in Psychiatric

Fertility WINTHROP

A. BURR,

ARTHUR

Outpatient

Clinic

FALEK, PH.D. Human Genetics Laboratory Mental Health Institute Georgia

Director, Georgia Atlanta,

LILO

#{149}Unwanted fertility is an important source of psychiatnc morbidity both for psychiatric patients and for their children (1,2). Thus psychiatric patients of childbearing age may have a special interest in deciding when and how many children to have. In addition, those who provide services to the patients can benefit from accurate information about fertility rates when assessing the need for and effectiveness of family planning programs. The offspring of schizophrenic patients, in particular,

M.D.

Staff Psychiatrist Veterans Administration Boston, Massachusetts

T. STRAUSS,

Outpatients

have an increased To a large extent

M.A.

Statistician, Family Planning Bureau of Epidemiology Centerfor Disease Control Attanta Georgia

Evaluation

(4,5), though

Division

rent

reproductive

have

some

Assistant Emory Atlanta,

B. BROWN,

Professor University Georgia

effect

M.D.

are

the

offspring

of Psychiatry School of Medicine

acquired

illness,

if actually

on

heterozygotes.

a

group

compares patients

of

them and

REVIEW of

address

at

the

VA

outpatient

clinic

is 17

Court

were

below those was accounted

Street, Boston, Massachusetts 02108. He is also an associate clinical professor of psychiatry at Tufts University School of Medicine in Boston. When this study was done, he was acting chief of the abortion surveillance branch, family planning evaluation division, bureau of epidemiology, Center for Disease Control, Atlanta, and was assistant clinicalprofessor of psychiatry at Emory University School of Medicine in Atlanta. Dr. Falek also is an associate professor of psychiatry (human genetics) at Emory University School of Medicine. This paper isbased on a presentation at the annual meeting of the Society of Biological Psychiatry held May 3-7, 1978, in Atlanta.

HOSPITAL

& COMMUNITY

PSYCHIATRY

tility

from

THE

among

and two

fertilhigh

con-

to demonstrate

have presents

a

not been nofertility data

outpatients

and

psychiatric

out-

general

population.

schizophrenics

in showing population

largely

not by lower in that

the

in

in the general for

low

LITERATURE

unanimous

meyer-Kimling mailing

attempts

nonschizophrenic

reproduction

19505

phrenics,

to

by

schizophrenic

to women

OF

Studies

late

female

(7).

only achieve its advantage were

selective advantage in schizophrenia tably successful (9-12). This paper on

parents

schizophrenics this genetically

accompanied

Yet

will

psychiatric

of schizophrenic

among since

in many generations, could prevalence (8) if a reproductive

A change Burr’s

rates interest,

ity

ferred

patients for

ofschizophrenic

Measurement of fertility may also be of theoretical

The fertility rates of 223 female schizophrenic outpatients and 479 female nonschizophrenic outpatients were compared to a probability sample of 300 women residing in the same geographic area, metropolitan Atlanta, and from the same social strata as the patients. Ageand race-adjusted comparisons showed that the mean number of children per woman and Levels of unwanted and unplanned fertility did not differ in the different diagnostic groups. Furthermore, the rates were not tower for the psychiatric patients than for the general population. In order to reduce an important source ofpsychiatric morbidity, those in the mental health professions need to pay more attention to the family planning desires oftheir patients.

Dr.

rates of schizophrenic future requirements only the minority

on

although

services, patients

SAMUEL

risk of developing schizophrenia (3). the risk is transmitted genetically it may be modified by experience (6). Cur-

by fewer

fertility

pattern

her

within was

first

colleagues,

cohorts

of

before

the

fertility rates far (13). That finding marriages

of schizo-

marriage observed

who

schizophrenic

(2). by Erlenmeasured ferpatients

admitted to New York State mental hospitals. Approximately 1500 cases were randomly selected from admissions occurring between 1934 and 1936, and approximately 1 100 were randomly selected from patients admitted 20 years later, between 1954 and 1956. Considerable increases in fertility rates were observed for both sexes in the later cohort as compared with the earlier one, and large gains in fertility relative to the gen-

