Abortion: Perspectives from an APA Past-President.

The United States Supreme Court's decision in Dobbs v. Jackson Women's Health Organization, eliminating the national right to abortion, poses challenges to psychiatrists and patients. Abortion laws now vary widely from state to state and are constantly changing and being challenged. The laws affect both patients and health care professionals; some prohibit not only the performance of abortion but efforts to inform and assist patients seeking abortion. Patients may become pregnant during and/or because of episodes of clinical depression, mania, or psychosis, and recognize that their current circumstances will not allow them to become adequate parents. Some laws allowing abortion to protect a woman's life or health explicitly exclude mental health risks; many prohibit transfer of a patient to a permissive venue. Psychiatrists working with patients contemplating abortion can convey the scientific evidence that abortion does not cause mental illness and help them identify and work through their own beliefs, values, and likely responses to the decision. Psychiatrists will also have to decide whether medical ethics or state laws will govern their own professional behavior.

Reproductive Rights and Women's Mental Health: Essential Information for the Obstetrician-Gynecologist.

Reproductive health care is crucial to women's well-being and that of their families. State and federal laws restricting access to contraception and abortion in the United States are proliferating. Often the given rationales for these laws state or imply that access to contraception and abortion promote promiscuity, and/or that abortion is medically dangerous and causes a variety of adverse obstetric, medical, and psychological sequelae. These rationales lack scientific foundation. This article provides the evidence for the safety of abortion, for both women and girls, and encourages readers to advocate against restrictions.

Recovery from depression.

Full recovery from depression, as contrasted with symptom improvement, is a relatively new concept and therapeutic goal. It is an important goal, because the failure to achieve this goal leaves many patients with less productive and fulfilling lives, it leaves some children with lasting deficits, and it deprives families and societies of loved ones' and employees' care and investment. As a new therapeutic concept, recovery from depression is not as easy to define as it might seem; many or most patients were not euthymic before an episode of depression or have had some level of depression throughout their lives. There is no measurable definition of euthymia. In addition to definitional difficulties, we need to study and address other barriers to the achievement of recovery from depression. All the barriers to the diagnosis and treatment of depression are barriers against recovery: negative social and professional attitudes, comorbidity, lack of access to demonstrably efficacious professional and social services, and inability to match patients with the antidepressants most likely to help them. Efforts to address many of these knowledge and attitude gaps are already underway. Long-term studies are needed, both observational and experimental. Most published studies encompass only weeks or at best months of follow-up, but recovery must be sustained to be meaningful. As noted previously, there has been little or no attention to the developmental impact of depression. The restoration of premorbid function is not sufficient when depression has hindered a patient's ability to form satisfying relationships and choose and perform satisfying work. We need to learn how to remediate patients whose history of depression has stifled their talents and aspirations. Studying these issues will not be easy, but millions of individuals with depression, and their physicians, will profit by it; it will be well worth the effort.

Psychiatric aspects of induced abortion.

Approximately one third of the women in the United States have an abortion during their lives. In the year 2008, 1.21 million abortions were performed in the United States (Jones and Koolstra, Perspect Sex Reprod Health 43:41-50, 2011). The psychiatric outcomes of abortion are scientifically well established (Adler et al., Science 248:41-43, 1990). Despite assertions to the contrary, there is no evidence that abortion causes psychiatric problems (Dagg, Am J Psychiatry 148:578-585, 1991). Those studies that report psychiatric sequelae suffer from severe methodological defects (Lagakos, N Engl J Med 354:1667-1669, 2006). Methodologically sound studies have demonstrated that there is a very low incidence of frank psychiatric illness after an abortion; women experience a wide variety of feelings over time, including, for some, transient sadness and grieving. However, the circumstances that lead a woman to terminate a pregnancy, including previous and/or ongoing psychiatric illness, are independently stressful and increase the likelihood of psychiatric illness over the already high baseline incidence and prevalence of mood and anxiety disorders among women of childbearing age. For optimal psychological outcomes, women, including adolescents, need to make autonomous and supported decisions about problem pregnancies. Clinicians can help patients facing these decisions and those who are working through feelings about having had abortions in the past.

Induced abortion and adolescent mental health.

