in clinical research. What evidence has been published indicates that the grief experienced by couples after a spontaneous miscarriage is as intense as that after a perinatal death.' In a study of 300 patients followed up one month after a miscarriage 96% reported experiencing a grief reaction and in 21% the grief had not yet resolved.' In a more detailed study 44% of 27 women interviewed several months after a miscarriage showed clinical levels of psychological distress as measured by the general health questionnaire.' In a study of 67 women one month after a miscarriage the prevalence of "psychiatric cases" as measured by the present state examination was 48%.' In two of these studies no demographic or clinical features were identified that could predict which women were liable to experience a normal or prolonged grief reaction.4 In particular, the grief experienced could not be related to the length of pregnancy. I'he only factor that seemed to alleviate the distress experienced was an opportunity to discuss the miscarriage with medical staff after the event.' Trhus all couples who experience a miscarriage should have the opportunity to avail themselves of information and counselling and not just those in whom "exceptional distress [is] caused by a miscarriage."' Offering couples what they need and want after a spontaneous miscarriage is sound clinical practice" and is not being "overzealous"' or pushing people "into magnifying miscarriage into a tragedy."' Nor do such couples require "skilled psychotherapeutic help."' The skills for supporting people after a personal loss are widely available among family, friends, and health care professionals and should not be allowed to be monopolised by psychotherapists. The language used in this editorial in relation to spontaneous miscarriage surprises me. I fail to understand why the degree of personal care advocated for couples bereaved in the second and third trimesters of pregnancy should not be extended to the first. For too long the feelings experienced by couples after early pregnancy loss have been dismissed too quickly by the medical
profession.
psychiatric problems, or single parenthood resulting in referral for treatment. Consequently it is not surprising that significant difficulties are reported in the mother-infant relationship. The impact of maternal postnatal depression on subsequent infant attachment and cognitive development warrants further investigation. Such research needs to take account of other family factors, such as marital difficulties-known to be associated with both postnatal depression4 and children's emotional and behaviour problems" -the effect of an infant's temperament. Research on community samples emphasises the wide variation in observed interaction between mothers with postnatal depression and their infants.'- Trhere certainly does not seem to be a typical postnatally depressed mother. Postnatal depression is a common and important disorder; untreated it may last for many months and be remembered for years. Preliminary findings suggest that antenatal identification of women vulnerable to postnatal depression is possible, and a controlled trial of group education and counselling starting in pregnancy for women vulnerable to postnatal depression has shown that the prevalence of postnatal depression can be significantly reduced.' Women experiencing postnatal depression warrant sensitive individual assessment, support, and treatment in their own right. I am concerned lest the belief that postnatal depression typically has adverse effects on child development becomes a potentially damaging orthodoxy in the same way that early mother-infant bonding was overemphasised in the past.9 The clinical features of postnatal depression often include guilt, poor self esteem, and a sense of failure and incompetence as a mother. Overemphasis on the possible consequences for the child will greatly add to the burdens of any mother with postnatal depression. TESSA LEVERTON
l)epartment of Psychological Medicine, Hospitals for Sick Children, Great Ormond Street, London WC1N 3JH
MICHAEL J TURNER Coombe Lying In Hospital, Dtiblini 8
1 Bourne S, Lewis E. Perinatal bereavement. BMJ 1991;302: I 1 67-8. (18 May.) 2 Lcppert PC, Pahlka BS. Grieving characteristics after spontaneous abortion: a management approach. Obstet Gvnecol
1984;64:1 19-22. 3 lies S. rhe loss of eariv pregnancy. Clin Obstet Gynecol 1989;3: 769-90. 4 Turner iJ, Flannelly GM, Wingfield M, Rasmussen MJ, Ryan R, Cullen S, et al. The miscarriage clinic: an audit of the first year. Brj Obstet Gvnaecol 1991;98:306-8. 5 Jackman C, MicGee HM, Turner MJ. The experience and psychological impact of early miscarriage. Irish Journal of Psvchologv (in press). 6 Friedman r, Gath D. The psychiatric consequences of spontaneous abortion. Brj Psychiatry 1989;155:810-3. 7 'lurner MJ. Spontaneous miscarriage: "this hidden grief." IrMedj 1989;82:145.
Postnatal depression and infant development SIR,-It is certainly true that health professionals "need to pay attention to the emotional aspects of pregnancy, childbirth, and early infant care," but it would be a mistake to suppose that postnatal depression requires early detection and treatment simply because of the possible effects on infant development.' Maternal postnatal depression may well affect mother-infant interaction. Two of the few studies of early mother-infant interaction cited by Dr Lynne Murray and colleagues report on small samples2" already identified as at risk because of marital problems or considerable regrets about the pregnancy2 or because of previous child abuse or neglect, previous admission to hospital because of
1466
I Murray L, Cooper PJ, Stein A. Postnatal depression and infant
development. BMJ 1991;302:978-9. (27 April.)