VOLUME

30 NUMBER

8 AUGUST

1979

527

Stevens was one of the first to assert that the fertility of schizophrenic women not only has increased but has

achieved levels that do not differ from those of the general pOpulation. eral population were clearly established. Those gains could be explained only in part on the basis of shorter hospitalization times (7,14). Analysis of the fertility level of white women of the later cohort compared with white women in the general population of the United States did show, however, that fertility of the schizophrenic women remained significantly lower. One measure of the difference-children born up to a period five to eight years following index admission-showed the fertility of the latter schizophrenic cohort to be approximately half that of U.S. women generally (14). Shearer and his co-workers reported a similar finding. They found a 36 per cent increase in the number of births occurring to women residing in Michigan’s six major state mental hospitals between 1950 and 1959, corresponding to a period of time before and after initiation of an “open-door” policy. These were inhospital deliveries; their absolute number was small, and no analysis was possible by diagnosis. Also, the undefined demographic nature of the patient group made cornpanson with the general population impossible (15). Further information on fertility in schizophrenia has come from the work of Stevens in London. She was one of the first to assert that the fertility of schizophrenic women not only has increased but, for all practical purposes, has achieved levels that do not differ from those of the general population (16-19). The basis of that assertion needs examination. In 1969 and 1970, Stevens reported on a sample of 500 schizophrenic women, aged 16 to 50, admitted to a London mental hospital between 1955 and 1963 and followed from three to 1 1 years. The legitimate fertility rate before index admission for white patients was 1.36 children per woman, compared with an expected number for age-matched British white women generally of 1.54 children. While that is a statistically significant difference, Stevens did not feel it was enough to constitute a difference of demographic import (18). Following index admission, legitimate fertility of the schizophrenic patients remained lower than those of the general population, but by only a small margin. One should keep in mind, though, that lower fertility within marriage had not characterized schizophrenic patients in past studies. In addition, her finding was that the illegitimate fertility rate among the schizo-

528

HOSPITAL

& COMMUNITY

PSYCHiATRY

phrenics was higher than in the general population (19). Stevens’ data merit cautious interpretation on several grounds. Follow-up of patients was approximately 80 per cent efficient, but was biased against childless women, perhaps because they were harder to trace. Fertility was measured quite early in the reproductive period, leaving the completed fertility rates of older women obscure. Furthermore, it was not possible to make adjustments for social class in using comparison data, and methods of ascertaining illegitimate fertility varied considerably between patients and the general population. Other British data were published in 1971 by Slater and his colleagues, who studied more than 2000 schizophrenic inpatients and outpatients at the Maudsley Hospital between 1952 and 1966. Using census findings for comparison, they concluded that ever-married British Protestant schizophrenic women had only 75 per cent as many children as women with uninterrupted first marriages in the general population (20). (Again, note the seeming paradox in that the older studies had not shown decreased legitimate fertility in schizophrenia.) The authors were careful to point out that the use of ever-married patients may overestimate the schizophrenic patients’ fertility, but that using women with uninterrupted first marriages for comparison might have helped to correct that bias. It was also noted that social class differences between the patient group and the comparison group may have had a confounding effeet. Still, Slater’s conclusions are not entirely in accord with those of Stevens from about the same period. The Slater group reports a much larger fertility gap between schizophrenics and controls (20). Rimmer and Jacobson reported on the fertility of a cohort of 27 Danish adopted schizophrenics in the middle of their reproductive years. They found strikingly lowered fertilities compared with a control group of adoptees matched for age and social class. Although the numbers were small, the sample was not biased toward schizophrenics who had been hospitalized (12). Thus most studies have focused on hospitalized cases, have focused on whites only, have been variable in their attention to matters of diagnostic rigor, and have paid inadequate attention to social class. It is quite possible, as one critic pointed out, that the effect of many of these biases is to underestimate the fertility of schizophrenic patients (21).

