NASHVILLE -- Pregnant patients with psychiatric conditions, such as depression, have a slightly different set of risk factors for suicide than non-pregnant patients, an expert said here.
While rates of suicide are lower in pregnant and post-partum women compared with non-perinatal women (1-5 per 100,000 vs 5-10 per 100,000, respectively), it still accounts for 5%-20% of deaths in the pregnant and post-partum population, said Kimberly Yonkers, MD, of Yale School of Medicine in New Haven, Connecticut.
Yonkers gave the Donald F. Richardson Memorial Lecture at the American College of Obstetricians and Gynecologists (ACOG) annual meeting, where she discussed the risk factors and psychiatric conditions associated with suicide, including patients who might be seen by ob/gyn clinicians.
When thinking about risk factors for depression, Yonkers said that regular depressive symptoms can "overlap" with pregnancy symptoms, such as sleep difficulties. Instead, she recommended focusing on cognitive symptoms, such as anhedonia, or lack of interest, depressed mood, concentration difficulties, as well as suicidal thoughts or recurrent thoughts of death.
Yonkers cited research from the Yale "," which followed around 2,500 women from pregnancy through the postpartum period. About 20% of the overall cohort had major depressive disorder, she said, and 4.5% of these women had thoughts of self-harm. Of these women, around a third apiece had either major depressive disorder or generalized anxiety disorder, with about 20% experiencing panic disorder.
Yonkers also cited research that found other differences in suicide risk factors in perinatal women versus non-perinatal women, including:
- More likely to have a duration of illness <1 year
- Less likely to have history of alcohol misuse
- More likely to use violent versus non-violent means
- Half as likely to be receiving pharmacological, psychological, or other treatment
Yonkers touched upon the last point, adding that not only do many pregnant women try to avoid using medication during pregnancy because they don't want to harm the baby, but many doctors don't want to put their patients on psychotropic medication even in pregnancy.
"They will take the risk that someone relapses rather than having a bad baby outcome. Where I work, I see that psychiatrists are more likely to take patients off their medication than my obstetrical colleagues," she said.
Patients Triggered by Pelvic Exams
A trigger may play a part in suicidal ideation, and Yonkers warned ob/gyns that for their patients with existing psychiatric conditions, such as post-traumatic stress disorder (PTSD), a pelvic exam may be triggering for many patients.
"A patient may have experienced sexual abuse, and having a pelvic exam can feel like that same sort of intrusion. That needs to be handled very sensitively," Yonkers said.
Dissociation is a symptom of PTSD, a "psychological trick not to be present when a trauma is occurring" -- for example, during a pelvic exam, Yonkers said. Other patients may experience flashbacks, even for a trauma they had forgotten existed.
"Some people forget about trauma for many years and maybe they're on your exam table and they're having their first pelvic, because they avoided pelvics and they start experiencing some thoughts of the trauma," she added.
Yonkers said that any psychiatric illness can increase the risk of substance use disorder, which could be related to the traumatic experience. But predicting which patients may be at risk for suicide is "one of the holy grails," she added.
Routine screening for depression, which is standard in pregnancy, can help, Yonkers said. Ob/gyn clinicians can also give their patients a list of providers for further counseling and treatment, and should encourage abstinence from substances. But the most important thing, she said, may be drawing upon the "therapeutic alliance" the ob/gyn provider has with the patient in order to broach the topic of suicidal thoughts.
For example, Yonkers suggested phrasing such as, "A lot of people who feel down think about wanting to be dead. Have you been feeling that way?"
"If you ask patients about suicidal thoughts, you are not introducing that notion into their head. But build up to it -- you know the patient, you have a caring relationship with the patient, and that goes a long way," she said.
Disclosures
Yonkers disclosed no relevant relationships with industry.
Primary Source
American College of Obstetricians and Gynecologists
Yonkers K "The Donald F. Richardson Memorial Lecture -- When Clinical Conditions Collide: Mental health, suicide and substance use disorder in women" ACOG 2019; COL8.