The psychological complications of therapeutic abortion. G Zolese and C V Blacker BJP 1992, 160:742-749. Access the most recent version at DOI: 10.1192/bjp.160.6.742
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This article cites 0 articles, 0 of which you can access for free at: http://bjp.rcpsych.org/content/160/6/742#BIBL To obtain reprints or permission to reproduce material from this paper, please write to [email protected] http://bjp.rcpsych.org/letters/submit/bjprcpsych;160/6/742 http://bjp.rcpsych.org/ on November 26, 2014 Published by The Royal College of Psychiatrists
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BritishJournalof Psychiatry(1992),160, 742—749
Review Article
The Psychological Complications of Therapeutic Abortion G. ZOLESE and C. V. A. BLACKER
Psychologicalor psychiatricdisturbancesoccurin associationwith therapeuticabortionsbut they seem to be marked, severe, or persistentin only a minority (approximately10%) of women. These consist mostly of casenessdepressionand anxiety. Psychosesare very uncommon,beingreportedin only0.003% of cases- mostof whom havea historyof previous psychiatricillness.Certaingroupsareespeciallyat riskfrom adversepsychologicalsequelae; these includethose with a past psychiatrichistory,youngerwomen, those with poorsocial support,
the multiparous,
and those
belonging
to sociocultural
groups
antagonistic
to abortion.
This is not to overlookthe fact that, adopting a crisis-resolutionframework, subsequent terminationof an unwanted pregnancyis itself ‘¿therapeutic'. A better understandingof the natureof the riskfactorswouldenablecliniciansto identifyvulnerablewomenfor whom some form of psychologicalinterventionmight be beneficial.
Abortion has always been a matter of controversy, but in recent years it has again come to the forefront of public discussion. The controversy has been particularly reawakened in the USA where, in 1989, in response to political pressures, President Ronald Reagan commissioned a large-scale prospective study entitled The Medical and Psychological Impact of Abortion in Women (Holden, 1989). It is not
appropriate for this review to explore the moral and sociological reasons for the renewed outcry towards abortion some years on from its legalisation. However, advances in medical technology with
Frank et a!, 1985; Drug & Therapeutic Bulletin,
1989). The majority of early abortions (41% are below 12 weeks' gestation) are now conducted on a day-patient basis. Nevertheless, a number of women who have been subject to delays or who for medical reasons are obliged to be admitted as in-patients, are
exposed to increased stress, possible stigma and medical risks. Psychiatric complications have been studied extensively, especially before and soon after
RU486) have played an important role by intensifying the ethical dilemmas. In the UK, where pro-life
the introduction of legal abortion. Faultless research designs are virtually impossible, especially in the mental health field; however, the studies on the psychological aspects of therapeutic abortion appear to be particularly vulnerable. There are many reasons but the most important is the nature of the procedure itself. Women who choose
groups have won the consensus of a large part of the public, the Abortion Act has been recently revised in conjunction with the Embryology Bill (Hall, 1990). One of the controversial issues again disputed is
abortion are not amenable to endless questions on how they feel, are less likely to return for follow up, and baseline assessments before they become pregnant are impossible.
regard to neonatology, in vitro fertilisation, and the development of an oral abortifacient (Mifepristone
Most of the studies reviewed were conducted when standardised psychiatric measurement instruments were not available (Table 1). A large number employed self-devised questionnaires without proven One in five pregnancies in England and Wales are reliability or used unstructured interviews often terminated on therapeutic grounds (Miller eta! 1980; administered by non-psychiatrists. Other problems Llewellyn-Jones, 1982; Kumar & Robson, 1978). were the small sample size, indirect data on outcome, More than half of those seeking abortion in the UK and high attrition rates (Rogers et a!, 1989). are single (63°1o) and between 20 and 24 years (32°lo) When evaluating the true negative effects of (OPCS, 1987; residents only). abortion on women's mental health, it is important Although the mortality rate following surgical to also consider a number of confounding variables. abortion is only 3.5 per 100 000 abortions (Lewis, Therefore, to what extent are these disturbances 1980), gynaecological complications are reported in unique to the abortion procedure? One possibility 5%- 10%, and major complications occur in is that they reflect disturbances associated with O.3°lo—2.l°1o of cases (Savage & Paterson, 1984; pregnancy itself since several studies have reported an
‘¿0 I
the effects of termination of pregnancy (TOP) on the mental health of women. The aim of this review is to examine critically the study designs and make comments for possible future research.
