Invited commentaries on... Abortion and mental health disorders

The finding that induced abortion is a risk factor for subsequent psychiatric disorder in some women raises important clinicaland training issues for psychiatrists. It also highlights thenecessity for developing evidence-based interventions for thesewomen. P.C. / Evidence suggesting a modest increase in mentalhealth problems after abortion does not support the prominenceof psychiatric issues in the abortion debate, which is primarily moral and ethical not psychiatric or scientific. M.O. et al.

Post-abortion psychiatric disorder: clinical and training implications

TOP

Post-abortion psychiatric...

The Christchurch Health and Development Study is a longitudinalstudy of a birth cohort of 1265 children born in Christchurch,New Zealand, 30 years ago. Fergusson et al’s study¹deals with the relationship between pregnancy-related events,including abortion, and subsequent mental health among womenassessed at several time points. The methodology and statisticalanalysis is complex and the control for over 30 confounders,including the issue of wanting the pregnancy or not, makes this study unique. These variables represent those that have beenidentified in the scientific literature as potentially leadingto problems when interpreting previous studies that have postulateda causal link between abortion and mental health problems.² The focus of Fergusson et al’s study is on common mentaldisorders, including substance misuse. It was not powered toexamine the relationship, if any, between induced abortionand psychotic disorders.

Robust design
The prospective design, cross-checked against retrospectiveinformation, its resilience to confounding, and the use ofstructured interviews as distinct from clinical diagnosis on consultation³ make Fergusson et al’s study arguablythe most robust in its field, conferring on it significantauthority. In addition, the attrition rate of 20% over 30 yearswas much lower than in other studies,⁴ and the accuracy ofabortion ascertainment was much higher.⁵ Based on the results,the authors conclude that abortion has a small causal link to subsequent mental health problems and that the impact on thereported prevalence of psychiatric disorders in women who havehad an abortion compared with women who have not was up to30%, while the attributable risk to the totality of psychiatricmorbidity in the general population was modest at 1.5–5.5%.

Medico-legal and clinical implications
The results of this study reinforce the opinion that the RoyalCollege of Psychiatrists was indeed wise in producing a nuancedposition statement on abortion and mental health⁶ and, althoughdemurring from supporting a causal link, advised that the conflicting scientific information on this be provided to women seekingabortion in the interests of fully informed consent. AlthoughFergusson et al address legislative concerns in their discussion,there are more immediate medico-legal implications flowingfrom the findings; namely, the prospect of litigation againstabortion providers for failing to provide women with informationof a possible causal link between abortion and subsequent mental health problems.

The clinical relevance of this study is arguably more important,since these women are vulnerable to mental problems and aspart of the wider population may present to their general practitionersor to the psychiatric services. Apart from issues of consent,there are other treatment implications. The first is the clearnecessity for vigilance for the possible onset of adverse reactionspost-abortion, as discussed by others,⁷ although the highproportion of women who fail to attend for post-abortion assessment will often not enable this. Moreover, since the emergence ofemotional problems and/or help-seeking may be delayed, generalpractitioners will have a key role in this. So, clear carepathways for those at risk of or suffering from psychiatricdisorders in the context of abortion should be incorporated into guidelines developed by the various professional bodies,as recommended in the College’s statement.⁶ These shouldinclude guidance on the agencies to which such women shouldbe referred.

There are some difficulties in this regard since it is the voluntarysector that offers much of the assistance to these women atpresent. Although it might be assumed that the obvious bodiesto offer post-abortion interventions are those providing abortionservices, there is evidence that women adversely affected byabortion do not return to the providers for this.

Developing interventions
Mental health professionals generally, with the possible exceptionof perinatal psychiatrists, have little experience in managingabortion-related disorders and, although these include a rangeof common psychiatric disorders, there are aspects of the symptomsthat require specific expertise. These include managing guilt,anger, avoidance and dissonance concerning the status of thefoetus. A further gap is the absence of scientific informationon the preferred interventions, whether psychological, pharmacologicalor a combination of these. Moreover, some women, even thosewithout specific religious beliefs, seek comfort from ministersof religion, and their role, along with that of voluntary organisations,in relation to that of doctors, will have to be clarified whendeveloping guidelines.

