Depression

Thomas W. Strahan Memorial Library
Index
Standard of Care for Abortion
Abortion Decision-Making
Psychological Effects of Abortion
Social Effects and Implications
Physical Effects of Abortion
Abortion and Maternal Mortality
Adolescents and Abortion
Definition of Terms
Women's Health After Abortion
Material Yet to be Cataloged
Strahan Summary Articles

Sub-Index
Psychological Effects
Validity of Studies
Reviews
Risk Factors
PTSD
Grief and Loss
Guilt
Ambivalence or Inner Conflict
Anxiety
Intrusion / Avoidance / Nightmares
Denial
Dissociation
Narcissism
Self-Image
Self Punishment
Depression
Psychiatric Treatment
Self-Destructive Behavior
Substance Abuse
Long-Terms Effects of Abortion
Replacement Pregnancies
Sterilization
Impact of Abortion On Others
Violence
Rape, Incest, Sexual Assault
After Late Term Abortion

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General Background Studies

"The effect of adolescent virginity status on psychological well-being" J. J. Sabiaa, D.I. Rees. Journal of Health Economics Volume 27, Issue 5, September 2008, Pages 1368-1381

Examining data from the National Longitudinal Study of Adolescent Health to explore virginity status affects self-esteem and depression, it was found that sexually active female adolescents are at increased risk of exhibiting the symptoms of depression relative to their counterparts who are not sexually active (19% vs 9.2%).

"Depressive symptoms during pregnancy: Relationship to poor health behaviors," B. Zuckerman et al.. Am. J. Obstet. Gynecol. 160: 1107-1111, 1989.

In a study of 1014 women of mostly poor and minority status at Boston City Hospital between 1984-1987, depressive symptoms during pregnancy were associated with increased life stress, decreased social support, poor weight gain, and use of cigarettes, alcohol and cocaine.

"Increasing Rates of Depression," . G.L. Klerman, M.M. Weissman, JAMA 261 (15):2229-2235, April 21, 1989.

Several studies have observed important changes in rates of depression among those born after W.W.II including a decrease in the age of onset with an increase in the late teenage and early adult years; an increase between 1960 and 1975 in the rates of depression for all ages; the risk of depression is consistently 2 to 3 times higher among women than men of all ages.

"Continuing Female Predominance In Depressive Illness, A.C," Leon, G.L. Klerman, P. Wickramaratne, Am.J. Public Health 83 (5): 754, May, 1993.

Women continued to show higher rates of depression than men. Regardless of sex or period of time, subjects seemed to be at greatest risk of a first major depressive episode between ages 16-25.

"Social Adjustment and Depression: A Longitudinal Study," E. S. Paykel and M. Weissman, Archives of General Psychiatry 28: 659-663 (1973).

Depressed women showed residual dysfunctions in the areas of interpersonal friction and inhibited communication that remained relatively unchanged even when other symptoms of depression and sodal maladjustment dissipated.

"Interpersonal Consequences to Depression," C. L. Hammen, and S.D. Peters, Journal of Abnormal Psychology 87: 322-332 (1978).

Depressed persons elicit more negative reactions from others than non-depressed.

"Irrational Beliefs in Depression," R.E. Nelson, J. of Consulting and Clinical Psychology 45: 1190-1191 (1977).

The strongest correlates of depression are general irrationality, a need to excel in all endeavors, a need to feel worthwhile as a person, a feeling that things are terrible when they are not like one wants, obsessive worry, and a belief that it is impossible to overcome one's past.

"Life Events and Depressive Order Reviewed," I and II, C. Lloyd, Archives of General Psychiatry 37: 529-535 May, 1980.

Loss of parents may double or triple the depressive factor.

"Epidemiology of Affective Disorders," Robert Hirschfield and C.K. Grass, Archives of General Psychiatry 39(1): 35 (1982).

A good summary of the literature.

"Hostility and Depression," E.S. Gershon, M. Cromer and G.L. Klerman, Psychiatry 31: 224-235 (1968).

Hostility may have separate mechanisms both for its initiation and its defensive alterations. The expression of hostility may drain off the awareness of depression. It may express a "great despairing cry for love."

"Life Events and Depression: A Controlled Study," E.S. Paykel, J.K. Myers, M. Dienelt, Archives of General Psychiatry 21: 753-760 (1969).

Study noted an excessive number of stressful life events prior to depression.

"Masked Depression in Children and Adolescents," Kurt Glaser, American Journal of Psychotherapy 566-574 (1966).

Behavior problems and delinquent behavior such as temper tantrums, disobedience, truancy, running away from home, failure to achieve in school may indicate depressive feelings.

"Sex Differences and the Epidemiology of Depression," Myron Weissman and Gerald Klerman, Archives of General Psychiatry 34: 98-111 (January 1977).

Authors review various studies and conclude that women predominate among depressives; psycho-social explanations include social status hypothesis of social discrimination against women. It is hypothesized that inequities lead to legal and economic helplessness, dependency on others, chronically low self-esteem, low aspirations and ultimately clinical depression. The learned helplessness theory proposes that socially conditioned, stereotypical images produce in women a cognitive set against assertion which is reinforced by societal expectations. Learned helplessness is characteristic of depression.

"Toward a Comprehensive Theory of Depression: A Cross Disciplinary Appraisal of Objects. Games and Meaning," Ernest Becker, Journal of Nervous and Mental Disease 135: 26- 35 (1962). Comments by the author:

Until Edward Bibring's theory, self-directed aggression was considered a primary mechanism in depression. Bibring signaled a radical departure from previous theory when he postulated that self-directed aggression was secondary to an undermining of self- esteem. Thereby, he delivered an apparently telling blow to formulations around the concepts of morality and aggression.

In the classical psychoanalytic formulation of depression, mourning and melancholic states, loss of a loved object was considered to be a crucial dynamic. The ego which (theoretically) grows by ideationally gathering objects into itself, was thought to sometimes massive trauma when loved objects had to be relinquished. The loss of an object in the real world meant a corresponding depletion of the ego.

The sociological view has stressed not object depletion in the ego as the motivation for funeral and mourning rites, but rather the social dramatization of solidarity at the loss of one of society's performance members. Ceremonies of mourning serve as a reaffirmation of social cohesiveness even though single performers drop out of the plot.

To lose an object is to lose someone to whom one has made appeal for self-validation.

It was formerly thought that depression was rare among the "simpler peoples for several reasons--it was thought that the accumulation of guilt so prominent in the depressive syndrome-there was also the lingering myth of the happy savage.

The most difficult realization for man is the possibility that life has no meaning.

"Acknowledgment of personal sin or confession of guilt may sometimes be a defense against the possibility that there may be no meaning in the world....

Guilt in oneself is easier to face than lack of meaning in life." (quoted from On Shame and Search for Identity Helen Merrell Lynd, Harcourt-Brace [1958] p. 58)

The more people to whom one can make appeal for his identity, the easier it is to sustain life-meaning. Object loss hits hardest when self-justification is limited to a few objects.

"The Mechanism of Depression," E. Bibring, in Greenacre, P., Ed., Affective Disorders, (New York: International Universities Press, 1953) pp. 13-48.

Depression, A.T. Beck, (New York: Hoeber, 1967)

Ed Note: This is an important work on depression.

Abortion-Related Depression

Abortion, substance abuse and mental health in early adulthood: Thirteen-year longitudinal evidence from the United States. Sullins DP. SAGE Open Medicine 2016 vol: 4 (0) pp: 2050312116665997

Objective: To examine the links between pregnancy outcomes (birth, abortion, or involuntary pregnancy loss) and mental health outcomes for US women during the transition into adulthood to determine the extent of increased risk, if any, associated with exposure to induced abortion.

Method: Panel data on pregnancy history and mental health history for a nationally representative cohort of 8005 women at (average) ages 15, 22, and 28 years from the National Longitudinal Study of Adolescent to Adult Health were examined for risk of depression, anxiety, suicidal ideation, alcohol abuse, drug abuse, cannabis abuse, and nicotine dependence by pregnancy outcome (birth, abortion, and involuntary pregnancy loss). Risk ratios were estimated for time-dynamic outcomes from population-averaged longitudinal logistic and Poisson regression models.

Results: After extensive adjustment for confounding, other pregnancy outcomes, and sociodemographic differences, abortion was consistently associated with increased risk of mental health disorder. Overall risk was elevated 45% (risk ratio, 1.45; 95% confidence interval, 1.30–1.62; p < 0.0001). Risk of mental health disorder with pregnancy loss was mixed, but also elevated 24% (risk ratio, 1.24; 95% confidence interval, 1.13–1.37; p < 0.0001) overall. Birth was weakly associated with reduced mental disorders. One-eleventh (8.7%; 95% confidence interval, 6.0–11.3) of the prevalence of mental disorders examined over the period were attributable to abortion.