742
I
PSYCHOLOGICAL
EFFECTS OF THERAPEUTIC
743
ABORTION
Table 1 Negative psychological outcome following abortion1 AuthorSample %Peck
followed follow methodCriteriaNegative upMean up:monthsAssessment
sizeNo.
outcome:
& Marcus(1966)74504.5lnt2Adverse reaction2Simon (1967)654661Ost3/lntDepression13Niswander eta!
health6.9Clarketal(1968)1201116GP4Worse0.9Patteta!(1969)483525.5lntHarmed14.3Pare & Paterson(1967)1701618OatEmotional depression17.2Whittington & Raven(1970)18416924lntGuilt, (1970)11531retro worse3Brodyeta!(1971)94801.5MMPI5Reductionin
for spectiveOatChange
anxiety—Fordeta!(1971)29216lnt/MMPIWorse14Margolis eta! (1971)50434.5Qst/MMPINegative reaction9.3Meyerowitzeta!(1971)1147743GPAdaptation9.1Osofsky (1972)2502501mtGuilt23.8Todd & Osofsky (1972)696324Qst/GPUnsatisfactory state5.8Wallerstein (1972)114226lntPsychosocial outcome31.8Ewing & Rouse(1973)17612612.3OatEmotional
reaction6.3McCance (1973)23419219.6BDIDepression22Perez-Reyes eta! (1973)61416Qat/IntDepression41Weston & Falk (1973)1541401Qst/lntGuilt11Lask
(1975)56506lnt/HRS7 outcome32Rosenthal (1975)34331lntFunctioning24.2Greer & Rothschild eta! (1976)3603263lnt/HRSPsychiatric treatment6.5Ashton (1980)103642.6lnt/OstGuilt7.8Frank eta! (1985)610561050.7GP/GynaePsychiatric morbidity2.5Lazarus
ZRS8Unfavourable
(1985)2942920.5OatDepression15
4'
1. 2. 3. 4. 5.
Adapted from Rogers eta! (1989). mt = unstructured psychiatric interview. Oat self-devised questionnaire. GP =general practitioner assessment. MMPI = Minnesota Multiphasic Personality Inventory.
fr
6. BDI—¿ BeckDepressionInventory. 7. HAS Hamilton RatingScale. 8. ZRS =Zung rating scale.
increased incidence of psychological difficulties in the first trimester in women not seeking abortions (Macdonald, 1958; Kumar & Robson, 1978; Ancill et a!, 1986). A further contribution to any observed psycho logical distress may come from the stigma associated with hospital admission, often to gynaecological wards where other women may be undergoing investigation for infertility. In addition there is the
@
-
@ @
impact
of
a
general
anaesthetic,
for
those
that
receive
one, and surgical interference, especially that involving gynaecological sites. It is not proposed to review these issues here but readers may care to
refer to the papers by Whitelaw (1979), Johnston (1980), and Cooper et a! (1982). A significant proportion of women presenting for abortion are also suffering from major social and relationship difficulties. Such women are already subject to a range of stresses which are essentially independent of those posed by the actual pregnancy! abortion but which contribute substantially to any observed psychological disturbance seen at this time. As already stated, some socially conditioned dis advantages may also be related to becoming pregnant in the first place. For example, of 360 women undergoing abortion examined by Beard et a! (1974),
744
ZOLESE & BLACKER
45% of those from social class 4 & 5 (compared with 14% from classes 1 & 2) were ignorant about contraception. It is likely that all these factors make at least some contribution to the psychological disturbances seen in association with therapeutic abortion. Studies of psychologicalsequelae Early studies The studies conducted between 1935 and 1964 were reviewed by Simon & Senturia (1966). In their opinion, the best designed studies were conducted in Europe (Table 2). These tried to make a distinction between psychological responses such as ‘¿guilt' and formal psychiatric syndromes. Their results showed
a wide variation in sequelae, which reflected differing methodological procedures: the use of unstructured psychiatric interviews and arbitrary measures of guilt. In particular, their high rates of psychiatric disturbance could be explained by the added distress
of seeking an abortion when it officially remained illegal.
