Major Depressive Disorder in the Six Months After Miscarriage
ABSTRACT & COMMENTARY
Approximately 500,000 women miscarry annually. thus, it is important to determine the mental health consequences of this event. However, systematic investigations of the psychiatric impact of miscarriage are rare. To date, only two studies have been conducted and neither had a control group. In a recent study, Neugebauer et al hypothesized that miscarriage would be associated with increased risk for major depression and that this risk would be higher in childless women, those with prior reproductive loss, and older women. The results revealed that women who miscarried had a 10.9% incidence of major depression in the subsequent six months compared to 4.3% of community women matched for sociodemographic characteristics, including reproductive history. Time in gestation and attitudes toward the pregnancy did not influence the risk. Prior reproductive loss, advanced maternal age, marital status, socioeconomic status, and history of a prior elective termination did not modify the association. However, more than 50% of miscarrying women and about 25% of community women with a history of major depression experienced a new episode during the six-month study period. The presence of children strongly protected against depression associated with miscarriage, but women with children had an increased prevalence of depression. Most depressions had their onset in the first four weeks after the event. However, many of the women in whom depression was triggered were still depressed five months later. The authors conclude that physicians should monitor women who miscarry in the first weeks after reproductive loss, particularly women who have a history of major depression or who are childless. A diagnostic evaluation will determine which women will benefit from supportive psychotherapy and which require the addition of antidepressant therapy. Tincture of time alone appeared to be an insufficient treatment plan. (Neugebauer R, et al. JAMA 1997;277:383-388.)
COMMENT BY SARAH L. BERGA, MD
The authors of this study note that miscarriage constitutes an unanticipated, physically traumatic event representing the death of a future child and disruption of reproductive plans. Doubts about procreative competence are engendered. Like infertility, miscarriage can be experienced as a psychological as opposed to physical death, and the usual bereavement process is activated. The partners of the women who miscarried were not included in this study, and one can only wonder if they too experienced depression or psychological disruption. In general, the prevalence of depression in men is about half that in women. These findings lend support to the notion that depression is triggered by negative life events and those predisposed to depression are most at risk when a loss occurs. This latter conclusion has implications for all physicians and health care professionals who care for women. It is always better to ask about depressive symptomatology than to assume that asking will make matters worse. What does make matters worse is not to receive the attention that is needed. Treatment for depression shortens the depressive episode and decreases the subsequent likelihood of recurrence. Therefore, the main take-home message is to ask and refer when needed. For those of us who care for infertility patients, it is important to remember that being childless increases the likelihood of a depressive reaction in response to a miscarriage. This caveat likely applies to women with a chemical pregnancy as well as those with a pregnancy of longer duration because gestational stage at the time of the miscarriage did not alter the subsequent risk of depression.
COMMENT BY STEVEN G. GABBE, MD
This community-based cohort study reveals that miscarriage in the first two trimesters of pregnancy significantly increases the likelihood of a major depressive disorder. Nearly one in ten women who experienced a miscarriage were found to have suffered depression, most often during the first month after the loss. For women who had a history of a major depressive disorder, more than half had a recurrence. Women who were childless and then miscarried were found to be at great risk for depression. However, it is surprising that the risk for depression was not greater in women with a prior history of reproductive loss.
Today, most women who miscarry, especially in the first or early second trimesters, are treated as outpatients. Based on the data presented in this paper as well as other studies that have confirmed the negative psychological impact of pregnancy loss, I believe it is essential that these patients have a follow-up contact made in the first weeks after a spontaneous abortion.