Conclusion: Evidence from the United States confirms previous findings from Norway and New Zealand that, unlike other pregnancy outcomes, abortion is consistently associated with a moderate increase in risk of mental health disorders during late adolescence and early adulthood.

NOTE:Table 1: Depression, adjusted OR 1.30 (95% CI 1.09-1.56); Number of mental health problems OR=1.54 (95% CI 1.42-1.68) ( "Exposure to induced abortion was consistently associated with increased rate of most mental disorders, with ORs ranging from 1.02 to 2.83. This trend is summarized in the fact that women exposed to abortion from ages 15 to 29 (on average) experienced overall rates of mental health problems 1.34 (95% confidence interval (CI), 1.22–1.47) times higher than those not exposed to abortion (p < 0.001)."

Depression Following Induced Abortion. Koyun, A., Kır Şahin, F., Çevrioğlu, S., Demirel, R., & Geçici, Ö. (2016). Gynecology Obstetrics & Reproductive Medicine, 13(2). doi:http://dx.doi.org/10.21613/GORM.2007.521

OBJECTIVE: To evaluate the effects of number of abortions and time passed after abortion in women with a history of induced abortion on the development of depression.

STUDY DESIGN: Women who admitted to family planning center during November 2003 – February 2004, answered a questionnaire. Depression levels between women who had induced abortion and those who did not were compared. Women with a history of previous abortion were classified according to the time passed after abortion (0-3 months, 3-6 months, more than 6 months). Depression levels were evaluated using Beck depression scale.

RESULTS: Rates of clinical depression in women with a history of induced abortion were increased (p<0,05). Depression scores were increased in women who have had induced abortions (p<0,001).

CONCLUSİONS: In women with a history of induced abortion, short term depression scores were found to be increased and clinical depression rates were markedly increased. Long term effects of this psychological trauma is a topic to be investigated. Our research data shows us that it may be helpful to provide pre- and postabortive psychological counseling to decrease the frequency and severity of depression encountered after induced abortion.

Note. The researchers also observed a dose effect, with multiple abortions increasing depression risk.

Abortion and depression: a population-based longitudinal study of young women. Pedersen W. Scand J Public Health. 2008 Jun;36(4):424-8.

AIM: Induced abortion is an experience shared by a large number of women in Norway, but we know little about the likely social or mental health-related implications of undergoing induced abortion. International studies suggest an increased risk of adverse outcomes such as depression, but many studies are weakened by poor design. One particular problem is the lack of control for confounding factors likely to increase the risk of both abortion and depression. The aim of the study was to investigate whether induced abortion was a risk factor for subsequent depression.

METHODS: A representative sample of women from the normal population (n=768) was monitored between the ages of 15 and 27 years. Questions covered depression, induced abortion and childbirth, as well as sociodemographic variables, family relationships and a number of individual characteristics, such as schooling and occupational history and conduct problems.

RESULTS: Young women who reported having had an abortion in their twenties were more likely to score above the cut-off point for depression (odds ratio (OR) 3.5; 95% confidence interval (CI) 2.0-6.1). Controlling for third variables reduced the association, but it remained significant (OR 2.9; 95% CI 1.7-5.6). There was no association between teenage abortion and subsequent depression.

CONCLUSIONS: Young adult women who undergo induced abortion may be at increased risk for subsequent depression.

Unplanned pregnancies and reproductive health among women with bipolar disorder. Marengo E, Martino DJ, Igoa A, Scápola M, Fassi G, Baamonde MU, Strejilevich SA. J Affect Disord. 2015 Jun 1;178:201-5.

Background: The aim of this study was to investigate reproductive health and level of planning of pregnancies among women with bipolar disorder (BDW).

Methods:63 euthymic women, with bipolar disorder type I, II or not otherwise specified diagnosis, were included and were matched with a control group of 63 healthy women. Demographic and clinical data, structured reproductive health measures and planning level of pregnancies were obtained and compared between groups.

Results: Lower level of planning of pregnancies and higher frequency of unplanned pregnancies were found among BDW. Women with bipolar disorder reported history of voluntary interruption of pregnancies more frequent than women from control group. Current reproductive health care showed no differences between groups.

Limitations: Data based on self-report of participants and retrospective nature of some collected measures may be affected by information bias. The pregnancy planning measure has not been validated in this population before. Demographic and clinical characteristics of the sample study limit generalization of these findings.

Conclusions: Adverse reproductive events, as unplanned pregnancies and elective interruption of pregnancies, may be more frequent among BDW. Clinician must be aware of the reproductive health during treatment of young BDW and take measures to improve better family planning access.

Specifics: 42.4% of the women with bipolar disorder had a history of abortion compared to only 13.5% of the control group. There was no significant difference in pregnancy rates or use of contraceptives.

Depression and termination of pregnancy (induced abortion) in a national cohort of young Australian women: the confounding effect of women's experience of violence. Taft AJ, Watson LF. BMC Public Health. 2008 Feb 26;8:75. doi: 10.1186/1471-2458-8-75.

BACKGROUND: Termination of pregnancy is a common and safe medical procedure in countries where it is legal. One in four Australian women terminates a pregnancy, most often when young. There is inconclusive evidence about whether pregnancy termination affects women's rates of depression. There is evidence of a strong association between partner violence and depression. Our objective was to examine the associations with depression of women's experience of violence, pregnancy termination, births and socio-demographic characteristics, among a population-based sample of young Australian women.

METHODS: The data from the Younger cohort of the Australian Longitudinal Study on Women's Health comprised 14,776 women aged 18-23 in Survey I (1996) of whom 9683 aged 22-27 also responded to Survey 2 (2000). With linked data, we distinguished terminations, violence and depression reported before and after 1996.We used logistic regression to examine the association of depression (CES-D 10) as both a dichotomous and linear measure in 2000 with pregnancy termination, numbers of births and with violence separately and then in mutually adjusted models with sociodemographic variables.

RESULTS: 30% of young women were depressed. Eleven percent (n = 1076) reported a termination by 2000. A first termination before 1996 and between 1996 and 2000 were both associated with depression in a univariate model (OR 1.37, 95%CI 1.12 to 1.66; OR 1.52, 95%CI 1.24 to 1.87). However, after adjustment for violence, numbers of births and sociodemographic variables (OR 1.22, 95%CI 0.99 to 1.51) this became only marginally significant, a similar association with having two or more births (1.26, 95%CI. 1.00 to 1.58). In contrast, any form of violence but especially that of partner violence in 1996 or 2000, was significantly associated with depression: in univariate (OR 2.31, 95%CI 1.97 to 2.70 or 2.45, 95% CI 1.99 to 3.04) and multivariate models (AOR 2.06, 95%CI 1.74 to 2.43 or 2.12, 95%CI 1.69 to 2.65). Linear regression showed a four fold greater effect of violence than termination or births.

CONCLUSION: Violence, especially partner violence, makes a significantly greater contribution to women's depression compared with pregnancy termination or births. Any strategy to reduce the burden of women's depression should include prevention or reduction of violence against women and strengthening women's sexual and reproductive health to ensure that pregnancies are planned and wanted.

Pregnancy loss and psychiatric disorders in young women: an Australian birth cohort study Kaeleen Dingle, Rosa Alati, Alexandra Clavarino, Jake M. Najman, and Gail M. Williams BJP 2008 193: 455-460.

Young women reporting a pregnancy loss had nearly three times the odds of experiencing a lifetime illicit drug disorder (excluding cannabis): abortion odds ratio (OR)=3.6 (95% CI 2.0–6.7) and miscarriage OR=2.6 (95% CI 1.2–5.4). Abortion was associated with alcohol use disorder (OR=2.1, 95% CI 1.3–3.5) and 12-month depression (OR=1.9, 95% CI 1.1–3.1).

Associations Between Abortion, Mental Disorders, and Suicidal Behaviour in a Nationally Representative Sample. Mota NP, Burnett M, Sareen J. The Canadian Journal of Psychiatry, Vol 55, No 4, April 2010

Methods: Data came from the National Comorbidity Survey Replication (n = 3310 women, aged 18 years and older). The World Health Organization–Composite International Diagnostic Interview was used to assess mental disorders based on the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, criteria and lifetime abortion in women. Multiple logistic regression analyses were employed to examine associations between abortion and lifetime mood, anxiety, substance use, eating, and disruptive behaviour disorders, as well as suicidal ideation and suicide attempts. We calculated the percentage of respondents whose mental disorder came after the first abortion. The role of violence was also explored. Population attributable fractions were calculated for significant associations between abortion and mental disorders.