The remaining 24 studies reviewed by Simon & Senturia were criticised on grounds of method, including problems with sample selection; in particular, no distinction was made between therapeutic,spontaneous and criminal abortions.
In addition, follow-up time was highly variable, ranging from a few weeks to several years, and operational criteria for psychiatric diagnosis were not employed. A number of the papers quoted by Simon & Senturia were case reports by psycho analysts who saw a request for abortion per se as indicative of psychopathology. These authors emphasised the importance of the ‘¿internal' reasons for seeking an abortion and at times considered the Table 2 Comparison
of outcome
in five studies conducted
in
Europeancontries1 Sample
%Malforms844312(Sweden, sizeGuilt: 1958)Arena1002323
(?)(Sweden, 1958)Siegfried6113131?)(Switzerland, 1951)Ekblad479111(Sweden, 1955)Brekke3400(Norway, 1958) 1. Adapted from Simon & Senturia (1966).
%Psychiatric
illness:
abortion as causing severe emotional disturbances (Deutsch, 1945; Ebaugh & Heuser, 1947; Lidz, 1954). Formal studies within the past 20 years Many studies have looked at the psychological complications of therapeutic abortion. Most agree that the abortion per se does not cause psychiatric disturbance but rather is beneficial to the woman's mental health (Ilisley& Hail, 1976;Romans-Clarkson, 1989). The results are best considered in terms of the ‘¿caseness' of the psychological sequelae they report. Although the literature contains several case reports of severe psychiatric syndromes resembling puerperal psychosis, these appear to be an uncommon occurrence. Brewer (1977),in a prospectivestudy,
obtained rates for post-abortion psychosis of 0.3 per 1000 abortions (rates for psychosis following childbirth are of the order of 1.7 per 1000live births). Major psychiatric disturbances following abortion appear to occur in women who have a pre-existing psychiatric disorder and who are therefore strongly predisposed to breakdown or relapse. As part of a continuing and extensive survey of the physical and psychiatric sequelae to therapeutic abortion, Frank eta! (1985) reported that only 2(0.03%)
‘¿1
‘¿0
out of 6105
patients required psychiatric hospital admission. Both patients were diagnosed as suffering from schizophrenia. Hospital admission is only an indirect measure of psychiatric morbidity and further publications containing more explicit diagnostic details are awaited. However, an interesting study by David (1985) examined psychiatric hospital admission rates among Danish women who had recently undergone therapeutic abortion (within the previous three months). When compared with an age-matched control group of non-pregnant women, admission rates for the abortion group were ‘¿0 consistently higher. Women who were separated, widowed, or divorced were found to be especially at risk of psychiatric hospital admission following abortion. Apart from psychosis, the principal formal psychiatric disturbances following therapeutic abortions are neurotic and affective in type for which rates of between 0°loand 41% are reported (Table 1). This wide variation in rates can largely be accounted for by the methodological problems discussed above. Outcome criteria varied from evaluative comments such as ‘¿harmed', to indirect data such as general practitioner's opinions of patients' mental state (see column ‘¿criteria' Table 1). The studies that used standardised psychiatric measurement instruments reported a rate of ‘¿negative I outcome' between 10 and 20%, confirming the
PSYCHOLOGICALEFFECTS OF THERAPEUTIC ABORTION +
view that therapeutic abortion is not a direct cause of psychiatric morbidity. The largest survey of women's mental health following therapeutic abortion is the one by Frank et a! (1985),
of the Royal
College
of General
745
incidence of new cases in the two-year period was only 6.5%. Significantly, only four of the 42 newly treated women felt that their psychiatric symptoms
had been connected with their abortion. The problems of ‘¿caseness' definition are more
Practitioners in collaboration with the Royal College of Obstetricians and Gynaecologists. The authors identified early psychiatric complications (within 21 days of abortion) in 2.5% of 6105women. Only 1.2% of these required psychiatric treatment. Diagnoses were made by GPs. Those with a previous history of depression were found to have a risk of post-abortion depression which was 2.59 times greater than expected. An often quoted review by Morrison-Friedman eta! (1974) calculated an average “¿negative psychological response rate―of 10%. If this observation is even approximately correct this would mean that some
pronounced when it comes to reporting rates for
17000
of presentation, when key relationships were pre
cases
of
abortion-related
psychiatric
