Transcript Exploring-the-relationship-between-miscarriage-and

Exploring the Relationship Between Miscarriage and Depression
Faraz Ahmad Abdul Hadi Djokhdem
Laura Danielle Pozzobon Sadad Rahman
`
Interdisciplinary School of Health Sciences, University of Ottawa
Abstract
Discussion
Results
Background: Miscarriages are a common outcome of pregnancies, with
approximately 15–20% of clinically recognized pregnancies resulting in miscarriages.
While the physical complaints associated with a miscarriage are routinely and easily
addressed, the psychological impact of a miscarriage is often overlooked. Previous
research has demonstrated poor psychological outcomes in women who have
miscarried. Objective: This review aims to explore the relationship between
miscarriage and depression. Methods: A structured literature review was conducted to
understand the association between miscarriage and depression. Articles were retrieved
by searching the databases SCOPUS and PubMed with the following key terms:
depression, miscarriage, psychological consequences, and spontaneous abortion.
Articles published in North America between 1990 and 2015 were included. The
search was limited to articles published in the English language. Results: The literature
search resulted in fifty-five articles. Eight articles of the fifty-five articles met the
inclusion criteria. Of the eight articles, three were literature reviews and five were
cohort studies. Conclusion: The literature suggests that depressive symptoms
frequently occur in women who have miscarried. Further research is required as there
is a lack of high quality study designed research on this topic.
Introduction
Article
Findings
•A summary of all studies revealed that 10-50% of patients were diagnosed as having major
depressive disorders (MDD) following miscarriage.
•Depressive symptoms persisted at an elevated state 6 months after miscarriage, and only
returned to normal after 1 year.
Cohort Study
•Case group consisting of miscarrying women
(n=382), and control group consisting of
pregnant women (n=283) and community
women not recently pregnant (n=318).
•Fully structured interviews
•Psychiatric diagnostic assessment tool:
Center for Epidemiologic Studies
Depression Scale (CES-D)
•Proportion of highly symptomatic women (according to CES-D) were 3.4 times higher
(95% confidence interval, 2.0 – 5.0) in the miscarrying group than in the pregnant women
group, and 4.3 times higher (95% confidence interval, 3.0-5.8) than in the community
women group.
•Women reinterviewed at 6 weeks and 6 months did not show elevated symptom levels.
Cohort Study
•39 women completed the full length of the
study.
•Mean age was 32.9 years (SD 4.4).
•Longitudinal assessments at 3, 6 and 12
months following miscarriage
•CES-D scale, Spanner Dyadic
Adjustment Scale, Rosenberg Self-Esteem
Scale, Impact of Pregnancy Loss
Questionnaire
•ANOVA analysis was used to determine
relationship between time, age, and
presence of children
•Findings confirm that miscarriage significantly impacts most women’s for 1 year following
the loss.
•At 3 months following miscarriage, depression levels were significantly higher than the
population standard, dipped back to normal at 6 months, and returned to elevated levels at 1
year.
•Age or having other children was not correlated with risk for depression.
•Structured Interview: Diagnostic
Interview Schedule (DIS)
•10.9 % of miscarrying women experienced an episode of major depressive disorder
(MDD), compared to 4.3% of community women.
•72% of cases of MDD began in the first month following loss.
•The overall relative risk for an episode of minor depression for miscarrying women was
2.5 (95% confidence interval, 1.2-23.6).
•Relative risk did not vary by history of prior reproductive loss, maternal age, time of
gestation or attitude towards pregnancy.
Neugebauer
et al. (1992)
Robinson et
al. (1994)
Cohort Study
•Hospital-based miscarriage cohort (n=229)
and cohort of non-pregnant women drawn from
the community (n=230).
•50% of women were aged between 25-34.
Klier et al.
(2000)
Cohort Study
•Hospital-based miscarriage cohort (n=229)
and cohort of non-pregnant women drawn from
the community (n=230).
•50% of women were aged between 25-34.
*analyzed same sample as above study, in the
context of minor depressive disorder.