Results: After adjusting for sociodemographics, abortion was associated with an increased likelihood of several mental disorders—mood disorders (adjusted odds ratio [AOR] ranging from 1.75 to 1.91), anxiety disorders (AOR ranging from 1.87 to 1.91), substance use disorders (AOR ranging from 3.14 to 4.99), as well as suicidal ideation and suicide attempts (AOR ranging from 1.97 to 2.18). Adjusting for violence weakened some of these associations. For all disorders examined, less than one-half of women reported that their mental disorder had begun after the first abortion. Population attributable fractions ranged from 5.8% (suicidal ideation) to 24.7% (drug abuse).

Conclusions: Our study confirms a strong association between abortion and mental disorders. Possible mechanisms of this relation are discussed.

Psychiatric admissions of low income women following abortion and childbirth. Reardon DC, Cougle JR, Rue VM, Shuping MW, Coleman PK, Ney PG. Can Med Assoc J. 2003; 168(10):1253-7

A study of California Medicaid (Medi-Cal) records of women aged 13–49 years at the time of either abortion or childbirth (n = 56 741 revealed taht women who had had an abortion had a significantly higher relative risk of psychiatric admission compared with women who had delivered for every time period examined. Significant differences by major diagnostic categories were found for adjustment reactions (odds ratio [OR] 2.1, 95% confidence interval [CI] 1.1–4.1), single-episode (OR 1.9, 95% CI 1.3–2.9) and recurrent depressive psychosis (OR 2.1, 95% CI 1.3–3.5), and bipolar disorder (OR 3.0, 95% CI 1.5–6.0). Significant differences were also observed when the results were stratified by age. Similar findings were reported in regard to outpatient treatment for the same women. See, State-funded abortions vs. deliveries: A comparison of outpatient mental health claims over five years. Coleman PK, Reardon DC, Rue VM, Cougle JR. American Journal of Orthopsychiatry, 2002; 72(1):141–52.

Using telemedicine for termination of pregnancy with mifepristone and misoprostol in settings where there is no access to safe services. Gomperts R, Jelinska K, Davies S, Gemzell-Danielsson K, Lleiverda G. BJOG 2008;115:1171–8.

About 30 percent of women taking abortion drugs purchased via the Internet reported depression and negative feelings accompanying the abortion.

Abortion and depression: A population-based longitudinal study of young women. Pedersen W. Scand J Public Health. 2008 Jul;36(4):424-8.

ABSTRACT

AIM: Induced abortion is an experience shared by a large number of women in Norway, but we know little about the likely social or mental health-related implications of undergoing induced abortion. International studies suggest an increased risk of adverse outcomes such as depression, but many studies are weakened by poor design. One particular problem is the lack of control for confounding factors likely to increase the risk of both abortion and depression. The aim of the study was to investigate whether induced abortion was a risk factor for subsequent depression. METHODS: A representative sample of women from the normal population (n=768) was monitored between the ages of 15 and 27 years. Questions covered depression, induced abortion and childbirth, as well as sociodemographic variables, family relationships and a number of individual characteristics, such as schooling and occupational history and conduct problems. RESULTS: Young women who reported having had an abortion in their twenties were more likely to score above the cut-off point for depression (odds ratio (OR) 3.5; 95% confidence interval (CI) 2.0-6.1). Controlling for third variables reduced the association, but it remained significant (OR 2.9; 95% CI 1.7-5.6). There was no association between teenage abortion and subsequent depression. CONCLUSIONS: Young adult women who undergo induced abortion may be at increased risk for subsequent depression.

Depression and termination of pregnancy (induced abortion) in a national cohort of young Australian women: the confounding effect of women's experience of violence. Taft AJ, Watson LF. BMC Public Health. 2008 Feb 26;8:75.

"The data from the Younger cohort of the Australian Longitudinal Study on Women's Health comprised 14,776 women aged 18-23 in Survey I (1996) of whom 9683 aged 22-27 also responded to Survey 2 (2000). With linked data, we distinguished terminations, violence and depression reported before and after 1996.We used logistic regression to examine the association of depression (CES-D 10) as both a dichotomous and linear measure in 2000 with pregnancy termination, numbers of births and with violence separately and then in mutually adjusted models with sociodemographic variables. RESULTS: 30% of young women were depressed. Eleven percent (n = 1076) reported a termination by 2000. A first termination before 1996 and between 1996 and 2000 were both associated with depression in a univariate model (OR 1.37, 95%CI 1.12 to 1.66; OR 1.52, 95%CI 1.24 to 1.87). However, after adjustment for violence, numbers of births and sociodemographic variables (OR 1.22, 95%CI 0.99 to 1.51) this became only marginally significant, a similar association with having two or more births (1.26, 95%CI. 1.00 to 1.58).In contrast, any form of violence but especially that of partner violence in 1996 or 2000, was significantly associated with depression: in univariate (OR 2.31, 95%CI 1.97 to 2.70 or 2.45, 95% CI 1.99 to 3.04) and multivariate models (AOR 2.06, 95%CI 1.74 to 2.43 or 2.12, 95%CI 1.69 to 2.65). Linear regression showed a four fold greater effect of violence than termination or births. CONCLUSION: Violence, especially partner violence, makes a significantly greater contribution to women's depression compared with pregnancy termination or births. Any strategy to reduce the burden of women's depression should include prevention or reduction of violence against women and strengthening women's sexual and reproductive health to ensure that pregnancies are planned and wanted."

"A Developmental Approach to Post-Abortion Depression," Frederick M. Burkle, The Practitioner 218:217, February 1977.

If the loss is valued depression will occur. To resolve the depression a process of mourning must occur.

"Reproductive Factors Affecting the Course of Affective Illness in Women," B.L. Parry, Psychiatric Clinics of North America 12(1): 207, March, 1989

Major depressive disorders are increasing with time, the age of onset is becoming earlier, and women continue to show an increased incidence of the disorder. Women are vulnerable to depressions associated with abortion.

"Testing a Model of the Psychological Consequences of Abortion," WB Miller et al in The New Civil War. The Psychology, Culture, and Politics of Abortion, ed. Linda J. Beckman and S Marie Harvey. (Washington, D.C.: American Psychological Association, 1998)

A multi-dimensional study of the psychological effects of induced abortion using mifepristone/misoprostol concluded that studies which emphasize unitary responses to abortion such as feelings of shame or guilt, loss or depression, and relief may be missing an important broader picture as what appears to happen following abortion involves not so much a unitary as a broad, multidimensional affective response. Findings suggest that during the first few days or weeks following an abortion, many women's reactions are incomplete and not necessarily representative of subsequent reactions. It is also very likely that different kinds of women follow a different time course. More studies are needed that examine the short-term consequences using sequential "snap shots" and there is more need for more postabortion longitudinal research.

"Personality and Self-Efficacy as Predictors of Coping with Abortion," C Cozzarelli, Journal of Personality and Social Psychology 65(6): 1224-1236, 1993

A wide range of depression scores was obtained on women immediately following abortion and at three weeks post-abortion.

2010

Do Depression and Low Self-Esteem Follow Abortion Among Adolescents? Evidence from a National Study Perspectives on Sexual and Reproductive Health, 42(4):230–235, (2010) Warren, Harvey, and Henderson.

Abstract

METHODS: Data from the National Longitudinal Study of Adolescent Health were used to examine whether abortion in adolescence was associated with subsequent depression and low self-esteem. In all, 289 female respondents reported at least one pregnancy between Wave 1 (1994–1995) and Wave 2 (1996) of the survey. Of these, 69 reported an induced abortion. Population-averaged lagged logistic regression models were used to assess associations between abortion and depression and low self-esteem within a year of the pregnancy and approximately five years later, at Wave 3 (2001–2002).

RESULTS: Abortion was not associated with depression or low self-esteem at either time point. Socioeconomic and demographic characteristics did not substantially modify the relationships between abortion and the outcomes.

CONCLUSIONS: Adolescents who have an abortion do not appear to be at elevated risk for depression or low self esteem in the short term or up to five years after the abortion.

EDITOR'S COMMENTS

1. This journal is published by the pro-abortion Alan Guttmacher Institute which was founded by Planned Parenthood.
2. The sample of women who aborted was very small (n= 69) reducing the statistical power.
   1. This is very important because with small sample size it is much more likely that one will not find any statistically significant results.
   2. The authors acknowledge on page 234 that “The lack of association between abortion and our outcomes could reflect other factors including insufficient sample size to detect an effect.”
   3. Very few control variables were employed despite the fact that this data set contains dozens of personal history, personality, relationship, situational, familial, and demographic variables that could have been controlled to isolate the effect of abortion.
   4. A common tactic of researchers trying to prove "no association" between A and B is to report results based on a small sample and may also include the use of only those control variables which reduce the statistical association.
   5. The 95% confidence interval reported by the authors (.027-2.09) indicates that it is 95% likely that the true risk of depression following abortion may be anywhere between 27% and 209% of depression rate found among teens who have not been pregnant. In other words, these findings do not contradict research showing higher rates of depression associated with abortion. Given the small sample size, this broad confidence interval is fully consistent with studies using larger populations which find the range of depression to be in the range of 110% to 200% higher than for women without a history of abortion.

