Sunday, January 8, 2017
Abortion, Women's Mental Health, and Politics...
Let me preface this post by saying that I am not a member of a political party and I do not endorse any political views about abortion. The only interest that I have in abortion is what women tell me about it in the context of a psychiatric evaluation and treatment. I also do not want to see women's mental health become a surrogate end point for the political debate on abortion. In the state where I practice the Minnesota Department of Health mails a report on the number of abortions in the state with a number of warnings about the legal requirements of reporting abortions (p 51-57 of this report) despite that fact that 99+% of all physicians and 100% of psychiatrists do not perform abortions. I bristle when I get that politically motivated report each year.
I am writing this post to examine whether or not any objective research on the mental health effects of abortion can be done. This examination was precipitated by a post on a forum of the Time story "Abortion Doesn’t Negatively Affect Women’s Mental Health: Study". Whenever I see an article like that I think of two things - the life experiences that women have told me over the years and where abortion fits in. I also try to think about how I would do a study of this issue. What would constitute mental health? Most large studies don't depend on interviews anymore and that typically means a checklist or some sort of psychometric instrument. There are typically cutoff scores and comparisons of cutoff scores between the research subjects and a control group. Correlations are made with come psychiatric diagnosis or psychological construct to determine mental health. With that kind of technology the underlying assumption is that these are good measures of mental health and that it covers all of the possibilities. Human consciousness covers a lot of ground and there are generally subtle problems that don't get covered by these gross measures.
The study in question (1) is based on telephone interviews semiannually over a period of 5 years of a cohort of women selected for having an abortion, having a first trimester abortion, being turned away from access to an abortion and giving birth and being turned away from access to abortion and not giving birth. In their results section, the authors plot the results of 11 interviews, but they point out that the subjects participated in an average of 8 over the 5 year period. The women who received an abortion presented within 2 weeks of the clinics gestational limit for abortions (N=452). Women with pregnancies up to 3 weeks past the gestational limit were turned away. The turnaway group either gave birth (N=161) or had an abortion or miscarried (N=70) as possible outcomes. Based on those outcomes they were identified as the turnaway-birth and turnaway-no-birth groups. The first trimester group (N=273) was included to study whether or not the psychological outcomes differed if a woman had an abortion early or late during the pregnancy.
The test metrics were all Likert scales. The depression and anxiety ratings came from the Brief Symptom Inventory (BSI) a 53 item rating scale of various psychological symptoms. There are grouped ratings for 9 different symptom constellations including anxiety and depression. All subjects are asked to rate their level of distress due to a symptom on a severity score ranging from 0 (not at all) to 4 (extremely). For anxiety and depression their are 6 items each and subjects were identified as a "case" of anxiety or depression if their aggregate score were 9 of the total possible score of 24.
Life satisfaction was determined by one item from the Satisfaction with Life Scale: "I am satisfied with my life." One item was also included for self esteem. Both were rated on a 5 - point scale from 1 (not at all) to 5 (extremely high life satisfaction/self esteem).
Using these variables, the trends were best illustrated in graphics of depressive cases versus time and depressive symptoms versus time (figure 1 above) and similar graphics for anxiety, self esteem, and life satisfaction. The general trend was for less anxiety and depression slightly higher self esteem and life satisfaction over the 5 year course of the study. I think analysis of the latter two elements was limited by the the single items 5 point scale and a regression toward the midpoint of the rating. There is the usual extensive statistical analysis of what I would see as fairly limited data. The turnaway groups and the near limit group generally had more depressive and anxiety symptoms and cases and lower self esteem and life satisfaction that the first trimester abortion group. Their statistical analysis is consistent with those observations.