•Diagnostic criteria: DSM-IV
•Structured Interview: Diagnostic
Interview Schedule (DIS)
•CES-D Scale
•Statistical Analysis: Unadjusted relative
risk (RR)
•5.4% of miscarrying women experienced an episode of minor depression, compared to
1.0% of community women.
•Relative risk of minor depression for miscarrying women was 5.2 (95% confidence
interval, 1.2-23.6).
•Risk did not vary based on gestation length, or attitude towards pregnancy.
•The majority of episodes began within one month following loss.
Geller et al.
(2010)
Literature Review
•Included a total of 1389 participants meeting
the inclusion criteria, distributed across a span
of 17 quantitative and qualitative studies, with
cross-sectional, longitudinal, retrospective, and
interview based research designs.
•Likert Scale questionnaires
•Semi-structured/structured interviews
•Impact of Events Scale
•Profile of Mood States
•General Health Questionnaire
•No correlation found between satisfaction with miscarriage aftercare and development of
depression.
Methods
Records after duplicates removed:
n=42
Measurements/ Statistical Analyses
•Psychiatric interviews: Present State
Examination (PSE) protocol
•Diagnostic criteria: Diagnostic and
Statistical Manual of Mental Disorders
(DSM-IV)
Literature Review
Research Question:
Do women who experience a miscarriage display higher levels of
depressive symptoms compared to women who do not miscarry?
Searched PubMed and SCOPUS for: (((depression) AND
miscarriage) AND psychological consequences) AND
spontaneous abortion
n=55
Population
•Included a total of 1243 meeting the inclusion
criteria, distributed across a span of 8 studies.
Studies included case-control, prospective
cohort, and longitudinal observational designs.
Lok &
Neugebauer
(2007)
Neugebauer
et al. (1997)
Miscarriage, the spontaneous termination of pregnancy prior to the 28th week of gestation, is
a complex biological process resulting in significant loss (Klier, Geller, and Neugebauer,
2000). For many women who experience a miscarriage, the loss of a desired child and the
physical pain of miscarriage can elicit negative psychological reactions (Neugebauer, 2003).
The physical complaints that are associated with miscarriage are usually resolved rapidly,
however, the psychological outcomes that can result are often overlooked (Lok and
Neugebauer, 2007). Previous research suggests depression as a psychological outcome of
miscarriage (Lok and Neugebauer, 2007).
Research Design
Carter et al.
(2007)
Literature Review
•Reviewed a total of 11 articles pertaining to
depression and/or depressive symptomatology.
•Diagnostic criteria: DSM-IV
•30-50% of women who miscarry experience some degree of depressive symptoms within 6
months of lost; majority within the first month.
•One analyzed study found an significantly increased suicide rate amongst miscarrying
women 1 year post-loss.
•Another study found that 54% of women who have had previous history of depression
relapse after miscarriage.
Neugebauer
(2003)
Cohort Study
•Miscarrying women cohort (n=114) and
community women cohort (n=318)
•CES-D Scale
•Substantial elevation of depressive symptoms in the miscarriage cohort compared to
community cohort with an adjusted difference in means between cohorts of 4.9 (95%
confidence interval, 2.3 -7.4).
•20.2% of miscarrying women were highly symptomatic (CES-D score = 30+), compared to
10.1% in community women (adjusted odds ratio 2.8, 95% confidence interval, 1.4 - 5.6).
•Impact on depressive symptoms significantly greater at 6-8 weeks following miscarriage,
than at 2 weeks following miscarriage.
•No correlation between depressive symptoms and number of living children, marital status,
ethnicity or educational level.
Records limited to English Studies:
n=41
Figure 2. Summary of Literature Review
Records limited to studies published since 1990:
n=37
Records limited to studies published in
North America:
n=9
Records excluded based on
screening abstracts for
relevance:
n=17
Records excluded due to
unavailability of full text:
n=1
Records used for structured literature review:
n=8
Findings of Structured Literature
 The search yielded 5 cohort studies and 3 literature reviews.