1. The outcome measures were superficial assessments. Specifically, the measure of depression was an abbreviated 9 item scale and self-esteem was measure with only 4 items.
2. The choice of the comparison group is suspect. The comparison group could have been unintended pregnancy carried to term since the data is available in ADD Health, but the researchers chose the broader “no pregnancy” group as their control group. Another study published regarding the same data set which did use unintended pregnancy delivered as the control group found significant associations between abortion history and marijuana usage, having received counseling for psychological or emotional problems, and sleep difficulties. Seeking professional counseling services is a much more valid measure of psychological distress than abbreviated self-report measures, one of which is merely “predictive of depression”. (See Coleman, P. K. (2006). Resolution of unwanted pregnancy during adolescence through abortion versus childbirth: Individual and family predictors and psychological consequences. The Journal of Youth and Adolescence, 35, 903-911.)

Depression Shortly Prior to Abortion

"Bluestein and CM Rutledge, Family Practice Research Journal 13(2): 149-156, 1993

Moderate to severe depression was found in women seeking abortion. Depression symptoms increased as measures of denial, difficulties with communicating with male partner, pregnancy symptoms, contraceptive use and dissatisfaction with abortion increased.

"Postabortion Psychological Adjustment: Are Minors at Increased Risk?" LM Pope et al, Journal of Adolescent Health 29:2-11, 2001

Thirty-five percent of young women aged 14-21 exhibited moderate to severe depression on the Beck Depression Inventory shortly prior to abortion.

"Psychological Factors that predict reaction to abortion," D.T. Moseley, D.R. Follingstad, H. Harley, R.V. Heckel, J. of Clinical Psychology 37(2):276,1981

A University of South Carolina study on women who elected abortion in an urban southern area administered the Multiple Affective Adjective Check List (MAACL) to women when they entered the clinic and a post-test in the recovery room prior to discharge following their abortion. Pre-abortion depression was much higher than the MAACL norms previously reported. Significant decreases in anxiety and depression were noted following abortion but not with respect to hostility. A woman's relationship with her partner was a crucial factor in post-abortion adjustment. Women with negative feelings toward their partners had higher levels of pre-abortion depression and post-abortion depression compared to women who were assisted in the decision by their sexual partners.

"Coping with Abortion," L. Cohen and S. Roth, Journal of Human Stress, Fall, 1984, pp. 140-145.

Researchers at Duke University of 55 women presenting for abortion a private clinic in Raleigh, NC evaluated symptoms of intrusion, avoidance, depression and anxiety upon their arrival at the clinic and in the recovery room after their abortion. The level of anxiety and depression was measured by the Symptom Checklist-90 (SCL-90). The mean level of depression decreased from 24.1 initially to 18.4 following abortion. Women exhibiting high avoidance had significantly higher level of depression both before and after their abortion compared to women exhibiting low avoidance.

"Psychological Factors Involved in Request for Elective Abortion, M," Blumenfield. The Journal of Clinical Psychiatry, Jan. 1978, pp. 17-25.

A study of 13 women requesting a first abortion and 13 women requesting a repeat abortion was undertaken at Kings County Hospital Clinic in New York utilizing a largely open-ended interview. The purpose was to determine the surrounding circumstances which gave rise to the request for abortion. It was found that the failure of contraception was not due to lack of access to adequate contraception. In 9 of 26 cases there was evidence of underlying psychological conflicts in the woman. These women were frequently lonely and/or depressed frequently because of isolation, loss of support, loss or separation from loved ones, or due to conflicts with partners. The data suggested that many of the male partners had a strong wish to father a child. The author stated "a pregnancy which leads to a request for an abortion usually reflects an underlying unresolved conflict which is being acted out through the pregnancy--a request for a repeat abortion would seem to indicate that the ambivalence has persisted and is being acted out through pregnancy once again or that a new circumstance has reawakened underlying conflicts.")

Depression During Subsequent Pregnancies

See also Depression#Postpartum_Depression

Previous pregnancy loss has an adverse impact on distress and behaviour in subsequent pregnancy. McCarthy F, Moss-Morris R, Khashan A, et al.BJOG An Int J Obstet Gynaecol. 2015;122(13):1757-1764. doi:10.1111/1471-0528.13233.

Objective: To investigate whether women with previous miscarriages or terminations have higher levels of anxiety, depression, stress, and altered behaviours in a subsequent pregnancy.

Design:A retrospective analysis of 5575 women recruited into the Screening for Pregnancy Endpoints (SCOPE) study, a prospective cohort study.

Setting:Auckland, New Zealand, Adelaide, Australia, Cork, Ireland, and Manchester, Leeds, and London, UK.

Population:Healthy nulliparous women with singleton pregnancies.

Methods: Outcomes were recorded at 15 and 20 weeks of gestation.

Main outcome measures: Short-form State–Trait Anxiety Inventory (STAI) score, Perceived Stress Scale score, Edinburgh Postnatal Depression Scale score, and pregnancy-related behaviour measured using behavioural responses to pregnancy score.

Results: Of the 5465 women included in the final analysis, 559 (10%) had one and 94 (2%) had two previous miscarriages, and 415 (8%) had one and 66 (1%) had two previous terminations of pregnancy. Women with one previous miscarriage had increased anxiety (adjusted mean difference 1.85; 95% confidence interval, 95% CI 0.61–3.09), perceived stress (adjusted mean difference 0.76; 95% CI 0.48–1.03), depression (adjusted odds ratio, aOR 1.26; 95% CI 1.08–1.45), and limiting/resting behaviour in pregnancy (adjusted mean difference 0.80; 95% CI 0.62–0.97). In women with two miscarriages, depression was more common (aOR 1.65; 95% CI 1.01–2.70) and they had higher scores for limiting/resting behaviour in pregnancy (adjusted mean difference 1.70; 95% CI 0.90–2.53) at 15 weeks of gestation.

Women with one previous termination displayed elevated perceived stress (adjusted mean difference 0.65; 95% CI 0.08–1.23) and depression (aOR 1.25; 95% 1.08–1.45) at 15 weeks of gestation. Women with two previous terminations displayed increased perceived stress (adjusted mean difference 1.43; 95% CI 0.00–2.87) and depression (aOR 1.67; 95% 1.28–2.18).

Conclusions:

This study highlights the psychological implications of miscarriage and termination of pregnancy.

Psychosocial Factors of Antenatal Anxiety and Depression in Pakistan: Is Social Support a Mediator? Fischer G, ed. Waqas A, Raza N, Lodhi HW, Muhammad Z, Jamal M, Rehman A. PLoS One. 2015;10(1):e0116510. doi:10.1371/journal.pone.0116510.

History of abortion significanty associated with anxiety and depression in subsequent pregnancies.

Frequency and Associated Factors for Anxiety and Depression in Pregnant Women: A Hospital-Based Cross-Sectional Study. Ali NS, Azam IS, Ali BS, Tabbusum G, Moin SS. Sci World J. 2012;2012:1-9. doi:10.1100/2012/653098.

Results: Depression was associated with previous adverse pregnancy outcome in past including death of a child, stillbirth or abortion ( P - value = 0 .013 )

Depression during pregnancy: Prevalence and obstetric risk factors among pregnant women attending a tertiary care hospital in Navi Mumbai. Ajinkya S, Jadhav PR, Srivastava NN. Ind Psychiatry J. 2013;22(1):37-40. doi:10.4103/0972-6748.123615.

RESULTS Prevalence of depression during pregnancy was found to be 9.18% based upon BDI, and it was significantly associated with several obstetric risk factors like gravidity (P = 0.0092), unplanned pregnancy (P = 0.001), history of abortions (P = 0.0001), and a history of obstetric complications, both present (P = 0.0001) and past (P = 0.0001).

Identifying the women at risk of antenatal anxiety and depression: A systematic review Biaggi A, Conroy S, Pawlby S, Pariante CM. J Affect Disord. 2015 Nov 18;191:62-77.

BACKGROUND: Pregnancy is a time of increased vulnerability for the development of anxiety and depression. This systematic review aims to identify the main risk factors involved in the onset of antenatal anxiety and depression.

METHODS: A systematic literature analysis was conducted, using PubMed, PsychINFO, and the Cochrane Library. Original papers were included if they were written in English and published between 1st January 2003 and 31st August 2015, while literature reviews and meta-analyses were consulted regardless of publication date. A final number of 97 papers were selected.

