How many psychiatrists does it take to change a light bulb?

Abortion is a highly emotive subject accompanied by polarised opinions. Catholic psychiatrists have described abortion as being ‘primarily moral and ethical, not psychiatric or scientific’. I would add ‘primarily social’. Since 1967, the law in England and Wales allows abortion on grounds of likely damage to the health of the mother or her children. Therefore psychiatrists are less involved in evaluation, the GP or gynaecologist often making the decision about health risk. Since my last editorial on the subject¹ there have been a number of publications of interest. Abortion is associated with a ‘small’ (30%) increase in mental disorders among women²; pregnancy loss per se (due to abortion or miscarriage) is associated with increased risk of mood and substance use disorders in Australian women³; a systematic review⁴ reported that the best research found no excess of psychiatric problems whereas flawed research found negative outcomes; a New Zealand study⁵ found that abortion was associated with high rates of both positive and negative emotional reactions (almost 90% of respondents believed that abortion was the right decision and number of negative responses was associated with subsequent mental health problems); a quantitative synthesis and analysis of the literature⁶ found moderate to highly increased risk of various mental health problems after abortion, although direction of causation could not be determined and the study was robustly criticised in relation to methodology, eg. regarding population attributable risk; and a Danish study of women who had experienced psychiatric admission at least nine months prior to first-trimester induced abortion or giving birth⁷ found no change in the risk of readmission in the year post-abortion but a marked increase in such admissions after parturition. One study⁸ found that women in Prague denied abortion had children who as adults had poorer mental health than their siblings or matched controls. One might ask if unwanted pregnancy correlates with psychosocial difficulties in the first place. Researchers⁹ assessed women for a depressive outcome using the National Longitudinal Study of Youth and found that married women carrying an unintended first pregnancy to term were at less risk of subsequent depression than women who aborted, but rates of high risk depression scores were comparable among unmarried women. According to Brockington¹⁰ puerperal psychosis (PP) following previous pregnancies is not an indication for abortion because PP is just as likely to follow abortion.

Because some women do experience psychological problems following abortion it is important that appropriate follow-up care be available.¹¹ That being said, there is no evidence that psychiatrists are particularly good at foretelling suicide.^12,13 This applies no matter how many psychiatrists are asked the question. If we are to legislate for abortion might we not learn from the English approach and leave psychiatrists out of the equation unless the person is thought to suffer from a recognised psychiatric disorder? 

References

1. O’Shea B. Irish Psychiatrist 2002; 3(3): 85
2. Fergusson DM. Psychiatric Bull 2008; 32: 321-4 
3. Dingle K et al. Br J Psychiatry 2008: 193: 455-60
4. Charles VE et al. Contraception 2008; 78: 436-50
5. Fergusson DM et al. Br J Psychiatry 2009; 195: 420-6
6. Coleman PK. Br J Psychiatry 2011; 199: 180-6
7. Munk-Olsen T et al. Arch Gen Psychiatry 2012; 69: 159-65
8. Kubicka L et al. J Nerv Ment Dis 2002; 190: 653-62
9. Reardon DC, Cougle JR. BMJ 2002; 324: 151-2
10. Brockington I. In: New Oxford Textbook of Psychiatry. 2nd ed. Gelder MG et al, eds. Oxford: Oxford University Press, 2012, p1119
11. Anonymous. Lancet 2008; 372: 602
12. O’Shea B. Irish Psychiatrist 2005; 6(1): 1
13. O’Shea B. Irish Psychiatrist 2005; 6(2): 45