Psychiatry in

O&G
and ICU
Learning Outcomes
At the end of this session:

● Understand the role of liaison psychiatric, the relationship of each liaison

posting and psychiatry
● Recognize their role and implications in treatments

Content:

● Psychiatric aspects in different non-psychiatric settings

● Basic management principles
Psychiatric aspects of Obstetrics
and Gynaecology
Pregnancy
● Psychiatric d/o more common in first and third trimester
● First trimester unwanted pregnancies are a/w anxiety and depression
● Third trimester there may be fears about the impending delivery or
doubts about the normality of the fetus.
● More common in women with previous psychiatric disorder
Management of Depression in
Pregnancy
1. Assessment

2. Consideration of treatment options

a. Psychoeducation

b. Psychological treatment

c. Anti depression (usually SSRI)

3. Providing patient with accurate information about risks and benefits.

 Use of Psychiatric Medicines during
Pregnancy and Breastfeeding
Pregnancy

● Avoid all medication if possible especially during first trimester.

● Antidepressants
○ No evidence that SSRIs causes fetal abnormalities

○ Use in minimal dosage

○ Possibility of SSRI withdrawal in neonates

● Lithium
○ Small risk of teratogenicity in first trimester
○ Toxic effect on fetus in late pregnancy
○ Ideally should be avoided in period of conception and early pregnancy
○ Unplanned pregnancy during long-term therapy, consider termination
or screening for malformations
○ Present in breast milk with possible risk of toxicity.
● Antipsychotic
○ Continue in minimal dose if there are major clinical indications
○ Occasional extrapyramidal side effects seen in neonates.
○ If breastfeeding, theoretical risk to nervous system development
Postpartum Mental Disorder
Maternity ‘Blues’
● Brief episode of irritability, lability of mood and episodes of crying
● Lability of mood is particularly characteristic
○ Rapid alternation between euphoria and and misery
● Symptoms reach their peak on 3rd and 4th day postpartum
● More frequent in primigravida
● Have often experience anxiety and depressive symptoms in the last
trimester of pregnancy.
● More likely to give history of premenstrual tension, fear of labour and
poor social adjustment.
● May be related to readjustment in hormones after delivery (not
established)
● Resolves spontaneous in a few days
Puerperal Psychosis (Postpartum
Psychosis)
● 1 - 2 per 1000 births

● More frequent in primiparous women and those who have suffered

previous major psychiatric illness

● More common in developing countries

Aetiology
● Genetic predisposition

● Drastic hormonal changes following delivery (no evidence)

● Precipitating factors:
○ Endocrine factors

○ Immunological factors

● Sleep deprivation associated with childbirth may play a role (disrupted

sleep can precipitate mania in vulnerable individuals)

Clinical Features
● Onset often within 2 - 3 days of delivery
● Usually within first 1 - 2 weeks
● Sudden, rapid deterioration
● Three types of clinical picture:
○ Delirium (less frequent now since puerperal sepsis was reduced by
antibiotics)
○ Mood disorder (bipolar disorder with mania or mixed features or
depressive psychosis)
○ Schizophreniform disorder (insomnia and overactivity are early
Management
● Prompt assessment and potential risks to mother and baby.
● Psychiatric assessment
● Treatment
○ Usually requires inpatient care
○ Best if the child can remain with the mother (minimize adverse
effects on bonding)
○ Consider child protection
○ Antipsychotic (mainstay)
○ Antidepressants (if depressive symptoms prominent)
○ Adjunct benzodiazepines (insomnia and sleep disturbances)
○ Lithium (clear bipolar component)
○ Consider early use of ECT
 Prognosis
● 75% have good outcome after puerperal psychosis

● Recovery usually within few months

● Risk of relapse high

● 70% have non-puerperal recurrence (usually bipolar disorder)

● Should be given preconception care and regular psychiatric support

during and immediately after each pregnancy.

● Maintenance medication (antipsychotic, mood stabilizers)

Postnatal Depression
● Less severe, more common than puerperal psychosis
● A third of cases starts during pregnancy
● Clinical features:
○ Tiredness
○ Irritability
○ Anxiety
○ Phobic and obsessional symptoms concerning fears about harming
baby
● Recover after 2 - 6 months
● High risk of relapse
Aetiology
● Precipitated in vulnerable mothers by psychological adjustment required
after childbirth, loss of sleep and hard work involved in the care of the baby.
● Main risk factors:
○ History of depression
○ Indication of social adversity
○ Low levels of partner or other support
○ Relationship difficulties
○ Domestic violence
○ Unintentional pregnancy
Management
● Screening (Edinburgh Postnatal Depression Scale)

○ The 10-question Edinburgh Postnatal Depression Scale (EPDS) is a

valuable and efficient way of identifying patients at risk for perinatal´

depression

● Non-directive counselling

● Antidepressant medication

● Referral to psychiatric services

Psychiatric Aspects of
Gynaecology
Premenstrual Syndrome and
Premenstrual Dysphoric Disorder

● A group of psychological and physical symptoms starting a few days

before and ending shortly after onset of menstrual period.