RESULTS: The most relevant factors associated with antenatal depression or anxiety were: lack of partner or of social support; history of abuse or of domestic violence; personal history of mental illness; unplanned or unwanted pregnancy; adverse events in life and high perceived stress; present/past pregnancy complications; and pregnancy loss.

LIMITATIONS: The review does not include a meta-analysis, which may have added additional information about the differential impact of each risk factor. Moreover, it does not specifically examine factors that may influence different types of anxiety disorders, or the recurrence or persistence of depression or anxiety from pregnancy to the postpartum period.

CONCLUSIONS: The results show the complex aetiology of antenatal depression and anxiety. The administration of a screening tool to identify women at risk of anxiety and depression during pregnancy should be universal practice in order to promote the long-term wellbeing of mothers and babies, and the knowledge of specific risk factors may help creating such screening tool targeting women at higher risk.

The Impact of Prior Abortion on Anxiety and Depression Symptoms During a Subsequent Pregnancy: Data From a Population-Based Cohort Study in China Huang Z, et al. Bulletin of Clinical Psychopharmacology 2012;22(1):51-8

Objective: The aim of the study was to assess anxiety and depression in women with history of spontaneous abortion or induced abortion during a subsequent pregnancy.

Methods: The data were consecutively obtained from seven maternal and child health (MCH) Centers in the Anhui Province of China. The sociodemographic characteristics of the women, the number of previous pregnancies, number of living children, and gestational age of the current pregnancy were ascertained at the time of the interview.

Results: The pregnant women who were in the first trimester of their pregnancy reported significantly higher scores than those in the second trimester both on SAS (Zung’s Self-Rating Anxiety Scale) and CES-D (The Center for Epidemiologic Studies-Depression Scale) (SAS score means: 32.11 vs 31.68, P=0.000; CES-D score means: 4.59 vs 4.06, P=0.012). The women with a history of induced abortions were significantly more likely to report more “cases” of depression (OR = 1.543, 95% CI = 1.055- 254) and more “cases” of anxiety (OR = 2.142, 95% CI = 1.294-3.561) during the first trimester than those with no history of abortion. Controlling for confounding variables yielded similar results. However, “cases” of depression and “cases” of anxiety were equally common in women with history of spontaneous abortions and in those with no abortion history.

Conclusions: These results suggest women who have experienced a previous induced abortion have omnipresent anxiety and depression symptoms during a subsequent pregnancy, specially during the first trimester.

"Abortion and Subsequent Pregnancy," C.F. Bradley, Canadian Journal Psychiatry29:494, Oct-1984.

A study of 254 pregnant women in Victoria, B.C. were followed from the second trimester of their pregnancy until 12 months post-partum. Twenty-eight women had a prior induced abortion and 216 had no prior induced abortion. Women who had a prior abortion had significantly higher levels of depressive effect in the third trimester of pregnancy (35 weeks gestation) and also at intervals of I month, 6 months and 12 months in the post- partum period. A Depressive Adjective Checklist developed by other researchers was used as the evaluation tool. Women with prior abortions also described themselves as less well-adjusted during the prenatal period and had lower self-esteem in the post- partum period than those without any abortion history. The author suggested that it may have been those factors which were related to their depressive mood.

"The Relationship Between Previous Elective Abortions and Postpartum," Depressive Reactions. N.E. Devore, Journal of Obstetric Gynecologic and Neonatal Nursing, July/August 1979, pp-237-240

In a study of 73 women among the obstetrical population at the Hospital of Albert Einstein College during 1975-76, 25 pregnant women who had one abortion and 48 women who were pregnant for the first time were interviewed 6-8 weeks postpartum. Seventy-one percent of the women with abortion history reported they were depressed at the time of the abortion, yet only 12% reported that they had received emotional counseling at the time of the abortion. The range of time from the earlier abortion to the current pregnancy was 2-8 years, mean 3.9 years. Using the Beck Depression Inventory, the study found postpartum moderate depression in 16% of women with a prior abortion compared to 12% of the women without any abortion. Eighty percent of the women with abortion history compared to 56% without abortion history reported the "baby blues." The study suggested that a few women who have had a previous elective abortion will still experience feelings of guilt or depression in connection with it. Spontaneous comment from the women with abortion history suggested that anxiety during pregnancy concurring the infants health was a greater source of discomfort than was post-partum depression.

"Previous induced abortion and ante-natal depression in primipare: preliminary report of a survey of mental health in pregnancy," R. Kumar, K. Robson, Psychological Medicine8:711-715, 1978

A British study of 119 pregnant women found an association between a previous abortion (legal or illegal) and depression and anxiety in an early subsequent pregnancy. An intensification of fears of fetal abnormality was noted in women having had a prior abortion. The study concluded that "unresolved feelings of guilt, grief and loss may remain dormant long after an abortion until they are apparently re-awakened by another pregnancy. Normal anxieties about the now desired fetus are intensified and such fears are often spontaneously interpreted in terms of retribution."

A Prospective Study of Emotional Disorders in Childbearing Women, R Kumar, K Robson, Brit J Psychiat 144:35-47, 1984

Prior induced abortion was associated with ante-natal depression and anxiety; thoughts about obtaining abortion was associated with both ante-natal and post-natal depression and anxiety.

"Psychiatric Morbidity in a Pregnant Population in Nigeria," OA Abiodun et. al General Hospital Psychiatry 15: 125-128, 1993

A previous history of induced abortion was significantly associated with psychiatric morbidity (mostly anxiety and neurotic depression) among 240 married Christian and Muslim women attending an antenatal clinic.

"Psychological and social correlates of the onset of affective disorders among pregnant women," T Kitamura et al, Psychological Medicine 23:967-975, 1993

A Japanese study found that among women with previous pregnancy, pregnancy-related affective disorder was recognized among 27% of those expecting their first baby where there had been a previous termination of pregnancy compared to 3% of women who had no previous termination of pregnancy.

Anniversary Depressive Reactions

"Aftermath of Abortion. Anniversary Depression and Abdominal Pain. J.O," Cavenar Jr A.A. Maltbie, J.L. Sullivan, Bulletin of the Menninger Clinic 42(5):433438, 1978

A case study was presented in which a woman had an apparently uneventful abortion, but which resulted in a depressive reaction which arose during the week of her expected delivery, necessitating psychiatric care.

"Adolescent Suicide Attempts Following Elective Abortion," C Tischler, Pediatrics 68(5):670, 1981

Adolescents attempted suicide on the perceived due date for their aborted child.

"Psychoses Following Therapeutic Abortion," J.G. Spaulding, J.O. Cavenar, Am.J.. Psychiatry 135(3):364, March 1978. (A case study of a 24 year old unmarried women who experienced post abortion insomnia, anorexia, agitation and severe depression that necessitated hospitalization 9 months after the time the child would have been conceived.

"Postabortion Depressive Reactions in College Women," N.B. Gould, J.Am. College Health Association 28:316320, 1980.

In a study of college women at Harvard University during 1978-79, cases of 3 women who had abortions are described who each experienced depressive reactions at the time of the expected delivery date which adversely affected classroom performance.

"Post-Abortion Perceptions: A Comparison of Self-Identified Distressed and Nondistressed Populations," GK Congleton and LG Calhoun, The International Journal of Social Psychiatry 39(4): 255, 1993

Women who reported post-abortion distress were more likely to report depression around the anniversary date of the abortion or the due date for birth compared to women who reported relieving/neutral responses specifically related to the baby, insomnia, inability to concentrate on studies, divisiveness in their relationships with partners, suicidal ideation, bouts of crying, inability to be consoled.

"Anniversary Reactions and Due Date Responses Following Abortion, K," Franco, N. Campbell, M. Taburrino. S. Jurs. J. Pentz, C. Evans, Psychother Psychosom 52:151-154, 1989.

In a study of 83 women in a patient-led post abortion support group in Ohio, 30 reported anniversary reactions associated with the abortion or the due date. Mean scores on the Beck Depression Inventory were 6.5 for those reporting anniversary reactions and 5.5 for those not reporting anniversary reactions. Those reporting anniversary reactions frequently reported physical symptoms including abdominal pain, dyspareunia, headaches and chest pain.

Depressive Reactions from Genetic Abortion

"Psychological impact on women after second and third trimester termination of pregnancy due to fetal anomalies versus women after preterm birth--a 14-month follow up study." Kersting A, Kroker K, Steinhard J, Hoernig-Franz I, Wesselmann U, Luedorff K, Ohrmann P, Arolt V, Suslow T. Arch Womens Ment Health. 2009 Aug;12(4):193-201. Epub 2009 Mar 6.