disturbances would develop annually in England & Wales (OPCS, 1989). One would anticipate that the majority of these disturbances would be seen and managed by GPs but clinical experience suggests that there can be a reluctance among those with abortion related disturbances to return to the original referrer. The thoroughly-designed prospective study by Greer eta! (1976) deserves individual attention. The authors followed up 360 women at 3, 15, and 24 months after they presented for abortion. A trained social worker made all the assessments which included examination of the mental state, the Hamilton Rating Scale for Depression (HRSD; Hamilton 1960), Eysenck Personality Inventory (Eysenck & Edwards, 1964) and measures of social, marital, interpersonal and sexual adjustment. Over 90% were traced at three months, by which time a marked drop in the mean HRSD score had occurred (11.7 to 4.4, P< 0.001) supporting the observations of the earlier studies that psychological sequelae of abortion are mostly short-lived. Only 60% of Greer's subjects were re-traced at two years, and outcome was defined in terms of the prevalence of psychiatric treatment. Given the low rate of psychiatric treat ment among those attending their GP with depression (Blacker & Clare, 1987), compounded by the additional reluctance to return to the original referrer following abortion, such a measure of outcome will inevitably underestimate the true prevalence of post abortion psychiatric sequelae. Greer et a! reported that the proportion of women who required psychiatric treatment from a GP or psychiatrist actually fell in the post-abortion period from 29% before abortion to 19.4% in the subsequent two years. Two-thirds of those undergoing psychiatric treatment following abortion had in fact had psychiatric treatment before, so the cumulative
loosely defmed psychological reactions such as ‘¿guilt' or sexual and marital adjustment. Greer eta! (1976), using a specially devised scale, identified moderate or severe guilt feelings in 37% of subjects before abortion. By three months, these rates had fallen significantly to 13% and by two years only 7% of the subjects admitted to feeling guilty. Using a self devised social adjustment scale, Greer et a! also reported a significant overall improvement on sexual adjustment by three months, although the relevant comparisons were made with adjustment at the time sumably under considerable strain. At follow up, Greer et a! report a surprising absence of change for better or worse in their measure of ‘¿marital' adjustment. Relationships were described as satisfactory both before and after the abortion by
75% of the samples although it is not clear whether the same couples were satisfied or dissatisfied on
both occasions. Finally, 96% of their subjects resumed normal daily work activities shortly after abortion. Greer's study suggests that the majority of women in this society make a successful psycho social adjustment within a few months of abortion. Long-term sequelae of abortion Many
studies
describe
mourning-like
reactions
following termination of pregnancy. Part et a!(1%9), using psychiatrist interviewers, identified guilt feelings in 12, and episodes of deliberate self-harm in 4, out of 35 women undergoing abortion. “¿Prolonged psychiatric symptoms―developed in 8 of the subjects two to six months after abortion, and these were judged to be related to an underlying bereavement process since their duration coincided with that of
the pregnancy had it continued. It may have been that these experiences were more pronounced in those who held ambivalent attitudes towards the abortion, but the authors do not comment on this. Lask (1975) found that 32°/sof a similarly small sample of 50 women experienced clinically significant feelings of loss, regret, guilt, and self-reproach at six months, again analogous to a mourning process. Some women never get over the feeling that they have ‘¿murdered'their child. Recently, Law (1989) a hospital chaplain, reported in the British Medica! Journa! that 80°/sof women he had seen who had undergone TOP 3—5years previously were still
746
ZOLESE
& BLACKER
working through the grief process. Of course, this figure is anecdotal and could be explained by the fact that religious women are more likely to be ambivalent towards abortion. The most important study in this respect is that by Kumar & Robson (1978) who studied 119 primiparous women throughout their entire pregnancy. “¿Clinically significant neurotic disturbances― were reported in 16°/s and found to be significantly higher (P
References Reprints/ permissions You can respond to this article at Downloaded from