-

EXPANDING

THE

DATA

BASE

The present study offers four additions to the data base. First, fertility data were collected in 1976, approximately ten years later than the most recent previously available. Second, our patients were seen in outpatient settings, which avoids some of the truncation of the spectrum of schizophrenia that occurs when only patients with histories of hospitalization are used. Third, black women and white women were included. And fourth, a comparison group was drawn from the same

live births, and number of pregnancies. Within the lower two socioeconomic strata, 92 per cent of the women identified by the sampling procedure as potential survey participants were completely interviewed. There appeared to be an underreporting of births to younger, unmarried women when compared with national data, however (24,25). Therefore, uses of these data are limited to women 25 years of age and older.

The reduction of unwanted pregnancy among psychiatric patients should be

emphasized

by those

in the mental health professions as a way of dealing with an important source of psychiatric morbidity.

RESULTS

social strata and geographic area of the patients. Between January and June 1976, women presenting at the walk-in and follow-up acute psychiatric services at Grady Hospital, a large public hospital in Atlanta, were interviewed. The interviewers were mental health technicians who were trained and supervised by one of the psychiatrists conducting the study. They contacted patients, as they appeared, from 8 a.m. to 8 p.m. five days per week. A total of 1056 patients were contacted; 294, or 28 per cent, either refused to be interviewed or were too ill to give informed consent. The interviews included a fertility questionnaire pattemed after that of the 1973 National Survey of Family Growth, conducted by the National Center for Health Statistics. Psychiatric diagnosis depended on the results of a standardized mental status evaluation recorded on the Mental Status Examination Record developed by Spitzer and Endicott (22). The information on mental status was then processed by a decision-tree type of program known as Diagno-III-M (23) for purposes of diagnosis. That program was designed to yield diagnoses as close as possible to those given at the academic psychiatric center where the program was developed. Therefore, the concept of schizophrenia used is not as narrow as certain European ones, although it does depend on explicit mental status criteria, and, since it is computer-generated, it is reliable within the limits of the mental status information. General population comparison data come from a household fertility survey of women between 15 and 44 years of age conducted by the Center for Disease Control in the summer and fall of 1971 in the most urbanized portions of the two counties that include the city of Atlanta (24). The area surveyed thus corresponds to the census definition of the Atlanta “urban” area, which is the same general area that was served by the psychiatric clinic. This survey was a stratified, random-sampling survey designed to describe the four socioeconomic strata of the area. Since the hospital serves a lower and lowermiddle socioeconomic group, only data from these two strata have been used. Interviews were conducted with women in the stated age range living in the sample households

terviews traceptive

whether

they

were brief, and use, sterilization,

were

married

contained marital

or

queries status,

not.

The

in-

about connumber of

OF

THE

SURVEY

Table 1 shows some selected characteristics of the psychiatric patient sample. The majority of the women in all diagnostic groups were black. Examination of the distribution of race by diagnosis showed no tendency for the black patients to receive a diagnosis of schizophrenia more or less commonly than white patients. The schizophrenic patients are a somewhat younger group than the nonschizophrenics. The mean number of live births per woman does not differ significantly among the three diagnostic groups. Examination of the age-adjusted number of live births indicates that differences in age distribution are not disguising a real difference. Because the number of live births per woman did not differ in the different diagnostic groups, all psychiatric patients were combined for purposes of comparison with the general population. Comparisons of selected characteristics of the subgroup of 414 psychiatric patients aged 25 to 44 with 300 women of the same age range in the Atlanta survey showed that the psychiatric patients were less frequently white (26 per cent, com-

TABLE

1

Selected

characteristics

of 762 female

psychiatric

patients Diagnosis

Not

Possibly Schizo-

schizo-

schizo-

phrenic’

phrenic1

(N=223)

(N=60)

phreni& (N=479)

Variable

N

%

N

%

N

%

Black

162 61

72.6 27.4

42 18

70.0 30.0

338 141

70.6 29.4

57

25.6

14

23.3

84

17.5

59

26.5

24

40.0

176

.17

2.08

.27

2.42 ±11

White

Less than 25 years old 40 years or older Mean live births per woman2 (±standard error)

2.26

±

±

36.7

Age-adjusted live births per woman3

2.39

2.09

2.36

1 Based on Mental Status Examination Record data processed Diagno-III-M program. 2 By Student’s t test, p > . 10 for all two-way comparisons. 3 Adjusted to the age distribution of the patient group as a whole.