2 Field T, Sandberg I), Garcia R, Vega Lahr N, Goldstein S, Guo L. Pregnancy problems, postpartum depression and early mother infant interactions. Developmental Psychologv 1985;12:
1152-6.
3 Cohn JF, Miatias R, Tronick EZ, Connell D, Lyons RK. Face to face interactions of depressed mothers and their infants. In: Tronick EZ, Field T, eds. Maternal depression and infant disturbance. San Francisco: josev Bass, 1986:31-44. 4 O'Hara MW, Sekoski EM. Postpartum depression: a comprehensive review. In: Kumar R, Brtckington IF,eds. Motherhood and mental illness. London: Wright, 1988:17-63. 5 Grvon JH, Fincham FD. Marital conflict and children's adjustment: a cognitive contextual framework. Psvchol Bull 1990; 1082:267-90. 6 Williams H, Carmichael A. Depression in mothers in a multiethnic industrial municipality in Melbourne. Actiological factors and effects on infants and preschool children. J Child
Psvchol Psychiatry 1985;26:277-87. 7 Stein A, Gath DH, Bucker J, Bond A, Day A, Cooper PJ. The relationship between postnatal depression and mother child interaction. BJPsychiatrv 1991;158:46-52. 8 Elliott SA, Sanjack M, Leserton TJ. Parent groups in pregnancy. A preventive intervention for postnatal depression. In: Gottlieb BMN, ed. Marshalling social support. f(n7ats, processes and effects. Beverly Hills: Sage, 1988. 9 Richards M. Bonding babies. Arch Dis Child 1985;60:293-4.
Trials of homoeopathy SIR,-Dr Peter Fisher and colleagues, in a recent letter,' complained that a trial of a homoeopathic treatment by Fisher et af had achieved only a relatively low score in the survey of such trials by Dr Jos Kleinen and colleagues.3 In this letter they failed to refer to the fact that my reanalysis of their original data showed that they had made elementary statistical errors and that the trial provided far less evidence for the effectiveness of the treatment than was originally suggested.4 In the light of this reanalysis I should have supposed that the rating of
Dr Kleijnen and colleagues was overgenerous. More seriously, it is going to be hard for readers to make any sense of the debate about homoeopathy if its proponents fail to refer to all relevant reports. D COLQUHOUN
Department of Pharmacology, University College London, London W'C I E 6BT I Fisher P, Huskisson EC, Scott DL, Turner P, Whitmarsh TE. Trials of homoeopathy. BMJ 1991;302:727. (23 March.) 2 Fisher P, Greenwood A, Huskisson EC, Turner P, Belon 1'. Effect of homoeopathic treatment on fibrositis (primary fibromyalgia). BM7J 1989;299:365-6. 3 Kleiinen J, Knipschild P, ter Riet G. Clinical trials of homoeopathv. BM7 1991;302:316-23. (9 February.) 4 Colquhoun D. Reanalysis of a clinical trial of a homoeopathic treatment of fibrositis. Lancet 1990;336:441-2.
Late bleeding after endoscopic sphincterotomy for bile duct calculi SIR,-Dr I A Finnie and colleagues' lesson of the week on late bleeding after endoscopic sphincterotomy for bile duct calculi' is important for two reasons. Firstly, it reports a complication of endoscopic sphincterotomy that, as it has not been reported before, must be very rare. Secondly, Podolsky et al suggested that endoscopic sphincterotomy can be performed on a day case basis, patients being allowed home four hours after the procedure provided that no complication is apparent.2 Thus Dr Finnie and colleagues' conclusion that general practitioners and others taking over the care of patients after sphincterotomy should be warned of this complication is clearly vital. We wonder why this complication occurred in five out of 200 patients who had sphincterotomy. In our experience of over 800 patients undergoing endoscopic sphincterotomy we have seen this complication only once. A 63 year old woman with chronic right heart failure from pulmonary stenosis underwent endoscopic sphincterotomy for stones in the common duct. The sphincterotomy was complicated by moderate bleeding, but this settled and over 48 hours in hospital she showed no evidence of continued bleeding. Seventy two hours after discharge she was readmitted because of postural hypotension due to recurrent bleeding, but this responded to conservative treatment with transfusion. In our experience it is true that the larger the sphincterotomy the greater the risk of bleeding, but no other factor, including the coagulation state, allows this complication to be predicted. We always perform endoscopic sphincterotomy with a braided wire Erlangen-type sphincterotome and a low power endoscopic diathermy unit set to deliver blended current at an output of about 30 watts (measured at an impedance of 100 ohms). Sphincterotomy is done in steady controlled increments with no more than 1 cm of the sphincterotomy wire in contact with tissue at any time. This technique permits virtually bloodless sphincterotomy, although occasional oozing is apparent. It would be useful to know whether Dr Finnie and colleagues adopt a different approach in terms of either equipment or technique, which might account for the frequency of the complication reported. DERRICK F MARTIN DAVID TWEEDLE
Withington Hospital, Manchester M20 8LR
MV, Miorris AI, Gilmore IT. Late bleeding after endoscopic sphincterotomv for bile duct calculi. B.MJ1 1991;302:1144. (11 Miay.) 2 Podolskv I, Kortan P, Kaber GP. Endoscopic sphincterotomv in outpatients. Gastrainnest Endosc 1989;35:372-6. I Finnic IA, Tobin
BMJ
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15 JUNE 1991
profession.