This study also has implications for psychiatrists in training.The reticence to routinely inquire about induced abortion duringhistory-taking is a noticeable deficiency among many trainees.Analogous to the growing awareness of sexual abuse during the1990s, which led to changes in history-taking, an increasingawareness that for a minority of women abortion may be of aetiologicalsignificance should stimulate training is this aspect of psychiatricinterviewing. The danger of either condemning the abortion decisionor minimising the emotional impact is one that has been identifiedby women themselves,⁸ and this sensitivity must specificallybe incorporated into training. Bearing in mind the increasingemphasis on service user involvement, a possible role for womenwho have had adverse reactions to abortion might assist in this aspect of training, along with qualitative studies.

The findings of this study will provoke controversy but theyshould not be clouded by ideology. Rather, the focus shouldbe on identifying vulnerable groups of women and providingoptimum treatment for them, whatever the aetiology of theirmental health problems.

Declaration of interest

P.C. is not a member of any campaigning organisation. She hasspoken at conferences to groups on both sides of the debate.She has made public comments on this topic as a psychiatristwith experience in treating women with abortion-related psychiatricdisorders. She gave evidence to the Parliamentary Science andTechnology Committee in relation to the Human Fertilisationand Embryology Bill. / M.O. was co-author of the 1994 Royal College of Psychiatrists’ statement on abortion. Sheis the psychiatric assessor for the Confidential Enquiry intoMaternal and Child Health (CEMACH) and past Chair of the PerinatalSection of the Royal College of Psychiatrists. R.C. is Chairof the Perinatal Section. I.J. is a member of the Executiveof the Perinatal Section. The authors are not supporters ofany pro-life or pro-choice group. M.O. and R.C. are not membersof any religious organisation. I.J. is a practising Anglican.

See pp. 444–451, this issue.

REFERENCES

TOP

REFERENCES

Fergusson DM, Horwood, LJ, Boden JM. Abortion and mental health disorders: evidence from a 30-year longitudinal study. Br J Psychiatry 2008; 193: 444 –451.[Abstract/Free Full Text]

Fergusson DM, Horwood LJ and Ridder EM. Abortion in young women and subsequent mental health. J Child Psychol Psychiatry 2006; 47: 16 –24.[CrossRef][Medline]

Gilchrist AC, Hannaford PC, Frank P, Kay CR. Termination of pregnancy and psychiatric morbidity. Br J Psychiatry, 1995; 167: 243 –8.[Abstract/Free Full Text]

Major B, Cozzarelli C, Cooper ML, Zubek J, Richards C, Wilhite M, Gramzow RH. Psychological responses of women after first-trimester abortion. Arch Gen Psychiatry 2000; 57: 777 –84.[Abstract/Free Full Text]

Schmiege S, Russo NF. Depression and unwanted first pregnancy: longitudinal cohort study. BMJ 2005; 331: 1303.[Abstract/Free Full Text]

Royal College of Psychiatrists. Position statement on women’s mental health in relation to induced abortion. 14 March 2008. Royal College of Psychiatrists, 2008 (http://www.rcpsych.ac.uk/members/currentissues/mentalhealthandabortion.aspx).

Gissler M, Berg C, Bouvier-Colle MH, Buekens P. Injury deaths, suicides and homicides associated with pregnancy, Finland 1987–2000. Eur J Public Health 2005; 15: 459 –63.[Abstract/Free Full Text]

Goodwin P, Ogden J. Women’s reflections upon their past abortions: an exploration of how and why emotional reactions change over time. Psychol Health 2007; 22: 231 –48.[CrossRef]

Margaret Oates, MBChB, DPM, MRCPsych, FRCPsych

Nottinghamshire Healthcare Trust, and University of Nottingham, and East Midlands Perinatal Mental Health Managed Clinical Network

Ian Jones, MSc, MBBS, MRCPsych, PhD

Cardiff University

Roch Cantwell, MB, BCh, FRCPsych

University of Glasgow, UK

Correspondence: Margaret Oates, Nottinghamshire Healthcare NHS Trust, Division of Psychiatry, Duncan Macmillan House, Porchester Road, Nottingham NG3 6AA, UK. Email: margaret.oates{at}nottingham.ac.uk

Abortion: a psychiatric issue?

TOP

Abortion: a psychiatric issue?