"The objective of this study was to compare psychiatric morbidity and the course of posttraumatic stress, depression, and anxiety in two groups with severe complications during pregnancy, women after termination of late pregnancy (TOP) due to fetal anomalies and women after preterm birth (PRE). As control group women after the delivery of a healthy child were assessed. A consecutive sample of women who experienced a) termination of late pregnancy in the 2nd or 3rd-trimester (N = 62), or b) preterm birth (N = 43), or c) birth of a healthy child (N = 65) was investigated 14 days (T1), 6 months (T2), and 14 months (T3) after the event. At T1, 22.4% of the women after TOP were diagnosed with a psychiatric disorder compared to 18.5% women after PRE, and 6.2% in the control group. The corresponding values at T3 were 16.7%, 7.1%, and 0%. Shortly after the event, a broad spectrum of diagnoses was found; however, 14 months later only affective and anxiety disorders were diagnosed. Posttraumatic stress and clinician-rated depressive symptoms were highest in women after TOP. The short-term emotional reactions to TOP in late pregnancy due to fetal anomaly appear to be more intense than those to preterm birth. Both events can lead to severe psychiatric morbidity with a lasting psychological impact."

"The psychological sequelae of abortion performed for a genetic indication," B.D. Blumberg, M.S. Globus, K.H. Hanson, Am.J. Obstet Gynecol 122(7):799, August 1, 1975.

In a study of 13 families where abortion was undergone due to a genetic defect in the fetus, the incidence of depression among women was as high as 92% among the women and 82% among the men. This was higher than elective abortion. Four families experienced separations during the pregnancy-abortion period.

"Sequelae and Support After Termination of Pregnancy for Fetal Malformation," J. Lloyd and KM Laurence, British Medical Journal 290:907-909, March 1985.

Seventy-seven percent of the women experienced an acute grief reaction following termination of pregnancy for fetal malformation. Forty-six percent still remained symptomatic after six months, some requiring psychiatric support. Depression with anxiety, often with considerable repressed anger, was noted. Severity of the reaction ranged from mild tearfulness, sadness, lethargy and insomnia to incapacitating grief with somatic symptoms, and finally to complete withdrawal. There was no opportunity to mourn. Some women had named the baby, usually secretly, which seemed to help the grieving process. Several would have liked some burial or formal recognition of the death. Several had problems severe enough to influence reproductive behavior.

Short Term Depressive Reactions

Medical or surgical abortion and psychiatric outcomes. Yilmaz N1, Kanat-Pektas M, Kilic S, Gulerman C. J Matern Fetal Neonatal Med. 2010 Jun;23(6):541-4. doi: 10.3109/14767050903191301.

AIM: The objectives of this study are to compare the risk of psychological depression after medical and surgical abortions in first two trimesters and to evaluate the risk factors for post-abortion depression.

METHOD: A retrospective study was conducted throughout 367 women who underwent surgical abortion and 458 women who underwent medical abortion between January 2006 and January 2007 in Dr. Zekai Tahir Burak Women's Health Hospital. Women were assessed by clinical psychologists one week after the intervention. The clinical characteristics and psychological assessment of these women were statistically correlated by means of non-parametric tests.

RESULTS: Of the study population, 27.1% was diagnosed with post-abortion depression. The frequency of post-abortion depression was 34.3% in surgical abortion patients and 22.8% in medical abortion patients. The women who underwent surgical abortion were found to have significantly elevated risk of post-abortion depression. The women with a high risk of post-abortion depression were significantly younger and had a more frequent history of psychiatric and depressive disorders.

CONCLUSION: An important quotient of women experiences post-abortion mood depression which is significantly more frequent after surgical abortion. Women with past psychiatric and anxiety disorders should be carefully monitored for depression when they would undergo an abortion.

"Outcome Following Therapeutic Abortion," E.C. Payne, A.R. Kravitz, M.T. Notman, J.V. Anderson, Arch Gen Psychiatry 33:725, June 1976.

A study of 102 women evaluated anxiety depression, anger, guilt and shame in women prior to abortion and at 24 hours, 6 weeks and 6 months following their abortion with respect to a multiple number of variables. Depressive reactions were significantly reduced following abortions although mild to moderate depression was still present in women 6 months after their abortion. Factors that significantly increased the likelihood of post abortion depression were immature object relationships, younger women, Catholic religion, no prior children, previous mental illness, borderline personality, a negative relationship with mother, a bad relationship with children, conflict with lover, ambivalence to abortion.

"Induced abortion operations and their early sequelae," P.I. Frank, C.R. Kay, S.L. Winsgrave, Journal of the Royal College of General Practitioners 35:175, 1985.

In this British study those with a history of depression had a rate of post abortion depression which was 2.59 times higher than expected.

"Pregnancy Decision Making as a Significant Life Event: A Commitment Approach," J Lydon et al, Journal of Personality and Social Psychology 71(1): 141-151, 1996

Initial commitment to the pregnancy prior to abortion predicted subsequent depression, guilt and hostility postabortion.

"Therapeutic Abortion and a Prior Psychiatric History," J.A. Ewing, B.A. Rouse, Am J. Psychiatry 130(l):37, January, 1973.

A North Carolina study of 126 women who had abortions in 1970-71 found that 36% of the women with a history of psychiatric problems reported depression following abortion compared with only 11% of the women who reported no prior psychiatric history. The responses ranged from a few weeks to two years post abortion. Women with a psychiatric history prior to abortion also had higher incidence of crying spells, anxiety, sleeplessness, worry and guilt.

"Depressive Symptoms in Late Adolescent and Young Adult Females: Effects of Pregnancy Resolution," J. Mesaros, D. Larson and J. Lyons, presented to the American Society for Psychosomatic Obstetrics and Gynecology, New York, New York, March 1990

A case / control of study of depressive symptoms in women 17-25 years of age compared women with prior induced abortion, delivery, spontaneous abortion and never pregnant on the Center for Epidemiologic Studies Depression Scale. Women with prior abortion had the highest frequency of depressive symptoms. Higher scores were found in women where there was a perceived loss of control in the decision to terminate, negative feelings about the termination and little meaningful religious experience.

"Attributions, Expectations and Coping with Abortion," B. Major, P. Mueller, K. Hildebrandt, J. of Personality and Social Psychology 48(3):585, 1985.

A study of 247 women who underwent abortions in a free-standing abortion clinic in a large U.S. metropolitan area found that their immediate (30 minutes post abortion) depression level following their abortion was mean of 4.17 (range 0-22) on the Beck Depression Inventory. Three weeks later on a sample of 99 women who later responded the mean response on the Beck Depression Inventory was a mean of 2.93 (range 0-17) on the Beck Depression Inventory.

"Law. Preventive Psychiatry and Therapeutic Abortion," H.I. Levene, F. J. Rigney, The J. of Nervous and Mental Disease 151(l):51, 1970.

A California study of 70 women who were granted a therapeutic abortion under California law found that 14% reported an increase in depressive symptomology 3-5 months post abortion.

"Short-term Psychiatric Sequelae to Therapeutic Termination of Pregnancy," B. Lask, Br. J. Psychiatry 126:173-177, 1975.

Fifty inpatients from a London hospital who underwent abortion were interviewed 6 months later. Thirty-two per cent had unfavorable outcomes. The outcome was considered unfavorable when the following criteria were fulfilled: (1) the patient regretted termination: (2) the patient had moderate or severe feelings of loss, guilt or self-reproach: (3) there was evidence of mental illness in the same degree as, or more severe than before the abortion. When moderate or severe adverse sequelae were reported, these were usually associated with depressive states. These varied in intensity from mild to sufficiently severe to necessitate hospital admission.

"Women's Self-Reported Responses to Abortion," G.M. Burnell, M.A. Norfleet, The Journal of Psychology 12(l):71-76

A study of 158 women who were members of a prepaid health plan in northern California reported in responding to a mailed questionnaire found that 17% reported depression following abortion which was the highest endorsement under a section entitled -worsened adjustment after abortion. The length of time from the time of the abortion and the questionnaire varied. A majority of the women completed the questionnaire within one and a half years after abortion.

"Long-term psychiatric follow-up," C. McCance, P. Olley, V. Edward in Experience with Abortion. Ed. G. Horobin, (Cambridge: Cambridge Univ. Press, 1973) 245-300.

This study found that 20% of the original sample of women who underwent induced abortion were depressed 13-24 months thereafter according to the Beck Depression Inventory.

"Psychological Responses of Women After First-Trimester Abortion," B Major et al, Arch Gen Psychiatry 57:777, 2000

20% of women had depression 2 years postabortion. Prepregnancy depression was a risk factor for postabortion depression. Negative postabortion emotions increased over time. Younger age and more children preabortion also predicted more negative abortion responses.

"Emotional Distress Patterns Among Women Having First or Repeat Abortions," E.W. Freeman, K. Rickels, G.R. Huggins, Obstetrics and Gynecology 55(5):630, May, 1980.

