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As of 2017, nearly one-third of women in the United States will have an induced abortion by the age of 45 years.1 Despite decades of studies showing that abortion does not cause mental illness, misinformation abounds. Women with psychiatric disorders are differentially vulnerable to conceiving pregnancies they do not intend or that occur at times when they do not consider themselves able to provide adequate parenting. Thus clinicians can expect to encounter many patients who have had abortions and some facing decisions about current pregnancies. Students, trainees, and policy makers need accurate information as well.
Complex psychodynamic and psychosocial realities underlie both public policy and clinical presentations of abortion. Women’s responses are influenced by the attitudes of their families and societies and by the realities of obtaining and undergoing the procedure. Women’s reproductive behaviors do not correspond to their religious or personal beliefs. The distribution of stated religious affiliations among women having abortions is the same as that of the general population.2 Opinions about abortion in the abstract are sequestered in a different brain or psychological region, so to speak, from decisions made when faced with an actual pregnancy in oneself, a loved one, or a sexual partner; thus a disparity exists between the incidence of abortion and the number of antiabortion votes and elected officials in the United States.
The understanding, study, and reporting of the psychiatric outcomes of abortions is methodologically challenging. The English language lends itself to a confusion between mental illnesses, such as mood and anxiety disorders, with normal human experiences, such as sadness and anxiety. This confusion has been exploited by antiabortion activists both in scientific publications and in public policy. To study the effects of an intervention, we need a control group of participants who do not undergo that intervention. However, women who have abortions are not necessarily comparable with the general population of women. They have abortions for reasons: ongoing mental illness, including alcohol and substance use disorders; current obligations; intimate partner violence, including coerced or forced sex; immaturity; poverty; the need to complete an education; and insufficient social support. Many of these circumstances consist of or are associated with an increased risk of mental illnesses and suicide. This makes constructing an appropriate control group difficult (but not impossible).
Once a woman is pregnant, delivery or termination are the only 2 options (miscarriage, or spontaneous abortion, removes both options). Pregnant women who choose to remain pregnant are the only meaningful control group for women who have abortions. However, there are serious confounding variables; women who choose to remain pregnant are likely to be in more supportive and healthy circumstances than those that lead women to terminate their pregnancies. One approach to dealing with this challenge is to compare women who have abortions with women whose requests for abortion are denied, which has been tested repeatedly over time.3 In 2017, Biggs et al4 matched samples of these populations and found that the women who were granted abortions had more favorable psychosocial outcomes than those denied. In this issue of JAMA Psychiatry, the article by Steinberg et al5 is an excellent example of the evolution of research using childbirth as a control for abortion. Drawing on the comprehensive population medical data in Denmark, they used first-time filled prescriptions for antidepressants as an indicator of the onset of clinical depression or anxiety. They compared women having a first abortion with women carrying a first pregnancy to term. Danish records yielded a total of 396 397 women aged 18 to 32 years between January 1, 2000, and December 31, 2012. Of these, 59 465 women (15.0%) received first-time prescriptions for antidepressants, which the authors use as an indicator for mild to moderate depression or anxiety. The authors report that, compared with women who had not had an abortion, women who had a first abortion had a higher risk of first-time antidepressant prescription. However, the risk of first-time antidepressant prescription was similar to the year before and after an abortion. Giving birth was associated a lower likelihood of a prescription, but this likelihood rose after childbirth and continued to rise for 5 years after delivery. The strongest predictors of new prescriptions for antidepressants were prior mental health contact and prior prescriptions for anxiolytics and antipsychotics.5
As the authors note, claims of negative mental health effects of abortion have been used to justify antiabortion legislation that has created burdensome waiting periods, ostensibly to provide women time to rethink their decisions; requirements that clinicians providing abortion tell patients, despite scientific evidence to the contrary, that abortions cause depression, substance abuse, or suicide; and requirements for parental notification or consent, ostensibly to protect minors from adverse mental health outcomes. Currently, all but 10 states in the United States have imposed at least one of these major abortion restrictions.6 Articles alleging negative abortion outcomes have been published in professional journals but are fraught with methodological errors, notably the failure to control for situational factors, including existing mental illnesses.7 Scholars have published detailed critiques of these articles.8
Roman Catholic and some evangelical health care systems, which constitute 14.5% of all health care systems in the United States, forbid not only the performance of abortions—even in cases where the mother’s life is threatened and/or the fetus has anomalies incompatible with extrauterine survival—but also the mention of contraception and abortion, including referral to facilities where patients could receive such information and services.9 Clinicians may be not aware of these restrictions, even those practicing within these health care systems.9
There is no evidence worldwide that limitations to abortion improve women’s health. However, there is substantial evidence of increased morbidity and mortality of women because of unsafe abortions in areas where safe abortions are either illegal or unattainable.10 Legal requirements and limitations and protesters at abortion facilities do little to reduce abortion incidence but have a large and negative influence on abortion outcomes. Women are willing to risk pain and death to prevent the birth of children they feel they cannot care for. The importance of reproductive choice and access to safe and legal abortion has led the American Psychiatric Association to take formal prochoice policy positions since 1978.11
How might the findings in this study and the other scientific evidence influence both the role of psychiatry in medical education and public discourse about abortion and the practice of individual clinicians? As teachers and citizens, we have an obligation to know and promulgate scientific evidence and advocate for laws and policies based on scientific evidence. In the United States, we should also advocate for improvements in our woefully inadequate policies regarding parental leave, child care, health care, and general support for pregnant women and the children they deliver.
As clinicians, we can expect to see many patients who have had abortions and who face decisions about pregnancies. While we have no reason to suspect that abortions cause psychopathology, they are still significant events in women’s lives and events that may occur under difficult circumstances. Questions about reproductive history and plans should be a part of every psychiatric evaluation and treatment plan. Pregnant patients who are contemplating abortion and concerned about sequelae should be given accurate information. The best outcomes prevail when women have the opportunity to review their own values, beliefs, and circumstances and come to autonomous decisions—and when they can expect nonjudgmental support regardless of the decisions they make.
Corresponding Author: Nada L. Stotland, MD, Rush University (email@example.com).
Published Online: May 30, 2018. doi:10.1001/jamapsychiatry.2018.0838
Conflict of Interest Disclosures: None reported.
Stotland NL, Shrestha AD. More Evidence That Abortion Is Not Associated With Increased Risk of Mental Illness. JAMA Psychiatry. 2018;75(8):775–776. doi:10.1001/jamapsychiatry.2018.0838
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