 The literature confirms an association between miscarriage and depression. It suggests
that women who experience a miscarriage are likely to display higher levels of
depressive symptoms compared to women who do not miscarry. 30-50% of women
who miscarried were found to have developed depressive symptoms within 6 months of
the loss (Carter et al., 2007). Robinson et al. (1994) used the Centre for Epidemiological
Study Depression Scale (CES-D), and found women at 3 months following miscarriage
had depression levels significantly higher than the population standard. Additionally,
women who miscarried were found to have a 6.6% higher absolute risk of experiencing
a major depressive disorder than the community women (Neugebauer et al., 1997).
Limitations
 Only articles written and published in the English language were accessed, articles
published prior to 1990 were not reviewed, and databases were not searched
individually. One article was excluded due to unavailability of the full text.
 Many studies selected for the review use convenience sampling as their method for
enrolling participants, for example, support groups and hospitals. This is a type of
selection bias as the sample is unlikely to be representative of the population.
 The definition of miscarriage used between studies varies. Miscarriage is frequently
defined in the research studies as loss prior to 28 weeks, whereas other studies in the
literature review refer to miscarriage as a loss of pregnancy prior to 20 weeks. A
varying definition makes it difficult to compare studies. This results in information bias,
. specifically, detection bias.
Implications
 Most studies revealed that depression was most prevalent in the early months following
miscarriage. With an understanding of the possibility for depression to result from
miscarriage, health care professionals (HCPs) can employ interventions to target the
prevention of depression in women who miscarry. Women who miscarry often criticize
the follow-up care they received on the basis that the care did not encompass emotional
well being. Intervention plans should focus on placing effective support groups that are
geared towards reducing the stress and discomfort associated with experiencing a
miscarriage.
Future considerations
 Generate an effective standardized screening tool for detecting depression after
miscarriage. This would allow for HCPs to detect women who are likely to develop
depression and identify those in need of further intervention.
 Few studies in the literature examine the possible psychological impact on the spouse
after a miscarriage and thus, more research should be conducted in this area as well.
Conclusion
There is evidence that suggests women who experience miscarriage are more likely to
develop depressive symptoms, and most often in the first month following miscarriage.
Factors of age, previous history of pregnancy loss, and having other children do not appear
to be correlated with risk of depression after miscarriage. Further research utilizing high
quality study designs is required on this topic.
References
Literature Review:
Carter et al. (2007), Geller et al. (2010),
Lok & Neugebauer (2007)
Cohort Study:
Neugebauer (2003), Klier et al. (2000), Neugebauer et al.
(1997), Robinson et al. (1994), Neugebauer et al. (1992)
Figure 1. Methodology
Figure 3. Pyramid of Evidence
1. Neugebauer, R. (2003). Depressive symptoms at two months after miscarriage: interpreting study findings from
an epidemiological versus clinical perspective.Depression and anxiety, 17(3), 152-161.
2. Neugebauer, R., Kline, J., O’Connor, P., Shrout, P., Johnson, J., Skodol, A., ... & Susser, M. (1992). Depressive
symptoms in women in the six months after miscarriage. American journal of obstetrics and gynecology, 166(1),
104-109.
3. Neugebauer, R., Kline, J., Shrout, P., Skodol, A., O'Connor, P., Geller, P. A., ... & Susser, M. (1997). Major
depressive disorder in the 6 months after miscarriage. JAMA, 277(5), 383-388.
4. Klier, C. M., Geller, P. A., & Neugebauer, R. (2000). Minor depressive disorder in the context of miscarriage.
Journal of affective disorders, 59(1), 13-21.
5. Carter, D., Misri, S., & Tomfohr, L. (2007). Psychologic aspects of early pregnancy loss. Clinical obstetrics and
gynecology, 50(1), 154-165.
6. Lok, I. H., & Neugebauer, R. (2007). Psychological morbidity following miscarriage. Best Practice & Research
Clinical Obstetrics & Gynaecology,21(2), 229-247.
7. Robinson, G. E., Stirtzinger, R., Stewart, D. E., & Ralevski, E. (1994). Psychological reactions in women
followed for 1 year after miscarriage. Journal of Reproductive and Infant Psychology, 12(1), 31-36.
8. Geller, P. A., Psaros, C., & Kornfield, S. L. (2010). Satisfaction with pregnancy loss aftercare: are women
getting what they want?. Archives of women's mental health, 13(2), 111-124.