The authors conclude: "Our findings add to the body of evidence rejecting the notion that abortion increases women’s risk of experiencing adverse psychological outcomes. Women who had an abortion demonstrated more positive outcomes initially compared with women who were denied an abortion." In their secondary analysis they show that a history of previous mental health problems or psychological trauma correlated with adverse outcomes and may have worse outcomes if they are denied an abortion. They discuss the importance of individualized care and recognizing the response to an abortion or in this case denial of abortion. One trend that I did not see any specific comments on was the turnaway-no-birth group and the fact that it seemed to have the best outcome at 5 years in terms of depressive symptoms/syndromes and higher self esteem and life satisfaction. In their overall conclusion the authors believe that their study shows that there is no necessity for laws warning women about the adverse psychological consequences of abortion and that being denied an abortion is potentially more detrimental.
In their own discussion of the limitations of the study, loss of subjects over time was significant - 43% over 5 years. They discuss the methods they used to limit bias due to loss (potentially of subjects with mental illnesses). They discuss their alteration of the BSI and point out that it is really a screening instrument so that the identified cases in their study would require additional screening for an actual diagnosis of an anxiety disorder or depressive disorder.
I had several thoughts when I read this study. Women don't generally come in to psychiatrists and say they are depressed or anxious as the result of an abortion or a denied abortion. That might be different in psychiatric clinics that specialize in women's health issues. They often don't discuss the issue at all in the initial diagnostic evaluation. They disclose these details along with other sensitive issues after a relationship has been established with a psychiatrist. In that context there can be discussions about thoughts, images, and feeling states related to abortion into other forms of psychopathology. An example would be intense guilt, rumination, and self criticism about the abortion during an episode of depression. When any person gets depressed it is a common experience to scan past personal history for stressful events from the past that lead to the same emotion. There can be daydreams and fantasies of what the child would have been like. There can be brief episodes of depression or anxiety related to self criticism, doubt, shame, or interpersonal conflict about having had an abortion. Many of these thoughts can occur at a future date when the history of an abortion can take on new meaning such as a new committed relationship. Any life event that impacts person's conscious state and causes them distress is significant to me, whether it is picked up by rating scales or not. I would see these reactions as being part of normal emotional life rather than anything pathological.
Equating the mental health of women to a DSM diagnosis or psychometric construct is a mistake. The DSM is a product of looking at the 5% of people who are outliers and trying to characterize their problems with with categories or continua. That approach removes human consciousness from the equation and that should no longer be acceptable to psychiatry or anyone interested in the conscious life of real people. An event with as much potential meaning as abortion can never be adequately characterized as a psychiatric diagnosis or a psychometric scale. The reactions are too diverse and nuanced. Suggesting that abortions or the lack of abortions does or does not affect women is more of a political statement than a statement that takes into account the most important aspect of the human psyche - the unique conscious state of every person. That conscious state is unique because what happens over the course of your lifetime matters and some events matter more than others.
My conclusion from practice is that abortion is one of many events that has the potential to significantly impact the conscious state of a woman. That should be the consideration in the case of contraception, pregnancy prevention, and abortion and not whether or not it causes mental illness or symptoms. A woman's unique conscious state should also be considered in the case of unplanned pregnancies and why that decision is much more complex than a list of social variables or whether or not contraception is used. A more appropriate focus on conscious state rather than mental illness or symptoms would yield a more realistic idea about the effect of life events like abortion. That result will be anything but simple and that is why simplistic political solutions or response to those solutions do not apply here.
I have a secondary conclusion about the place of politics in both the research and clinical care of women. It has no place at all.
It is as obvious as an annual vaguely threatening letter about abortion reporting to a psychiatrist from the state government. When politicians practice medicine nothing good happens, but this letter goes way beyond that.
George Dawson, MD, DFAPA
1: Biggs MA, Upadhyay UD, McCulloch CE, Foster DG. Women's Mental Health and Well-being 5 Years After Receiving or Being Denied an Abortion: A Prospective, Longitudinal Cohort Study. JAMA Psychiatry. 2016 Dec 14. doi: 10.1001/jamapsychiatry.2016.3478. [Epub ahead of print] PubMed PMID: 27973641.
1: Graphic at the top is from Reference 1 with permission from the American Medical Association - Order Number 4024950066424
2: Thanks to Pearson Assessments for sending me a sample copy of the Brief Symptom Inventory. www.pearsonassessments.com