of the
abortion process since the procedure is typically per-
formed 1 to 2 weeks after the first visit.
In conclusion, women with psychiatric disorders are
commonly found in a gynecologic setting. They have
Bixo et al 401
more somatic symptoms in general, and abdominal pain
is the most common diagnosis in their medical chart. In
addition, their visits are more frequent and more often
unscheduled, and hospitalization for acute care is more
common in this group.
Dr Karin Bishop Bondestam is greatly appreciated for
the English language revision.
REFERENCES
1. Kessler RC, McGonagle KA, Zhao S, Nelson CB, Hughes M,
Eshleman S, et al. Lifetime and 12-month prevalence of DSM-
III-R psychiatric disorders in the United States. Results from the
National Comorbidity Survey. Arch Gen Psychiatry 1994;51:
8-19.
2. Wittchen H-U, Essau CA, von Zerssen D, Krieg J-C, Zaudig M.
Lifetime and six-month prevalence of mental disorders in the
Munich follow-up study. Eur J Psychiatry Neurosci 1992;241:
247-58.
3. Weissman MM, Klerman GL. Sex differences in rates of depres-
sion: cross-national perspectives. Arch Gen Psychiatry 1977;34:
98-111.
4. Ernst C, Angst J. The Zurich study. XII. Sex differences in de-
pression. Evidence from longitudinal epidemiological data. Eur
Arch Psychiatry Clin Neurosci 1992;241:222-30.
5. Breslau N, Schultz L, Peterson E. Sex differences in depression:
a role for preexisting anxiety. Psychiatry Res 1995;58:1-12.
6. O’Hara MW. Psychologic and biologic factors in postpartum de-
pression. In: Demers LM, McGuire JL, Phillips A, Rubinow DR,
editors. Premenstrual, postpartum and menopausal mood
disorders. Baltimore-Munich: Urban & Schwarzenberg; 1989;
p. 139-52.
7. Williams KE, Koran LM. Obsessive-compulsive disorder in preg-
nancy, the puerperium, and the premenstruum. J Clin Psychia-
try 1997;58:330-4.
8. Rivera-Tovar AD, Frank E. Late luteal phase disorder in young
women. Am J Psychiatry 1990;147:1634-6.
9. Pearlstein TP, Frank E, Rivera-Tovar A, Thofi JS, Jacobs E,
Mieczkowski TA. Prevalence of axis I and axis II disorders in
women with late luteal phase dysphoric disorder. J Affect Disord
1990;20:129-34.
10. Graze KK, Nee J, Endicott J. Premenstrual depression predicts
future major depressive disorder. Acta Psychiatr Scand 1990;81:
201-5.
11. Avis NE, Brambilla D, McKinlay SM, et al. A longitudinal analysis
of the association between menopause and depression. Ann Epi-
demiol 1995;4:214-20.
12. Wool CA, Barsky AJ. Do women somatize more than men?
Gender differences in somatization. Psychosomatics 1994;35:
445-52.
13. Kroenke K, Price RK. Symptoms in the community: prevalence,
classification, and psychiatric comorbidity. Arch Intern Med
1993;153:2474-80.
14. Katon W, Kleinman A, Rosen G. Depression and somatization:
A review. Am J Med 1982;72:127-35,241-7.
15. Kroenke K, Spitzer RL. Gender differences in the reporting of
physical and somatoform symptoms. Psychosom Med 1998;60:
150-5.
16. Sundström L, Bixo M, Björn I, Åström M. Prevalence of psychi-
atric disorders in gynecologic outpatients. Am J Obstet Gynecol
2001;184:8-13.
17. Spitzer RL, Williams JB, Kroenke K, Linzer M, deGruy FV, Hahn
SR, et al. Utility of a new procedure for diagnosing mental dis-
orders in primary care. JAMA 1994;272:1749-56.
18. Kobak KA, Taylor LH, Dottl SL, Greist JH, Jefferson JW, Bur-
roughs D, et al. Computerized screening for psychiatric disor-
ders in an outpatient community mental health clinic. Psychiatr
Serv 1997;48:1048-57.
19. Lepine JP, Gastpar M, Mendlewicz J, Tylee A. Depression in the
community: the first pan-European study DEPRES (Depression
402 Bixo et al
Research in European Society). Int Clin Psychopharmacol
1997;12:19-29.
20. Byrne P. Psychiatric morbidity in a gynaecology clinic. An epi-
demiological survey. Br J Psychiatry 1984;144:28-34.
21. Smith GR. Somatization disorder and undifferentiated somato-
form disorder. In: Gabbard GO, editor. Treatments of psychi-
atric disorders. 2nd ed. Washington (DC): American Psychiatric
Press; 1995. p. 1718-1733.
22. Vaeroy H, Merskey H. The prevalence of current major depres-
August 2001
Am J Obstet Gynecol
sion and dysthymia in a Norwegian general practice. Acta Psychiatr
Scand 1997;95:324-8.
23. Buekens P, van Heeringen K, Boutsen M, Smekens P, Mattellaer P.
Depressive symptoms are often unrecognized in gynaecological
practice. Eur J Obstet Gynecol Reprod Biol 1998;81:43-5.
24. Turell SC, Armsworth MW, Gaa JP. Emotional response to abortion: a
critical review of the literature. Women & Therapy 1990;9(4):49-68.
25. Adler NE, David HP, Major BN, Roth SH, Russo NF, Wyatt GE. Psy-
chological factors in abortion. Am Psychol 1992;47:1194-204.