This article cites 0 articles, 0 of which you can access for free at: http://bjp.rcpsych.org/content/160/6/742#BIBL To obtain reprints or permission to reproduce material from this paper, please write to [email protected] http://bjp.rcpsych.org/letters/submit/bjprcpsych;160/6/742 http://bjp.rcpsych.org/ on November 26, 2014 Published by The Royal College of Psychiatrists
To subscribe to The British Journal of Psychiatry go to: http://bjp.rcpsych.org/site/subscriptions/
BritishJournalof Psychiatry(1992),160, 742—749
Review Article
The Psychological Complications of Therapeutic Abortion G. ZOLESE and C. V. A. BLACKER
Psychologicalor psychiatricdisturbancesoccurin associationwith therapeuticabortionsbut they seem to be marked, severe, or persistentin only a minority (approximately10%) of women. These consist mostly of casenessdepressionand anxiety. Psychosesare very uncommon,beingreportedin only0.003% of cases- mostof whom havea historyof previous psychiatricillness.Certaingroupsareespeciallyat riskfrom adversepsychologicalsequelae; these includethose with a past psychiatrichistory,youngerwomen, those with poorsocial support,
the multiparous,
and those
belonging
to sociocultural
groups
antagonistic
to abortion.
This is not to overlookthe fact that, adopting a crisis-resolutionframework, subsequent terminationof an unwanted pregnancyis itself ‘¿therapeutic'. A better understandingof the natureof the riskfactorswouldenablecliniciansto identifyvulnerablewomenfor whom some form of psychologicalinterventionmight be beneficial.
Abortion has always been a matter of controversy, but in recent years it has again come to the forefront of public discussion. The controversy has been particularly reawakened in the USA where, in 1989, in response to political pressures, President Ronald Reagan commissioned a large-scale prospective study entitled The Medical and Psychological Impact of Abortion in Women (Holden, 1989). It is not
appropriate for this review to explore the moral and sociological reasons for the renewed outcry towards abortion some years on from its legalisation. However, advances in medical technology with
Frank et a!, 1985; Drug & Therapeutic Bulletin,
1989). The majority of early abortions (41% are below 12 weeks' gestation) are now conducted on a day-patient basis. Nevertheless, a number of women who have been subject to delays or who for medical reasons are obliged to be admitted as in-patients, are
exposed to increased stress, possible stigma and medical risks. Psychiatric complications have been studied extensively, especially before and soon after
RU486) have played an important role by intensifying the ethical dilemmas. In the UK, where pro-life
the introduction of legal abortion. Faultless research designs are virtually impossible, especially in the mental health field; however, the studies on the psychological aspects of therapeutic abortion appear to be particularly vulnerable. There are many reasons but the most important is the nature of the procedure itself. Women who choose
groups have won the consensus of a large part of the public, the Abortion Act has been recently revised in conjunction with the Embryology Bill (Hall, 1990). One of the controversial issues again disputed is
abortion are not amenable to endless questions on how they feel, are less likely to return for follow up, and baseline assessments before they become pregnant are impossible.
regard to neonatology, in vitro fertilisation, and the development of an oral abortifacient (Mifepristone
Most of the studies reviewed were conducted when standardised psychiatric measurement instruments were not available (Table 1). A large number employed self-devised questionnaires without proven One in five pregnancies in England and Wales are reliability or used unstructured interviews often terminated on therapeutic grounds (Miller eta! 1980; administered by non-psychiatrists. Other problems Llewellyn-Jones, 1982; Kumar & Robson, 1978). were the small sample size, indirect data on outcome, More than half of those seeking abortion in the UK and high attrition rates (Rogers et a!, 1989). are single (63°1o) and between 20 and 24 years (32°lo) When evaluating the true negative effects of (OPCS, 1987; residents only). abortion on women's mental health, it is important Although the mortality rate following surgical to also consider a number of confounding variables. abortion is only 3.5 per 100 000 abortions (Lewis, Therefore, to what extent are these disturbances 1980), gynaecological complications are reported in unique to the abortion procedure? One possibility 5%- 10%, and major complications occur in is that they reflect disturbances associated with O.3°lo—2.l°1o of cases (Savage & Paterson, 1984; pregnancy itself since several studies have reported an
‘¿0 I
the effects of termination of pregnancy (TOP) on the mental health of women. The aim of this review is to examine critically the study designs and make comments for possible future research.
