Depression Risk After Miscarriage Often Overlooked

Although the mental health impact of miscarriage is often minimized or overlooked because miscarriages are so common, the experience can have serious consequences for the woman and her family members.

Miscarriages occur in up to 18 percent of pregnant women in the United States, said Gail Robinson, M.D., at a symposium on women's health issues at APA's 2008 annual meeting in Washington, D.C., in May. Robinson is a researcher in the Division of Behavioral Sciences and Health at Toronto General Research Institute and a consultant and past president of the APA Assembly Women's Caucus.

Because most miscarriages occur early in pregnancy, Robinson said many are uncounted, and the actual rate may be much higher—affecting as many as 50 percent of women over their lifetimes, according to a 1989 study by Jennie Kline and colleagues.

“Women are often left with a feeling of loss, and they don't know why it has gone on and on,” she said.

Few controlled studies have examined the mental health impact of miscarriage on women, Robinson said, and those that have been done used inconsistent control groups and little follow-up.

Women who miscarry often feel anxious, fearful, and helpless because of the loss of control over their pregnancy. The research disagrees over the time span in which these feelings evolve from a short period of depressive symptoms to six months or one year of the symptoms. Even the research that identified depressive symptoms long after a miscarriage failed to monitor study participants continuously, so it was unclear whether the symptoms were long term or transient.

The research is more clear on who is at risk for depression following a miscarriage. Those at higher risk include previous depression sufferers, childless women, and those who strongly wanted the pregnancy and may have concerns about fertility. No relationship was found between postmiscarriage depression and social status, age, or previous abortion.

Less certain is the impact of the length of gestation on the likelihood for developing depression. Also, the effect of a previous miscarriage is unclear. A contributing factor in preventing depression may be the presence of a supportive partner who helps the woman, as opposed to someone who generates pressure regarding the need to have children.

The grief in postmiscarriage patients is unusual in that it tends to be related to the future, as opposed to the past, Robinson said. It's related to a yearning for a future baby and the life he or she would lead.

Some research has found that women were even more anxious than depressed after a miscarriage because of a “guilt factor.”

“It's related to the fact that [often physicians] can't tell them why it happened,” Robinson said.

In one study 85 percent of women said the miscarriage made them “very stressed,” while 78 percent said the stress created was equal to or greater than any previous stress in their lives. The stress can feed the feeling that the woman did something that caused the miscarriage and that there is some action she must take to prevent a future loss of a pregnancy.

Other impacts of miscarriage include the largely unknown effects on the father and other children. There have been few studies about the feelings of the woman's partner, although the limited work indicates men show fewer depressive symptoms and that they may grieve differently. The effects on the parents' other children also require more study, she said, because they may be confused and frightened by the parents' reactions to the end of the pregnancy.

“Parents can add to these feelings by becoming either distant or overly protective,” Robinson said.

Psychiatrists have an important role to play in both preventing and treating mental health problems that stem from the loss of a pregnancy, Robinson said.

New patients who recently had a miscarriage should be provided with clear explanations about the potential sequelae of that loss and given help to address their feelings of guilt and loss of control. Psychiatrists and mental health professionals also should warn the patient about the responses of some people, who often ignore or play down the seriousness of a miscarriage in the mistaken belief that such an approach is helpful.

For existing patients who become pregnant, psychiatrists should provide preventive help by talking to the patient about the possibility of miscarriage and should talk to their staff to ensure they show sensitivity toward miscarriage when talking to patients who have had one.

In a departure from past practices, Robinson said, hospital staff should be encouraged to allow women who have had late miscarriages or still-born babies an opportunity to hold the baby or take a picture of it to help ease their grief. Many patients also find that it helps to name such babies, provide them funerals, and bury them.

Psychiatrists also should be aware that future pregnancies may induce anxiety, but could also help heal the previous loss. She recommended that psychiatrists have their patients return for an assessment when a new pregnancy begins. ▪