psychiatric problems, or single parenthood resulting in referral for treatment. Consequently it is not surprising that significant difficulties are reported in the mother-infant relationship. The impact of maternal postnatal depression on subsequent infant attachment and cognitive development warrants further investigation. Such research needs to take account of other family factors, such as marital difficulties-known to be associated with both postnatal depression4 and children's emotional and behaviour problems" -the effect of an infant's temperament. Research on community samples emphasises the wide variation in observed interaction between mothers with postnatal depression and their infants.'- Trhere certainly does not seem to be a typical postnatally depressed mother. Postnatal depression is a common and important disorder; untreated it may last for many months and be remembered for years. Preliminary findings suggest that antenatal identification of women vulnerable to postnatal depression is possible, and a controlled trial of group education and counselling starting in pregnancy for women vulnerable to postnatal depression has shown that the prevalence of postnatal depression can be significantly reduced.' Women experiencing postnatal depression warrant sensitive individual assessment, support, and treatment in their own right. I am concerned lest the belief that postnatal depression typically has adverse effects on child development becomes a potentially damaging orthodoxy in the same way that early mother-infant bonding was overemphasised in the past.9 The clinical features of postnatal depression often include guilt, poor self esteem, and a sense of failure and incompetence as a mother. Overemphasis on the possible consequences for the child will greatly add to the burdens of any mother with postnatal depression. TESSA LEVERTON
l)epartment of Psychological Medicine, Hospitals for Sick Children, Great Ormond Street, London WC1N 3JH
MICHAEL J TURNER Coombe Lying In Hospital, Dtiblini 8
1 Bourne S, Lewis E. Perinatal bereavement. BMJ 1991;302: I 1 67-8. (18 May.) 2 Lcppert PC, Pahlka BS. Grieving characteristics after spontaneous abortion: a management approach. Obstet Gvnecol
1984;64:1 19-22. 3 lies S. rhe loss of eariv pregnancy. Clin Obstet Gynecol 1989;3: 769-90. 4 Turner iJ, Flannelly GM, Wingfield M, Rasmussen MJ, Ryan R, Cullen S, et al. The miscarriage clinic: an audit of the first year. Brj Obstet Gvnaecol 1991;98:306-8. 5 Jackman C, MicGee HM, Turner MJ. The experience and psychological impact of early miscarriage. Irish Journal of Psvchologv (in press). 6 Friedman r, Gath D. The psychiatric consequences of spontaneous abortion. Brj Psychiatry 1989;155:810-3. 7 'lurner MJ. Spontaneous miscarriage: "this hidden grief." IrMedj 1989;82:145.
Postnatal depression and infant development SIR,-It is certainly true that health professionals "need to pay attention to the emotional aspects of pregnancy, childbirth, and early infant care," but it would be a mistake to suppose that postnatal depression requires early detection and treatment simply because of the possible effects on infant development.' Maternal postnatal depression may well affect mother-infant interaction. Two of the few studies of early mother-infant interaction cited by Dr Lynne Murray and colleagues report on small samples2" already identified as at risk because of marital problems or considerable regrets about the pregnancy2 or because of previous child abuse or neglect, previous admission to hospital because of
1466
I Murray L, Cooper PJ, Stein A. Postnatal depression and infant
development. BMJ 1991;302:978-9. (27 April.)
2 Field T, Sandberg I), Garcia R, Vega Lahr N, Goldstein S, Guo L. Pregnancy problems, postpartum depression and early mother infant interactions. Developmental Psychologv 1985;12:
1152-6.