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30 NUMBER

8 AUGUST

1979

by

529

TABLE woman

2 Mean number of live births per ever-pregnant for all psychiatric patients and Atlanta survey age 25 to 44, by race

subjects,

Psychiat

nc patients Mean live births (±standard error)’

N of

Race

women

White

86

Black

281

‘

vey

Age

adjusted

Atlanta

2.84

±

3.29±

N of women

subjects

Mean live births (±standard error)

.17

92

2.90

±

.17

.13

172

3.31

±

.16

to the distribution

of the ever-pregnant

Atlanta

sun-

subjects.

pared with 34 per cent of the Atlanta survey women). In addition, the psychiatric patients were somewhat younger (mean age of 32.6 years, compared with 34 years in the Atlanta survey women), and, among whites only, had less frequently ever been pregnant (79.6 per cent, compared with 91.2 per cent of the Atlanta survey women). Table 2 shows the mean number of live births per ever-pregnant woman, age 25 to 44, by race. From these data it is evident that the differences between the patients and the general population are not significant in either racial group, nor is there a significant difference between patient and nonpatient groups as a whole. Because of the lower ever-pregnant rates among white patients compared with white women in the general population, we addressed the question of over-all fertility among the white women. Table 3 shows there are no statistically significant differences between the white psychiatric patients and the white Atlanta survey women either over-all or within any age group. An attempt was also made to assess whether pregnancies among the psychiatric patients were planned or wanted. We asked a standard question about each pregnancy: “When you became pregnant this time, did you actually want to have another baby at some time?” That question was then followed by another: “As you recall, is that the way you felt before you became pregnant or did you come to feel that way later?” Unplanned or unwanted pregnancies were those to which the answer to the first question was no, or the anTABLE 3 Mean number of live births per white woman for all psychiatric patients and Atlanta survey subjects, age 25 to 44, by age group Psychiatric patients

Atlanta

Age group

Mean live births (±standard error)

Mean live births (±standard error)

25 30 35 40 All

1.49 2.14 2.68 3.33 2.24

1.86± 2.80 2.64 3.58 2.62

530

to 29 to 34 to 39 to 44 ages

± ± ± ± ±

.26 .30 .39 .52 .18

HOSPITAL

& COMMUNITY

subjects

± ± ± ±

.20 .40 .44 .41 .18

PSYCHIATRY

swer to the first question was yes but the patient came to feel that way later. In other words, they were pregnancies reported to be unwanted at the time of conception. By those criteria, 39 per cent of pregnancies to the schizophrenic women and 35 per cent of pregnancies to nonschizophrenic women were unplanned or unwanted. We also assessed the timing failures by asking, “Did you become pregnant sooner than you wanted, later than you wanted, or just about the right time?” Fortysix per cent of the pregnancies of schizophrenic women were reported as occurring sooner than wanted, whereas 33 per cent of the pregnancies to nonschizophrenic women fell into that category. It is worth noting that in 1971 approximately 36 per cent of the pregnancies to the Atlanta survey women were classifled as unplanned (24). That number is not strikingly different from those listed above, even though the questions asked about the pregnancy planning were not exactly the same. VALIDATING