742
I
PSYCHOLOGICAL
EFFECTS OF THERAPEUTIC
743
ABORTION
Table 1 Negative psychological outcome following abortion1 AuthorSample %Peck
followed follow methodCriteriaNegative upMean up:monthsAssessment
sizeNo.
outcome:
& Marcus(1966)74504.5lnt2Adverse reaction2Simon (1967)654661Ost3/lntDepression13Niswander eta!
health6.9Clarketal(1968)1201116GP4Worse0.9Patteta!(1969)483525.5lntHarmed14.3Pare & Paterson(1967)1701618OatEmotional depression17.2Whittington & Raven(1970)18416924lntGuilt, (1970)11531retro worse3Brodyeta!(1971)94801.5MMPI5Reductionin
for spectiveOatChange
anxiety—Fordeta!(1971)29216lnt/MMPIWorse14Margolis eta! (1971)50434.5Qst/MMPINegative reaction9.3Meyerowitzeta!(1971)1147743GPAdaptation9.1Osofsky (1972)2502501mtGuilt23.8Todd & Osofsky (1972)696324Qst/GPUnsatisfactory state5.8Wallerstein (1972)114226lntPsychosocial outcome31.8Ewing & Rouse(1973)17612612.3OatEmotional
reaction6.3McCance (1973)23419219.6BDIDepression22Perez-Reyes eta! (1973)61416Qat/IntDepression41Weston & Falk (1973)1541401Qst/lntGuilt11Lask
(1975)56506lnt/HRS7 outcome32Rosenthal (1975)34331lntFunctioning24.2Greer & Rothschild eta! (1976)3603263lnt/HRSPsychiatric treatment6.5Ashton (1980)103642.6lnt/OstGuilt7.8Frank eta! (1985)610561050.7GP/GynaePsychiatric morbidity2.5Lazarus
ZRS8Unfavourable
(1985)2942920.5OatDepression15
4'
1. 2. 3. 4. 5.
Adapted from Rogers eta! (1989). mt = unstructured psychiatric interview. Oat self-devised questionnaire. GP =general practitioner assessment. MMPI = Minnesota Multiphasic Personality Inventory.
fr
6. BDI—¿ BeckDepressionInventory. 7. HAS Hamilton RatingScale. 8. ZRS =Zung rating scale.
increased incidence of psychological difficulties in the first trimester in women not seeking abortions (Macdonald, 1958; Kumar & Robson, 1978; Ancill et a!, 1986). A further contribution to any observed psycho logical distress may come from the stigma associated with hospital admission, often to gynaecological wards where other women may be undergoing investigation for infertility. In addition there is the
@
-
@ @
impact
of
a
general
anaesthetic,
for
those
that
receive
one, and surgical interference, especially that involving gynaecological sites. It is not proposed to review these issues here but readers may care to
refer to the papers by Whitelaw (1979), Johnston (1980), and Cooper et a! (1982). A significant proportion of women presenting for abortion are also suffering from major social and relationship difficulties. Such women are already subject to a range of stresses which are essentially independent of those posed by the actual pregnancy! abortion but which contribute substantially to any observed psychological disturbance seen at this time. As already stated, some socially conditioned dis advantages may also be related to becoming pregnant in the first place. For example, of 360 women undergoing abortion examined by Beard et a! (1974),
744
ZOLESE & BLACKER
45% of those from social class 4 & 5 (compared with 14% from classes 1 & 2) were ignorant about contraception. It is likely that all these factors make at least some contribution to the psychological disturbances seen in association with therapeutic abortion. Studies of psychologicalsequelae Early studies The studies conducted between 1935 and 1964 were reviewed by Simon & Senturia (1966). In their opinion, the best designed studies were conducted in Europe (Table 2). These tried to make a distinction between psychological responses such as ‘¿guilt' and formal psychiatric syndromes. Their results showed
a wide variation in sequelae, which reflected differing methodological procedures: the use of unstructured psychiatric interviews and arbitrary measures of guilt. In particular, their high rates of psychiatric disturbance could be explained by the added distress
of seeking an abortion when it officially remained illegal.