3 Cohn JF, Miatias R, Tronick EZ, Connell D, Lyons RK. Face to face interactions of depressed mothers and their infants. In: Tronick EZ, Field T, eds. Maternal depression and infant disturbance. San Francisco: josev Bass, 1986:31-44. 4 O'Hara MW, Sekoski EM. Postpartum depression: a comprehensive review. In: Kumar R, Brtckington IF,eds. Motherhood and mental illness. London: Wright, 1988:17-63. 5 Grvon JH, Fincham FD. Marital conflict and children's adjustment: a cognitive contextual framework. Psvchol Bull 1990; 1082:267-90. 6 Williams H, Carmichael A. Depression in mothers in a multiethnic industrial municipality in Melbourne. Actiological factors and effects on infants and preschool children. J Child
Psvchol Psychiatry 1985;26:277-87. 7 Stein A, Gath DH, Bucker J, Bond A, Day A, Cooper PJ. The relationship between postnatal depression and mother child interaction. BJPsychiatrv 1991;158:46-52. 8 Elliott SA, Sanjack M, Leserton TJ. Parent groups in pregnancy. A preventive intervention for postnatal depression. In: Gottlieb BMN, ed. Marshalling social support. f(n7ats, processes and effects. Beverly Hills: Sage, 1988. 9 Richards M. Bonding babies. Arch Dis Child 1985;60:293-4.
Trials of homoeopathy SIR,-Dr Peter Fisher and colleagues, in a recent letter,' complained that a trial of a homoeopathic treatment by Fisher et af had achieved only a relatively low score in the survey of such trials by Dr Jos Kleinen and colleagues.3 In this letter they failed to refer to the fact that my reanalysis of their original data showed that they had made elementary statistical errors and that the trial provided far less evidence for the effectiveness of the treatment than was originally suggested.4 In the light of this reanalysis I should have supposed that the rating of
Dr Kleijnen and colleagues was overgenerous. More seriously, it is going to be hard for readers to make any sense of the debate about homoeopathy if its proponents fail to refer to all relevant reports. D COLQUHOUN
Department of Pharmacology, University College London, London W'C I E 6BT I Fisher P, Huskisson EC, Scott DL, Turner P, Whitmarsh TE. Trials of homoeopathy. BMJ 1991;302:727. (23 March.) 2 Fisher P, Greenwood A, Huskisson EC, Turner P, Belon 1'. Effect of homoeopathic treatment on fibrositis (primary fibromyalgia). BM7J 1989;299:365-6. 3 Kleiinen J, Knipschild P, ter Riet G. Clinical trials of homoeopathv. BM7 1991;302:316-23. (9 February.) 4 Colquhoun D. Reanalysis of a clinical trial of a homoeopathic treatment of fibrositis. Lancet 1990;336:441-2.
Late bleeding after endoscopic sphincterotomy for bile duct calculi SIR,-Dr I A Finnie and colleagues' lesson of the week on late bleeding after endoscopic sphincterotomy for bile duct calculi' is important for two reasons. Firstly, it reports a complication of endoscopic sphincterotomy that, as it has not been reported before, must be very rare. Secondly, Podolsky et al suggested that endoscopic sphincterotomy can be performed on a day case basis, patients being allowed home four hours after the procedure provided that no complication is apparent.2 Thus Dr Finnie and colleagues' conclusion that general practitioners and others taking over the care of patients after sphincterotomy should be warned of this complication is clearly vital. We wonder why this complication occurred in five out of 200 patients who had sphincterotomy. In our experience of over 800 patients undergoing endoscopic sphincterotomy we have seen this complication only once. A 63 year old woman with chronic right heart failure from pulmonary stenosis underwent endoscopic sphincterotomy for stones in the common duct. The sphincterotomy was complicated by moderate bleeding, but this settled and over 48 hours in hospital she showed no evidence of continued bleeding. Seventy two hours after discharge she was readmitted because of postural hypotension due to recurrent bleeding, but this responded to conservative treatment with transfusion. In our experience it is true that the larger the sphincterotomy the greater the risk of bleeding, but no other factor, including the coagulation state, allows this complication to be predicted. We always perform endoscopic sphincterotomy with a braided wire Erlangen-type sphincterotome and a low power endoscopic diathermy unit set to deliver blended current at an output of about 30 watts (measured at an impedance of 100 ohms). Sphincterotomy is done in steady controlled increments with no more than 1 cm of the sphincterotomy wire in contact with tissue at any time. This technique permits virtually bloodless sphincterotomy, although occasional oozing is apparent. It would be useful to know whether Dr Finnie and colleagues adopt a different approach in terms of either equipment or technique, which might account for the frequency of the complication reported. DERRICK F MARTIN DAVID TWEEDLE
Withington Hospital, Manchester M20 8LR
MV, Miorris AI, Gilmore IT. Late bleeding after endoscopic sphincterotomv for bile duct calculi. B.MJ1 1991;302:1144. (11 Miay.) 2 Podolskv I, Kortan P, Kaber GP. Endoscopic sphincterotomv in outpatients. Gastrainnest Endosc 1989;35:372-6. I Finnic IA, Tobin
BMJ
VOLUME 302
15 JUNE 1991