PURPOSE OF REVIEW: Induced abortion is widely believed - by the public, healthcare professionals, and policy-makers - to lead to adverse mental health sequelae. This belief is false, as it applies both to adult women and adolescents. However, it has been used to rationalize, and been quoted in, restrictive and intrusive legislation in several states and in proposed federal legislation. It is essential for gynecologists to have accurate information, as clinicians, for their patients, and, as key experts, for policy makers. RECENT FINDINGS: New articles concluding that there are adverse psychological outcomes from induced abortion continue to be published. The methodological flaws in these articles are so serious as to invalidate those conclusions. Several recent scholarly analyses detail these flaws. Methodologically sound studies and reviews continue to demonstrate that psychosocial problems play a role in unwanted conception and the decision to abort unwanted pregnancies but are not the result of abortion. SUMMARY: Clinicians may have to reassure patients making decisions about their pregnancies that abortion does not cause psychiatric illness. They can do so on the basis of recent analyses substantiating that finding.

Is there an "abortion trauma syndrome"? Critiquing the evidence.

The objective of this review is to identify and illustrate methodological issues in studies used to support claims that induced abortion results in an "abortion trauma syndrome" or a psychiatric disorder. After identifying key methodological issues to consider when evaluating such research, we illustrate these issues by critically examining recent empirical studies that are widely cited in legislative and judicial testimony in support of the existence of adverse psychiatric sequelae of induced abortion. Recent studies that have been used to assert a causal connection between abortion and subsequent mental disorders are marked by methodological problems that include, but not limited to: poor sample and comparison group selection; inadequate conceptualization and control of relevant variables; poor quality and lack of clinical significance of outcome measures; inappropriateness of statistical analyses; and errors of interpretation, including misattribution of causal effects. By way of contrast, we review some recent major studies that avoid these methodological errors. The most consistent predictor of mental disorders after abortion remains preexisting disorders, which, in turn, are strongly associated with exposure to sexual abuse and intimate violence. Educating researchers, clinicians, and policymakers how to appropriately assess the methodological quality of research about abortion outcomes is crucial. Further, methodologically sound research is needed to evaluate not only psychological outcomes of abortion, but also the impact of existing legislation and the effects of social attitudes and behaviors on women who have abortions.

The recovery concept: clinician and consumer perspectives.

This article presents an overview of the concept of recovery in serious and persistent mental illness from the perspective of both clinicians and consumers. Dr. Stotland, a psychiatrist, first highlights how treatment goals for bipolar disorder have changed in recent years, moving beyond symptomatic recovery to also encompass functional recovery (return to the level of functioning the person enjoyed before onset of the illness). She then discusses factors that play an important role in the recovery process, including resilience, the consumer's understanding of and participation in the treatment and recovery process, and collaboration between clinician and patient in setting specific functional goals as treatment progresses. She also focuses on the need for policy and system changes to facilitate recovery, including improved funding for recovery-oriented care, implementation of recovery-oriented, collaborative care models that bring together psychiatrists and primary care providers, and dissemination of improved tools for monitoring symptoms and functioning over time. Two relevant performance measures for monitoring changes in symptoms and level of functioning are discussed, with results of their field testing. Matthew Mattson, Director of Training for the Depression and Bipolar Support Alliance (DBSA), and Sue Bergeson, President of DBSA, then present the consumer's perspective on recovery-oriented care. Drawing on recommendations from the Institute of Medicine, the President's New Freedom Commission, the U.S. Surgeon General, and the Annapolis Coalition on the Behavioral Health Workforce, they stress that the ultimate goal of treatment must be recovery; that, to the greatest extent possible, care should based on consumers' needs and values; that consumers should take an active role in the design and delivery of their own care; and that a priority of all care delivery should be to engender hope. Promising research on peer support groups and the use of peer sup-port specialists as consumer-providers is then reviewed. The article concludes with 20 specific recommendations to help mental health professionals move beyond a focus on symptom reduction alone to more recovery-oriented care.

Women's bodies, doctors' dynamics.

Medicine treats men's and women's reproductive organs and functions markedly differently. Interventions affecting male functioning are regarded as very serious and are seldom undertaken except to treat significant pathology. Interventions affecting perfectly normal female functioning, such as treatment for menstrual cycle mood changes, menopause, episiotomy, cesarean and other assisted delivery, hormonal contraception, and even hysterectomy, are rampant. These interventions can be attributed to men's unconscious (and conscious) curiosity, jealousy, hostility, and helplessness about female reproduction, coupled with the fact that men have dominated the field of medicine for most of its history. This article describes these interventions and the rationalizations for them, and questions their utility and meaning in the light of current knowledge.