The remaining 24 studies reviewed by Simon & Senturia were criticised on grounds of method, including problems with sample selection; in particular, no distinction was made between therapeutic,spontaneous and criminal abortions.
In addition, follow-up time was highly variable, ranging from a few weeks to several years, and operational criteria for psychiatric diagnosis were not employed. A number of the papers quoted by Simon & Senturia were case reports by psycho analysts who saw a request for abortion per se as indicative of psychopathology. These authors emphasised the importance of the ‘¿internal' reasons for seeking an abortion and at times considered the Table 2 Comparison
of outcome
in five studies conducted
in
Europeancontries1 Sample
%Malforms844312(Sweden, sizeGuilt: 1958)Arena1002323
(?)(Sweden, 1958)Siegfried6113131?)(Switzerland, 1951)Ekblad479111(Sweden, 1955)Brekke3400(Norway, 1958) 1. Adapted from Simon & Senturia (1966).
%Psychiatric
illness:
abortion as causing severe emotional disturbances (Deutsch, 1945; Ebaugh & Heuser, 1947; Lidz, 1954). Formal studies within the past 20 years Many studies have looked at the psychological complications of therapeutic abortion. Most agree that the abortion per se does not cause psychiatric disturbance but rather is beneficial to the woman's mental health (Ilisley& Hail, 1976;Romans-Clarkson, 1989). The results are best considered in terms of the ‘¿caseness' of the psychological sequelae they report. Although the literature contains several case reports of severe psychiatric syndromes resembling puerperal psychosis, these appear to be an uncommon occurrence. Brewer (1977),in a prospectivestudy,
obtained rates for post-abortion psychosis of 0.3 per 1000 abortions (rates for psychosis following childbirth are of the order of 1.7 per 1000live births). Major psychiatric disturbances following abortion appear to occur in women who have a pre-existing psychiatric disorder and who are therefore strongly predisposed to breakdown or relapse. As part of a continuing and extensive survey of the physical and psychiatric sequelae to therapeutic abortion, Frank eta! (1985) reported that only 2(0.03%)
‘¿1
‘¿0
out of 6105
patients required psychiatric hospital admission. Both patients were diagnosed as suffering from schizophrenia. Hospital admission is only an indirect measure of psychiatric morbidity and further publications containing more explicit diagnostic details are awaited. However, an interesting study by David (1985) examined psychiatric hospital admission rates among Danish women who had recently undergone therapeutic abortion (within the previous three months). When compared with an age-matched control group of non-pregnant women, admission rates for the abortion group were ‘¿0 consistently higher. Women who were separated, widowed, or divorced were found to be especially at risk of psychiatric hospital admission following abortion. Apart from psychosis, the principal formal psychiatric disturbances following therapeutic abortions are neurotic and affective in type for which rates of between 0°loand 41% are reported (Table 1). This wide variation in rates can largely be accounted for by the methodological problems discussed above. Outcome criteria varied from evaluative comments such as ‘¿harmed', to indirect data such as general practitioner's opinions of patients' mental state (see column ‘¿criteria' Table 1). The studies that used standardised psychiatric measurement instruments reported a rate of ‘¿negative I outcome' between 10 and 20%, confirming the
PSYCHOLOGICALEFFECTS OF THERAPEUTIC ABORTION +
view that therapeutic abortion is not a direct cause of psychiatric morbidity. The largest survey of women's mental health following therapeutic abortion is the one by Frank et a! (1985),
of the Royal
College
of General
745
incidence of new cases in the two-year period was only 6.5%. Significantly, only four of the 42 newly treated women felt that their psychiatric symptoms
had been connected with their abortion. The problems of ‘¿caseness' definition are more
Practitioners in collaboration with the Royal College of Obstetricians and Gynaecologists. The authors identified early psychiatric complications (within 21 days of abortion) in 2.5% of 6105women. Only 1.2% of these required psychiatric treatment. Diagnoses were made by GPs. Those with a previous history of depression were found to have a risk of post-abortion depression which was 2.59 times greater than expected. An often quoted review by Morrison-Friedman eta! (1974) calculated an average “¿negative psychological response rate―of 10%. If this observation is even approximately correct this would mean that some
pronounced when it comes to reporting rates for