A study of 413 women at the University Hospital in 1977-78 using the SCL-90, a multidimensional self-report inventory measured depression before abortion and 2 weeks following abortion. The adjusted mean value prior to abortion was 1.06. After 2 weeks the adjusted mean value was 0.60 (one abortion) and 0.74 (two abortions). Women who repeated abortions showed significantly higher scores on interpersonal sensitivity, paranoid ideation, phobic anxiety and sleep disturbance compared to women with one abortion.

"Before and after therapeutic abortion," P. Mackenzie, Canadian Medical Association Journal 111:667, October 5, 1974.

A 1973 study at Queens University School of Medicine of 150 Canadian women two weeks post abortion had 53% respond to a questionnaire survey. Based on self reports of the women 39% said they were depressed a lot from the pregnancy (21% said they were a little depressed). Two weeks post abortion 4% said they were depressed a lot from the abortion and 28% said they were depressed a little and 39% said they were not at all depressed.

"Induced abortion after feeling fetal movements: Its causes and emotional consequences," C. Brewer, J. Biosocial Science 10:203-208.

In a study of 40 women who had abortions between 20-24 weeks gestation. Twenty-five were followed-up 30 months post abortion. Five reported feeling depressed about their abortion. One had taken time off from school or work for this reason. None had sought specialist advice.

Long Term Depressive Reactions

Defined here as reactions five years or more since abortion.

[http://www.jad-journal.com/article/S0165-0327(15)00003-8/fulltext#s0035 Hormone-related factors and post-menopausal onset depression: Results from KNHANES (2010–2012) Sun Jae Jung, Aesun Shin, Daehee Kang. J Affective Disorders. April 1, 2015 p 176–183.

Method: Of 13,918 women who participated in the Korean National Health and Nutrition Examination Survey (KNHANES) V, a total of 4869 post-menopausal women who had completed information on depression onset age and additional reproductive factors were included in the analysis. A multivariate logistic regression was applied to calculate the odds ratios between reproductive factors and post-menopausal onset depression.

Relevant Finding: Induced abortion was significantly associated with a 40% increased risk of post-menopausal onset depression. (RR=1.40 CI=1.03–1.90)

"Psychological profile of dysphoric women post abortion," K.N. Franco, M. Tamburrino, N. Campbell, J. Pentz, S. Jurs, J. of the American Medical Women's Assoc. 44(4):113, July/Aug. 1989.

In a survey of 81 women approximately 10 years post abortion who were in a patient led support group for women who described themselves as having poorly assimilated their abortion experience, the mean Beck Depression Inventory Score for all women studied was 5.3 (mild depression). For women with one abortion it was 4.7 (none to minimal depression). For women with multiple abortions it was 9.4 (moderate depression). Other risk factors for post abortion dysphoria were pre morbid psychiatric illness, lack of family support, ambivalence and feeling coerced into having a abortion.

Post-Abortion Trauma, Jeanette Vought, (Grand Rapids: Zondervan Publishing House, 1991).

A study of 68 religiously oriented, primarily Protestant women who were studied 10-15 years post-abortion, 76% reported depression as one of the emotional effects of abortion.

"A Survey of Postabortion Reactions," David C. Reardon, (Springfield, IL: The Elliot Institute for Social Science Research, 1987).

In a 1987 Survey of Postabortion reactions among 100 women members of Women Exploited by Abortion an average of 11 years since their abortion, 87% agreed or strongly agreed with the statement, "After my abortion I experienced feelings of depression." Fifty per cent of these women were 20 years of age or younger at the time of their abortion.

Psycho-Social Stress Following Abortion, Anne Speckhard, (Kansas City MO: Sheed & Ward, 1987).

In a study of 30 women who reported chronic and long term stress from their abortion 92% expressed feelings of depression following abortion. Fifty per cent of these women had their abortion in the second trimester (46%) or third trimester (4%) of their pregnancy. The majority (64%) had their abortion 5-10 years previously, 20% were less than 5 years and 16% ranged from 11-25 years post abortion.

"Depression associated with abortion and childbirth: A long-term analysis of the NLSY cohort," JR Cougle et al, Clinical Method & Health Research NetPrints, April 25, 2001 (Abstract)

This study used the National Longitudinal Survey of Youth which contains a number of psychological variables related to pregnancy outcome. Compared to post-childbirth women, women who had abortions were found to have significantly higher depression scores as measured an average of 10 years after their pregnancy outcome. Post-abortion women were also 41% more likely to score in the "high risk " range for clinical depression compared to non-aborting women. A self-assessment questionnaire administered in 1998 also found that aborting women were 73% more likely to complain of "depression, excessive worry, or nervous trouble of any kind" compared to women with other pregnancy outcomes.

"Psychiatric history and mental status," W.L. Sands in Diagnosing Mental lllness:Evaluation in Psychiatry and Psychology, Eds. Freedman and Kaplan, (New York: Athenum, 1973) 31.

"The significance of abortions may not be revealed until later periods of emotional depression. During depressions occurring in the fifth or sixth decades of the patient's life, the psychiatrist frequently hears expressions of remorse and guilt concerning abortions that occurred twenty or more years earlier."

Postpartum Depression

See also: Postpartum_Depression_During_Subsequent_Pregnancies

Obstetrical, pregnancy and socio-economic predictors for new-onset severe postpartum psychiatric disorders in primiparous women. Meltzer-Brody S, Maegbaek ML, Medland SE, Miller WC, Sullivan P, Munk-Olsen T. Psychol Med. 2017 Jan 23:1-15. doi: 10.1017/S0033291716003020. [Epub ahead of print]

METHOD: A population-based cohort study using Danish registers was conducted in 392,458 primiparous women with a singleton delivery between 1995 and 2012 and no previous psychiatric history. The main outcome was first-onset postpartum psychiatric episodes. Incidence rate ratios (IRRs) were calculated for any psychiatric contact in four quarters for the first year postpartum.

Results: Previous abortion was associated with a significantly higher rate of any postpartum pyschiatric disorder (without substance abuse), IRR 1.13 (1.04-1.22), and postpartum depression, IR 1.18 (1.03-1.37), and acute stress reactions, IRR 1.11 (0.98-1.26).

All-Cause Mortality in Women With Severe Postpartum Psychiatric Disorders. Johannsen BM, Larsen JT, Laursen TM, Bergink V, Meltzer-Brody S, Munk-Olsen T. Am J Psychiatry. 2016 Jun 1;173(6):635-42. doi: 10.1176/appi.ajp.2015.14121510. Epub 2016 Mar 4.

-- Women with postpartum psychiatric disorders had a higher MRR (3.74; 95% CI=3.06-4.57) than non-postpartum-onset mothers (MRR=2.73; 95% CI=2.67-2.79) when compared with mothers with no psychiatric history. However, childless women with psychiatric diagnoses had the highest MRR (6.15; 95% CI=5.94-6.38). Unnatural cause of death represented 40.6% of fatalities among women with postpartum psychiatric disorders, and within the first year after diagnosis, suicide risk was drastically increased (MRR=289.42; 95% CI=144.02-581.62) when compared with mothers with no psychiatric history.

Increased risk for postpartum psychiatric disorders among women with past pregnancy loss. Giannandrea SA, Cerulli C, Anson E, Chaudron LH. J Womens Health (Larchmt). 2013 Sep;22(9):760-8. doi: 10.1089/jwh.2012.4011.

Abstract Background: Scant literature exists on whether prior pregnancy loss (miscarriage, stillbirth, and/or induced abortion) increases the risk of postpartum psychiatric disorders-specifically depression and anxiety-after subsequent births. This study compares: (1) risk factors for depression and/or anxiety disorders in the postpartum year among women with and without prior pregnancy loss; and (2) rates of these disorders in women with one versus multiple pregnancy losses.

Methods: One-hundred-ninety-two women recruited at first-year pediatric well-child care visits from an urban pediatric clinic provided demographic information, reproductive and health histories. They also completed depression screening tools and a standard semi-structured psychiatric diagnostic interview.

Results: Almost half of the participants (49%) reported a previous pregnancy loss (miscarriage, stillbirth, or induced abortion). More than half of those with a history of pregnancy loss reported more than one loss (52%). Women with prior pregnancy loss were more likely to be diagnosed with major depression (p=0.002) than women without a history of loss. Women with multiple losses were more likely to be diagnosed with major depression (p=0.047) and/or post-traumatic stress disorder (Fisher's exact [FET]=0.028) than women with a history of one pregnancy loss. Loss type was not related to depression, although number of losses was related to the presence of depression and anxiety.

Conclusions: Low-income urban mothers have high rates of pregnancy loss and often have experienced more than one loss and/or more than one type of loss. Women with a history of pregnancy loss are at increased risk for depression and anxiety, including post-traumatic stress disorder (PTSD), after the birth of a child. Future research is needed to understand the reasons that previous pregnancy loss is associated with subsequent postpartum depression and anxiety among this population of women.