THE

CONCLUSIONS

In contrast to earlier studies that have demonstrated reduced fertility rates for institutionalized women with a diagnosis of schizophrenia, data from this study indicate that fertility rates are approximately equal among the groups of psychiatric patients-schizophrenic and nonschizophrenic-and women in the general population. One major causal factor may lie in the recent emphasis on shorter-term hospitalizations. Consequently, those women who have been diagnosed as schizophrenic are encouraged to quickly re-enter familiar surroundings, and thus they are exposed to a greater potential for reproduction. Increased reproduction would result in a greater number of high-risk individuals in the next generation. There are some reasons for using caution in interpreting these data, however. No one study can claim that its patient sample is representative of schizophrenic women generally. Although there is no obvious reason why these conclusions could not be tentatively extrapolated to the kinds of patients seen in urban public mental health settings, there remains a need to measure fertility in other groups of psychiatric patients and in rural and suburban settings. In addition, there is a five-year gap between the general population survey and the survey of psychiatric patients conducted in 1976. Since fertility in the United States population declined in that interval to the extent that births per 1000 women between 15 and 44 years of age fell 20 per cent, and the birth rate per 1000 population fell 15 per cent (25,26), it might not be inappropriate to conclude that the fertility of the psychiatric patients is in fact higher than that of the general population. Furthermore, attention has to be paid to the accuracy of fertility information gathered by questionnaire. The conclusion that the fertility of the patients is at least as high as that of the general population would be

threatened if there were significant underreporting of fertility in the general population sample. Mindful of that possibility, we compared the Atlanta general-population data on married women with the 1970 National Fertility Survey conducted by Princeton’s Office of Population Research and reported on by Anderson and Smith (24). The race-specific fertilities of the Atlanta married women were found to be higher than those of women in the nation as a whole. That finding lends support to the validity of the data in this study. The fertility of this sample of patients was at least as high, if not higher, and rates of unwanted and unplanned pregnancy were also at least on a par with those of women in general. From the data on unwanted and unplanned fertility obtained in this study, it is evident that more attention should be paid to the family planning needs of psychiatric patients. Particular care must be taken to decide under which circumstances special family planning programs should be provided and under which circumstances the clinician need only refer patients to programs already available. What is necessary in the long term is the development of family planning programs in psychiatric facilities. In any case, the reduction of unwanted and unplanned pregnancy among psychiatric patients should be emphasized by those in the mental health professions as a positive means of dealing with an important source of psychiatric morbidity. REFERENCES 1) tion, 2) ning

Group for the Advancement of Psychiatry, Humane Repn,ducNew York City, 1973. V. D. Abernethy and H. Grunebaum, “Toward a Family PlanProgram in Psychiatric Hospitals,” American Journal of Public Health, Vol. 62, December 1972, pp. 1638-1648. 3) N. Garmezy, “Children at Risk: The Search for the Antecedents of Schizophrenia,” Schizophrenia Bulletin, Spring 1974, pp. 14-90, and Summer 1974, pp. 55-125. 4) D. Rosenthal, “Searches for the Mode of Genetic Transmission in Schizophrenia: Reflections and Loose Ends,” Schizophrenia Bulktin, Vol. 3, No. 2, 1977, pp. 268-276. 5) I. I. Gottesman and J. Shields, “A Critical Review of Recent Adoption,

Twin,

and

Family

Studies

of

Schizophrenia:

Schizophrenics and Their Half-Siblings,” Acta rncz, Vol. 54, September 1978, pp. 161-166. 13) C. Goldfarb and L. Erlenmeyer-Kimling, Trends try, F.

in

Schizophrenia,”

J.

Kallman,

in

Expanding Coals Grime & Stratton,

editor,

Psychiatrica

Scandina-

“Mating

and

Fertility

ofGenetics

in Psychia-

New

City,

York

1962,

pp. 42-51. 14) L. Erlenmeyer-Kimling, in

Fertility

Rates

of

J.

S. Nicol, Schizophrenic

D. Rainer,

Patients

in

at al., New

York

“Changes State,”

American Journal ofPsychiatry, Vol. 125, January 1969, pp.916-927. 15) M. L. Shearer, A. C. Cain, S. M. Finch, at al., “Unexpected Effects of an ‘Open Door’ Policy on Birth Rates of Women in State Hospitals,” American Journal ofOrthopsychiatry, Vol. 38, April 1968, pp. 413-417.