Psychological symptoms Physical symptoms

Anxiety Breast tenderness

Irritability Abdominal discomfort

Mood lability Feeling of distension

Food cravings

Depression
 Diagnostic Criteria of
Premenstrual Dysphoric Disorder
A. In the majority of menstrual cycles, at least five symptoms must be present
in the final week before the onset of menses, start to improve within few
days after onset of menses, and become minimal or absent in the week
postmenses.
B. One (or more) of the following symptoms must be present:
1. Marked affective lability (e.g., mood swings; feeling suddenly sad or
tearful, or increased sensitivity to rejection).
2. Marked irritability or anger or increased interpersonal conflicts.
3. Marked depressed mood, feelings of hopelessness, or self-deprecating
thoughts.
4. Marked anxiety, tension, and/or feelings of being keyed up or on edge.
C. One (or more) of the following symptoms must be additionally be present, to
reach a total of five symptoms when combined with symptoms from Criterion B.

1. Decreased interest in usual activities (e.g., work, school, friends,

hobbies).
2. Subjective difficulty in concentration.
3. Lethargy, easy fatigability, or marked lack of energy.
4. Marked change in appetite; overeating or specific food cravings.
5. Hypersomnia or insomnia
6. A sense of being overwhelmed or out of control.
7. Physical symptoms such as breast tenderness or swelling, joint or
muscle pain, a sensation of ‘bloating,’ or weight gain.
D. The symptoms are associated with clinically significant distress or
interference with work, school, usual social activities, or relationships with
others (e.g., avoidance of social activities; decreased productivity and
efficiency at work, school, or home).

E. The disturbance is not merely an exacerbation of the symptoms of another

disorder, such as major depressive disorder, panic disorder, persistent
depressive disorder (dysthymia), or a personality disorder (although it may co-
occur with any of these disorders).
F. Criterion A should be confirmed by prospective daily ratings during at least
two symptomatic cycles. (Note: The diagnosis may be made provisionally prior
to this confirmation.)

G. The symptoms are not attributable to the physiological effects of a

substance (e.g., a drug of abuse, a medication, other treatment) or another
medical condition (e.g., hyperthyroidism).
Treatment
PMS PMDD
Progesterone SSRIs
Oral contraceptive Oral contraceptives (improve physical
symptoms)
Bromocriptine Cognitive behavioural therapy
Diuretics Lifestyle modifications
Psychotropic drugs
No convincing evidence of
effectiveness, high placebo response
The Menopause
● Physical symptoms
○ Flushing,
○ Sweating
○ Vaginal dryness
● Often complain of headache, dizziness and depression
● Causes:
○ Hormonal changes (notably deficiency of estrogen)
○ Psychiatric symptom could well reflect changes in woman’s role as
her children leave home, relationship with her husband alters, own
parents become ill or die.
● No specific treatment
Psychiatric in ICU
Psychiatric Intensive Care Units
● Low level security units or locked sections of general psychiatric hospital

● Catering only few patients at a time

● 1:1 nursing

● Manage acutely disturbed patients who cannot be safely treated in an

open ward.
De-escalation Techniques (First-Line)
● Physical restraint or seclusion should only be used when appropriate
psychological and behavioural approaches have failed or are
inappropriate.
● Encourage the patient to go into a room or area designated for reducing
agitation, which is away from other patients and visitors.
● Speak confidently, using clear, slow speech and avoiding changes in
volume or tone.
● Adopt a non-threatening body posture—reduce direct eye contact, keep
both hands visible, and make slow movements (or pre-warn ‘I am going to
● Explain clearly to the patient what is happening, why, and what will
happen next.
● Ask the patient to explain any problems, how they are feeling, and why
the situation has arisen. Try and develop a rapport with the patient, show
empathy and concern, and offer realistic solutions to any problems.
● If weapons are involved, make sure the minimum number of people are
in the room and ask the patient to put the weapon down in a neutral
position.
● Use non-threatening verbal and non-verbal communication
Intervention (Tranquilizer)
Aim:

● calm the person

● reduce the risk of violence and harm, rather than treat the underlying
psychiatric condition.

Disadvantage:

● Patient unable to participate in further assessment and treatment at that

time.
● The equipment and expertise to do cardiopulmonary resuscitation should
be available, as should antidotes to commonly used sedatives (e.g.
flumazenil, a benzodiazepine antagonist).
● Ideally, a drug would be used that has a rapid onset, short half-life,
minimal side effects, and is easily reversible.
Physical Intervention and Seclusion
● Restraint used only for the shortest amount of time possible.
● Examples of when it is appropriate:
○ to administer essential intramuscular medications;
○ to allow a doctor to perform an essential physical examination or
conduct investigations (e.g. a blood test or vital signs monitoring);
○ in order to move a patient to a place of safety so as to reduce the risk
to others;
○ to prevent continued serious self-harm.
Seclusion
● Last resort in managing behavioural disturbance with high risk to others
● Seclusion room must have:
○ have clear facilities for staff observation (within eyesight);
○ have a comfortable area for the patient to lie down and sleep (e.g. a
mattress);
○ be well insulated and ventilated;
○ have a private toilet and washing facilities;
○ be able to withstand attacks/damage.
● reviewed by staff every 2 hours, and by a doctor every 4 hours
● Moved back into usual environment if rapid tranquilization starts to take
effect