"Predictors of postpartum post-traumatic stress disorder in primiparous mothers.[Article in French] Montmasson H1, Bertrand P, Perrotin F, El-Hage W. J Gynecol Obstet Biol Reprod (Paris). 2012 Oct;41(6):553-60. doi: 10.1016/j.jgyn.2012.04.010. Epub 2012 May 21.

A history of abortion was associated with a six fold increased risk of subsequent postpartum PTSD.

Fear of childbirth predicts postpartum depression: a population-based analysis of 511 422 singleton births in Finland. Räisänen S, Lehto SM, Nielsen HS, Gissler M, Kramer MR, Heinonen S. BMJ Open. 2013 Nov 28;3(11):e004047. doi: 10.1136/bmjopen-2013-004047.

Abstract

OBJECTIVES: To study how reproductive risks and perinatal outcomes are associated with postpartum depression treated in specialised healthcare defined according to the International Classification of Diseases (ICD)-10 codes, separately among women with and without a history of depression.

DESIGN: A retrospective population-based case-control study.

SETTING: Data gathered from three national health registers for the years 2002-2010.

PARTICIPANTS: All singleton births (n=511 422) in Finland.

PRIMARY OUTCOME MEASURES: Prevalence of postpartum depression and the risk factors associated with it.

RESULTS: In total, 0.3% (1438 of 511 422) of women experienced postpartum depression, the prevalence being 0.1% (431 of 511 422) in women without and 5.3% (1007 of 18 888) in women with a history of depression. After adjustment for possible covariates, a history of depression was found to be the strongest risk factor for postpartum depression. Other strong predisposing factors for postpartum depression were fear of childbirth, caesarean birth, nulliparity and major congenital anomaly. Specifically, among the 30% of women with postpartum depression but without a history of depression, postpartum depression was shown to be associated with fear of childbirth (adjusted OR (aOR 2.71, 95% CI 1.98 to 3.71), caesarean birth (aOR 1.38, 95% CI 1.08 to 1.77), preterm birth (aOR 1.65, 95% CI 1.08 to 2.56) and major congenital anomaly (aOR 1.67, 95% CI 1.15 to 2.42), compared with women with no postpartum depression and no history of depression.

CONCLUSIONS: A history of depression was found to be the most important predisposing factor of postpartum depression. Women without previous episodes of depression were at an increased risk of postpartum depression if adverse events occurred during the course of pregnancy, especially if they showed physician-diagnosed fear of childbirth.

Editor's Note: Women with a history of abortion were 41% more likely to have post-partum depression compared to both women without any history of prior depression (OR=1.41; CI 1.08 to 1.84) and compared women with a prior history of depression (OR=1.41; CI = 1.21 to 1.67), as shown in Table 4. Prior miscarriage was not significantly associated with a higher risk of post-partum depression.

Re-analysis of Table 1, indicates that among the subset of all women without a prior history of depression, those who had a history of abortion were 49% more likely to experience post-partum depression (95% CI 1.15 to 1.93; incident rate per 100,000 of 123 versus 82.)

Identification of Factors Associated with Postpartum Depression among Saudi Females in Riyadh City Nesreen Al-Shami. King Saud University College of Nursing, Department of Maternal and Child Health Nursing. June 2, 2010.

A study of 200 women drawn from four hospitals in Riyadh City all of whom had reported postpartum depression. Survey instruments were used to measure socioeconomic factors, gynecological and obstetric history, life stressor events, and post-partum depression symptoms.

Risk factors for postpartum depression include first birth, ambivalence about the pregnancy, lack of social support, economical problems, history of abortion, died infant, gender of infant, medical or surgical history, number of pregnancies, type of delivery, life stressor event, lack of partner, and a history of depression or another depression illness.

"The Relationship Between Previous Elective Abortions and Postpartum, Depressive Reactions." N.E. Devore, Journal of Obstetric Gynecologic and Neonatal Nursing, July/August 1979, pp-237-240

In a study of 73 women among the obstetrical population at the Hospital of Albert Einstein College during 1975-76, 25 pregnant women who had one abortion and 48 women who were pregnant for the first time were interviewed 6-8 weeks postpartum. Seventy-one percent of the women with abortion history reported they were depressed at the time of the abortion, yet only 12% reported that they had received emotional counseling at the time of the abortion. The range of time from the earlier abortion to the current pregnancy was 2-8 years, mean 3.9 years. Using the Beck Depression Inventory, the study found postpartum moderate depression in 16% of women with a prior abortion compared to 12% of the women without any abortion. Eighty percent of the women with abortion history compared to 56% without abortion history reported the "baby blues." The study suggested that a few women who have had a previous elective abortion will still experience feelings of guilt or depression in connection with it. Spontaneous comment from the women with abortion history suggested that anxiety during pregnancy concurring the infants health was a greater source of discomfort than was post-partum depression.

Increased risk for postpartum psychiatric disorders among women with past pregnancy loss. Giannandrea SA, Cerulli C, Anson E, Chaudron LH. J Womens Health (Larchmt). 2013 Sep;22(9):760-8. doi: 10.1089/jwh.2012.4011.

Abstract Background: Scant literature exists on whether prior pregnancy loss (miscarriage, stillbirth, and/or induced abortion) increases the risk of postpartum psychiatric disorders-specifically depression and anxiety-after subsequent births. This study compares: (1) risk factors for depression and/or anxiety disorders in the postpartum year among women with and without prior pregnancy loss; and (2) rates of these disorders in women with one versus multiple pregnancy losses.

Methods: One-hundred-ninety-two women recruited at first-year pediatric well-child care visits from an urban pediatric clinic provided demographic information, reproductive and health histories. They also completed depression screening tools and a standard semi-structured psychiatric diagnostic interview.

Results: Almost half of the participants (49%) reported a previous pregnancy loss (miscarriage, stillbirth, or induced abortion). More than half of those with a history of pregnancy loss reported more than one loss (52%). Women with prior pregnancy loss were more likely to be diagnosed with major depression (p=0.002) than women without a history of loss. Women with multiple losses were more likely to be diagnosed with major depression (p=0.047) and/or post-traumatic stress disorder (Fisher's exact [FET]=0.028) than women with a history of one pregnancy loss. Loss type was not related to depression, although number of losses was related to the presence of depression and anxiety.

Conclusions: Low-income urban mothers have high rates of pregnancy loss and often have experienced more than one loss and/or more than one type of loss. Women with a history of pregnancy loss are at increased risk for depression and anxiety, including post-traumatic stress disorder (PTSD), after the birth of a child. Future research is needed to understand the reasons that previous pregnancy loss is associated with subsequent postpartum depression and anxiety among this population of women.

Pregnancy loss and anxiety and depression during subsequent pregnancies: data from the C-ABC study. Gong X, Hao J, Tao F, Zhang J, Wang H, Xu R. Eur J Obstet Gynecol Reprod Biol. 2013 Jan;166(1):30-6. doi: 10.1016/j.ejogrb.2012.09.024. Epub 2012 Nov 10.Source School of Public Health, Anhui Medical University, Hefei, Anhui, China.

OBJECTIVE: Previous studies have shown that pregnancy loss may affect the mental health of women in subsequent pregnancies. The China Anhui Birth Defects and Child Development cohort study therefore aimed to investigate the influence of pregnancy loss on anxiety and depression in subsequent pregnancies.

STUDY DESIGN: In total, 20,308 pregnant women provided written informed consent and completed the study questionnaire. The Self-rating Anxiety Scale and Center for Epidemiologic Studies-Depression Scale were used to evaluate anxiety and depression in pregnant women. Pearson's χ(2) test and binary logistic regression were used for statistical analyses.

RESULTS: Of 20,308 pregnant women, 1495 (7.36%) had a history of miscarriage and 7686 (37.85%) had a history of induced abortion. The binary logistic regression model found that pregnant women with a history of miscarriage had a significantly higher risk of anxiety and depression in the first trimester than primigravidae after stratified analysis according to the timing of the first prenatal visit (p<0.05). Compared with pregnant women with no history of miscarriage, women who had a history of miscarriage and an interpregnancy interval of less than 6 months had increased risk of anxiety symptoms (p<0.05) and depression symptoms (p<0.05) during the first trimester. Women with an interpregnancy interval of 7-12 months had a 2.511-fold higher risk of depression (p<0.05) than women with no history of miscarriage. These findings were not changed after adjustment for maternal age, maternal education, family income, place of residence and pre-pregnancy body mass index.

CONCLUSIONS: Women with a history of miscarriage experienced significant anxiety and depression during their next pregnancy. A short interpregnancy interval and the first trimester are risk factors for adverse mental health