Fergusson et al in this issue¹ show ‘a modest increase’in risk of subsequent mental health problems in women who havean abortion. Their discussion of research problems is well balanced and describes the intrusion of the moral stance of researchersin the interpretation of results and the hijacking of studieswith inconclusive evidence by both sides of the divide to supporttheir cause. Professor Fergusson’s recent Editorial inthe Psychiatric Bulletin is to be welcomed.²

However, even in their careful paper¹ there are problems.The cohort size did not allow for any examination of the riskof serious mental illness. The modest increase in risk of mildproblems might be accounted for by ‘a minority of women[for whom] abortion is a highly stressful life event whichevokes distress, guilt and other negative feelings that maylast for many years’. Unfortunately, they did not identifywho this minority of women might be. Research suggests thatwomen with multiple pregnancy loss and those who have a latetermination for foetal abnormality face an increased risk ofmental health problems.³ Could this account for the increasedrisk identified in this paper?

Are there vulnerable groups?
Despite these caveats, if abortion were associated with a modestincrease in mental health problems this would not be surprising.Reproductive and gynaecological events have long been associatedwith psychological sequelae. Aetiological fashions change,as do research methodology, societal attitudes, reproductiveepidemiology and technology. Studies of links between these events and adverse sequelae have produced variable resultsbut consistently there are vulnerable subgroups who are atincreased risk. Is this not also likely to be true for abortion?

Perhaps future research might help to better identify the vulnerable subgroups. It is unlikely that it will resolve whether or notabortion causes more mental health problems than continuingwith a pregnancy. It will never be possible ethically to conductrandomised controlled trials. Women who choose to abort anunwanted pregnancy will be different from those who choose to continue; comparison will always be problematic.

The reasons for an abortion are personal and distressing. Someof these have changed since the Abortion Act 1967, when singlemotherhood was considered to be shameful. On the other hand,technology has changed and early-pregnancy diagnosis of foetalabnormality has given rise to new reasons for abortion. Inthe UK prior to the Abortion Act, and still throughout low- and middle-income countries, illegal abortion was a leadingcause of maternal death.⁴ This, together with protecting doctorsfrom prosecution, was a factor in the legalisation of abortion.

What are the implications of this study for the legal statusand practice of abortion? The rights or wrongs of abortionare not primarily psychiatric or even scientific questions,but rather moral, ethical and legal issues. There are, however,two areas of controversy for which these findings have implications.

The Abortion Act: Clause C
First, very few women seeking an abortion have a mental illnessand fewer will see a psychiatrist, yet 94% of abortions takeplace under Clause C in Certificate A (which the doctor approvingthe abortion must sign).⁵ Interestingly, despite ‘therisk to mental health’ to which it refers this is oftencalled ‘the social clause’. It is not possibleto know whether a woman would have done better if she had proceeded with the pregnancy, kept her baby or given it up for adoption. Population-based studies showing a modest increase in mentalhealth consequences are unlikely to help the individual clinicianor woman. Because of these difficulties and the equivocal natureof the evidence, should society and legislators consider movingto a legal framework that acknowledges the ‘fig leaf’of Clause C and the reality of almost unrestricted access tofirst-trimester abortion?

Counselling and informed consent
Second, some have argued for mandatory counselling and informedconsent about risk to mental health for all women seeking abortion.^6,7 All women should be asked by the professionals involvedabout their reasons and alternatives should be discussed. Mostwomen will therefore receive this form of ‘counselling’.A wise clinician should spot the vulnerable subgroups. Thesecould include women whose pregnancy was initially wanted but then they became terrified of some consequence, including therecurrence of a previous postnatal illness; the very young;those who have been put under undue pressure; those with previousabortions; and those whose ambivalence was evident. Such womenmight be referred for further counselling or psychiatric opinion.Late abortions, particularly for foetal abnormality, are associated with an increased risk of major depressive illness in the shortand medium term. These women too might benefit from talkingthrough their decisions and from the offer of support. However,this is a far cry from mandating counselling for all. A possibleconsequence of this could be delay, with more late terminationsand an increase in psychiatric morbidity. It would be remarkableif abortion was not associated with a rise in distress and even episodes of anxiety and depression: all other gynaecologicaland reproductive events, and most surgical procedures, are,as indeed are life events. Informed consent for surgery doesnot include a warning of psychological hazard. We do not believethat the evidence is strong enough to support mandating such advice for abortion.

Perhaps the Royal College of Psychiatrists should not have astatement on abortion. Some medical Royal Colleges have thispolicy. There will never be a consensus among the College’smembers; indeed, there are a range of opinions among the authorsof this commentary. We do, however, agree that abortion isnot a psychiatric but a moral, ethical and legal issue, andthat the views of College members will be as diverse as inthe population at large.

REFERENCES

TOP