16) B. C. Stevens, Schizophrenia

Marriage

or Affective

and Disorders,

Fertility Oxford

of Women University

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From Lon-

don, 1969. 17) B. C. Stevens,

of Community-Oriented Psychiatry on Psychotic Women,” British Medical Journal, Vol. 4, October 1969, pp. 22-24. 18) B. C. Stevens, “Probability of Marriage and Fertility of Women Suffering From Schizophrenia or Affective Disorders,” Population Studies, Vol. 23, November 1969, pp.435-484. 19) B. C. Stevens, “Illegitimate Fertility of Psychotic Women,” JournalofBlosocial Science, Vol. 2, January 1970, pp. 17-30. 20) E. Slater, E. H. Hare, and J. S. Price, “Marriage and Fertility of Psychiatric Patients Compared With National Data,” Social Biology, Vol. 18, September 1971, pp. 80-73. 21) E. Lane, “Biasing Factors Affecting Estimates of Fertility Rates of Schizophrenics,” Journal ofPsychology, Vol. 78, May 1971, pp. 4963. 22) R. L. Spitzer and J. Endicott, “An Integrated Group of Forms for Automated Psychiatric Case Records,” Archives of General Psychiatry, Vol. 24, June 1971, pp. 540-547. 23) R. L Spitzer and J. Endicott, “Computer Diagnoses in an Automated Record Keeping System: A Study of Clinical Acceptability,” in Progress in Mental Health Information Systems: Computer Applications, J. L. Crawford, D. W. Morgan, and D. T. Gianturco, editors, Ballinger, Cambridge, Massachusetts, 1974, pp. 73-101. 24) J. E. Anderson and J. C. Smith, “Planned and Unplanned Fertility in a Metropolitan Area: Black and White Differences,” Family Planning Perspectives, Vol. 7, November-December 1975, pp. 281285. 25) Bureau of the Census, Monthly Vital Statistics Report, Annual Summary for the United States, 1976, Vol. 25, December 12, 1977, p. 13. 26) Bureau of the Census, Monthly Vital Statistics Report, Annual Summary for the United States, 1971, Vol. 20, August 30, 1972, p. 13. Marriage

and

Fertility

“Impact of

Behavioral

Genetics Perspectives,” Schizophrenia Bulletin, Vol. 2, No. 3, 1976, pp. 380-398. 6) M. J. Goldstein and E. H. Rodnick, “The Family’s Contribution to the Etiology of Schizophrenia: Current Status,” Schizophrenia Bulktin, Fall 1975, pp. 48-63. 7) L. Erlenmeyer-Kimling, J. D. Rainer, and F. J. Kallmann, “Current Reproductive Trends in Schizophrenia,” in Psychopathology of Schiwphrenia, P. N. Hoch and J. Zubin, editors, Grune & Stratton, New York City, 1966, pp. 252-276. 8) H. M. Babigian, “Schizophrenia: Epidemiology,” in Coinprehensine Textbook of Psychiatry, 2nd edition, A. M. Freedman, H. I. Kaplan, and B. J. Sadock, editors, Williams & Wilkins, Baltimore, 1975, pp. 880-866. 9) C. Buck, H. Simpson, and J. M. Wanklin, “Survival of Nieces and Nephews of Schizophrenic Patients,” British Journal of Psychiatry, Vol.130, May 1977, pp. 506-508. 10) C. Buck, G. E. Hobbs, H. Simpson, et aL, “Fertility of the Sibs of Schizophrenic Patients,” British Journal of Psychiatry, Vol. 127, September 1975, pp. 235-239. 11) C. A. Larson and G. E. Nyman, “Differential Fertility in Schizophrenia,” Acta Psychiatrica Scandinavica, Vol. 49, 1973, pp. 272-280. 12) J. Rimmer and B. Jacobsen, “Differential Fertility of Adopted

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