17000
of presentation, when key relationships were pre
cases
of
abortion-related
psychiatric
disturbances would develop annually in England & Wales (OPCS, 1989). One would anticipate that the majority of these disturbances would be seen and managed by GPs but clinical experience suggests that there can be a reluctance among those with abortion related disturbances to return to the original referrer. The thoroughly-designed prospective study by Greer eta! (1976) deserves individual attention. The authors followed up 360 women at 3, 15, and 24 months after they presented for abortion. A trained social worker made all the assessments which included examination of the mental state, the Hamilton Rating Scale for Depression (HRSD; Hamilton 1960), Eysenck Personality Inventory (Eysenck & Edwards, 1964) and measures of social, marital, interpersonal and sexual adjustment. Over 90% were traced at three months, by which time a marked drop in the mean HRSD score had occurred (11.7 to 4.4, P< 0.001) supporting the observations of the earlier studies that psychological sequelae of abortion are mostly short-lived. Only 60% of Greer's subjects were re-traced at two years, and outcome was defined in terms of the prevalence of psychiatric treatment. Given the low rate of psychiatric treat ment among those attending their GP with depression (Blacker & Clare, 1987), compounded by the additional reluctance to return to the original referrer following abortion, such a measure of outcome will inevitably underestimate the true prevalence of post abortion psychiatric sequelae. Greer et a! reported that the proportion of women who required psychiatric treatment from a GP or psychiatrist actually fell in the post-abortion period from 29% before abortion to 19.4% in the subsequent two years. Two-thirds of those undergoing psychiatric treatment following abortion had in fact had psychiatric treatment before, so the cumulative
loosely defmed psychological reactions such as ‘¿guilt' or sexual and marital adjustment. Greer eta! (1976), using a specially devised scale, identified moderate or severe guilt feelings in 37% of subjects before abortion. By three months, these rates had fallen significantly to 13% and by two years only 7% of the subjects admitted to feeling guilty. Using a self devised social adjustment scale, Greer et a! also reported a significant overall improvement on sexual adjustment by three months, although the relevant comparisons were made with adjustment at the time sumably under considerable strain. At follow up, Greer et a! report a surprising absence of change for better or worse in their measure of ‘¿marital' adjustment. Relationships were described as satisfactory both before and after the abortion by
75% of the samples although it is not clear whether the same couples were satisfied or dissatisfied on
both occasions. Finally, 96% of their subjects resumed normal daily work activities shortly after abortion. Greer's study suggests that the majority of women in this society make a successful psycho social adjustment within a few months of abortion. Long-term sequelae of abortion Many
studies
describe
mourning-like
reactions
following termination of pregnancy. Part et a!(1%9), using psychiatrist interviewers, identified guilt feelings in 12, and episodes of deliberate self-harm in 4, out of 35 women undergoing abortion. “¿Prolonged psychiatric symptoms―developed in 8 of the subjects two to six months after abortion, and these were judged to be related to an underlying bereavement process since their duration coincided with that of
the pregnancy had it continued. It may have been that these experiences were more pronounced in those who held ambivalent attitudes towards the abortion, but the authors do not comment on this. Lask (1975) found that 32°/sof a similarly small sample of 50 women experienced clinically significant feelings of loss, regret, guilt, and self-reproach at six months, again analogous to a mourning process. Some women never get over the feeling that they have ‘¿murdered'their child. Recently, Law (1989) a hospital chaplain, reported in the British Medica! Journa! that 80°/sof women he had seen who had undergone TOP 3—5years previously were still
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& BLACKER
working through the grief process. Of course, this figure is anecdotal and could be explained by the fact that religious women are more likely to be ambivalent towards abortion. The most important study in this respect is that by Kumar & Robson (1978) who studied 119 primiparous women throughout their entire pregnancy. “¿Clinically significant neurotic disturbances― were reported in 16°/s and found to be significantly higher (P
