Screen for mental health, safety concerns at well woman visits

CHICAGO — In addition to routine medical screening, clinicians should assess women for life factors that may affect their overall well-being during regular well visits, according to a presenter here.

Specifically, patients should be screened for mental health issues, alcohol use and safety concerns.

Depression

Depression is prevalent in 10% of the United States population and in 21% of the population over the life course, according to Juliana (Jewel) M. Kling, MD, MPH, NCMP, FACP, an associate professor of medicine, chair of the division of women's health internal medicine, assistant director of the women's health center and associate chair of equity, inclusion and diversity for the department of medicine at the Mayo Clinic in Scottsdale, Arizona.

However, without screening, only half of the patients with major depression would be diagnosed.

“One of the reasons that we’re talking about screening is because, unfortunately, about two-thirds of patients don’t directly come into the office, sit down and say, ‘Hey, doctor, I think I’m depressed,’” Kling said during her presentation at the ACP Internal Medicine Meeting. “They come into the office and they have headaches, abdominal pain, bloating, not sleeping well — so, somatic symptoms.”

When screening, Kling advised taking the reproductive life span into consideration, as 45% to 68% of perimenopausal women experience elevated depressive symptoms compared with 28% to 31% of premenopausal women and 28% to 47% of early perimenopausal women.

Kling added that screening alone cannot improve clinical outcomes and must be coupled with treatments such as antidepressants, cognitive behavioral therapy and psychotherapy, which may also help with menopausal symptoms. Estrogen therapy may improve depressive symptoms in perimenopausal women, although this is not an FDA-approved depression treatment and is ineffective in postmenopausal women.

Alcohol use

Additionally, routine screening should include evaluation of alcohol use. In the U.S., 28% of adults have unhealthy alcohol use — defined as an average of more than seven standard drinks per week or more than three drinks on any day for women — and 14% meet criteria for alcohol use disorder.

“The USPSTF recommends that all adults in primary care be screened to identify unhealthy alcohol use annually, and for those that we flag as having unhealthy alcohol habits, we do some brief counseling intervention,” Kling said.

Screening with short — even single-item — questionnaires is “ideal in this setting,” Kling said. If patients screen positive for unhealthy use, it is important to assess whether they have a substance use disorder.

“You want to take the opportunity in this setting to ask about consequences of use, including medical risks,” Kling added. “Is she getting in her car and driving after she’s using alcohol? Is this appropriate with the medications she’s taking? Those types of things.”

Safety concerns

Kling also recommended evaluating patients for intimate partner violence (IPV) on an annual basis, taking risk factors and potentially indicative symptoms into account.

Risk factors for IPV include individual, relationship, community and societal factors. Kling emphasized that these are not causes of or justifications for IPV, and that they may also be risk factors for IPV perpetration.

She also added that household firearm ownership increases the risk for harm and death among victims of IPV.

Physical and psychological symptoms such as headaches, chest pain, STIs, substance use, anxiety and depression may point to IPV, Kling added. IPV may also correlate with pregnancy morbidity and mortality, high-risk sexual behavior and child maltreatment.

How providers frame questions surrounding IPV is important, according to Kling, and they need to ensure that patients feel safe and comfortable to disclose information. “You're going to want to normalize this,” Kling said. “[Say] something like, ‘You know, there are high rates of intimate partner violence in our community and that impacts everybody.’”

If women report IPV, ensure that they remain safe and have access to resources such as counseling. It is also important to make sure that perpetrators are held accountable, and to keep careful records if the patient decides to pursue legal action.

However, if patients deny IPV, continue to screen for it in future visits, Kling said.

Another safety concern to screen for is exploitation, such as sex trafficking. Risk factors for sex trafficking include childhood sexual abuse, identifying as LGBT and having been involved in the child welfare system.

To screen for trafficking, make sure to talk to patients one-on-one, inform them about what you are required to report, ask about immediate safety needs and provide resources, Kling explained.

Also, “avoid the rescue fantasy,” she said.

“Many of us went into medicine because we wanted to make a difference and help our patients, but the idea that in a situation like sex trafficking or intimate partner violence, that whatever we say in that short 15-minute visit is going to cure them or get them out of the life or make them safe forever is just not realistic,” Kling said. “So, it doesn't fall to us to rescue them. It falls to us to screen and identify and share information and resources, and then be there to be a trusted partner in their life.”