Witness Testimony

My name is Nada L. Stotland, M.D. I hold Doctor of Medicine and Master of Public Health degrees and have been a practicing psychiatrist for more than 25 years. Currently, I have a private clinical practice and am also Professor of Psychiatry and Professor of Obstetrics and Gynecology at Rush Medical College. I have devoted most of my career to the psychiatric aspects of women's reproductive health care.

I speak today on behalf of the American Psychiatric Association (APA), where I presently serve as an elected member of the Board of Trustees. APA is the medical specialty society representing more than 35,000 psychiatric physicians nationwide. Our members are on the front lines of treating mental illness across the country. They serve as clinicians, academicians, researchers, and administrators. I also speak today as a Board member of Physicians for Reproductive Choice and Health (PRCH), which represents more than 6,300 physician and non-physician members nationally. PRCH is a national not-for-profit created to enable concerned physicians to take a more active and visible role in support of universal reproductive health. PRCH is committed to ensuring that all people have the knowledge, access to quality services, and freedom of choice to make their own reproductive health decisions.

By way of personal background, my interest began with the psychology of pregnancy, labor, and childbirth. I gave birth to four wonderful daughters, now adults, and I was determined that their births be as safe as possible. I studied methods of prepared childbirth, used them, and became the Vice President of the national Lamaze prepared childbirth organization.

I commend the Subcommittee for holding this important hearing and for attempting to keep the focus on a general discussion of post pregnancy mental health in women. Let me say at the outset that I appreciate the Chairman's stated hope that we can explore the frank differences between some of the witnesses with a mutually respectful examination of the facts.

Before I begin my testimony, I want to take a brief moment to say that I was delighted to meet with my Congressman - Representative Bobby Rush - before today's hearing, and I was pleased to have been invited by Representative Rush to speak before the Congressional Black Caucus symposium on postpartum depression in 2001. I greatly appreciate his leadership on this vital issue, particularly with respect to the impact of untreated depression in minority populations, including minority women. This is an important and sorely neglected issue.

Mental Health Issues and Women:

Before focusing on post-pregnancy depression, it would be useful to discuss some general issues related to women's mental health. Burt and Hendrick, writing in their "Concise Guide to Women's Mental Health," put it succinctly, noting that "Women use more health care services than any other group in the United States. They make more visits to doctors' offices than do men, fill more prescriptions, have more surgeries . . . and spend two out of every three health care dollars."

Specific gender differences in the prevalence of mental illnesses in the United States are well recognized. This is true of prevalence rates for some disorders, but also in the way in which some disorders present at the diagnostic interview, and also in comorbidities. For example, not only are depression and dysthymia (a chronic form of depression) more common in women than men, but both are more likely to be accompanied by anxiety disorders in women than men. And the features of psychiatric illnesses present in women are likely to be different than when present in men.

The landmark Surgeon General's Report on Mental Health, issued by then-Surgeon General David Satcher, M.D., in 1999, provides much valuable information. Anxiety disorders (panic disorder, phobias, obsessive compulsive disorder, panic disorder, PTSD, etc.) are the most prevalent disorders in adults and are found twice as often in women as in men. Panic disorder is about twice as common among women as men, with the most common age of onset between late adolescence and mid-adult life. In the general (non-military) population, the one-year prevalence rate of posttraumatic stress disorder is about 3.6 percent, with women accounting for nearly twice the prevalence as men. The highest rates of PTSD are found among women who are the victims of crime, especially rape.

Mood disorders take a huge toll in the form of human suffering, lost productivity and suicide. They rank among the top ten disabling conditions worldwide. The most familiar mood disorders include major depression, dysthymia and cyclothymia (alternating depression and manic states that do not rise to the level of bipolar disorder). Again, with the exception of bipolar disorder, mood disorders are twice as common in women as in men, and in the case of seasonal affective disorder (depression occurring in the late fall and winter), seven times more common in women than men. Victims of domestic violence (an estimated 8 to 17 percent of women in the United States each year) are at increased risk for mental health problems. The mental health problems of domestic violence include depression, anxiety disorders including as noted PTSD, eating disorders, substance abuse and suicide.

Few would doubt the huge impact of depression alone on society and on the economy. Major depression is a seriously debilitating illness. Depressed persons see their physicians more often than others, and misdiagnosed depression can lead to extensive, expensive diagnostic tests (with obvious implications for health care costs). The most serious consequence of untreated depression is suicide. Major depressive disorders account for up to one-third of all deaths by suicide. While men in the U.S. commit suicide four times as often as women, women attempt suicide four times as often as men.

Time does not permit a more detailed discussion of gender-based differences in the prevalence, course and treatment of mental disorders in women. I hope this brief summary helps frame the questions before you today: What do we know about post-pregnancy depression? and What can we do about it?

The Importance of the Diagnostic and Statistical Manual of Mental Disorders (DSM):

Psychiatrists and other mental health professionals depend on accurate diagnostic tools to help them identify precisely the mental illnesses their patients suffer, an essential step in deciding what treatment or combination of treatments the patient needs. The Diagnostic and Statistical Manual of Mental Disorders (or DSM) has become a central part of this process. DSM is, simply, the internationally-recognized standard for the diagnosis of mental disorders. As such, it provides the most comprehensive diagnostic framework for defining and describing mental disorders. DSM-IV is embodied in over 650 state and federal statutes and regulations.

The DSM-IV is based on decades of research and was developed through an open process involving more than 1,000 national and international researchers and clinicians drawn from a wide range of mental and general health fields. The special 27-member DSM-IV Task Force worked for five years to develop the manual in a process that involved 13 work groups, each of which focused on a section of the manual. I myself was a member of the work group addressing late luteal phase dysphoric disorder, or premenstrual dysphoric disorder, as it came to be known. The work groups and each of their advisory groups of 50 to 100 individuals developed the manual in a three-step process.

The first step in the three-stage empirical review was the development of 150 reviews of the scientific literature, which provided the empirical database upon which DSM-IV decisions could be made. In the second step, task force work groups reanalyzed 50 separate sets of data which provided additional scientific information to that available in the published literature. Finally, the task force conducted 12 field trials with funding from the National Institute of Mental Health, National Institute on Drug Abuse, and the National Institution of Alcoholism and Alcohol Abuse, involving more than 88 sites in the United States and internationally and evaluations of more than 7,000 patients. As you can see, the DSM-IV is based on systematic, empirical studies.

The DSM-IV's codes are in agreement with the International Classification of Diseases, Ninth Edition, Clinical Modification (ICD-9-CM). ICD-9-CM is based on the ICD-9, a publication of the World Health Organization, used worldwide to aid in consistent medical diagnoses.

The DSM-IV's codes often are required by insurance companies when psychiatrists, other physicians and other mental health professionals file claims. Even the Centers for Medicare and Medicaid Services (CMS) require mental health care professionals to use the DSM codes for the purposes of Medicare reimbursement.

DSM and Depression and Psychosis:

One of the more unfortunate aspects of our culture is that we tend to toss around diagnostic criteria in commonplace language. We say, for example, that a student who gets a "C" on a mid-term is "depressed," or that someone who is acting in an agitated way is "psychotic." Doing so underscores the lack of understanding and the stigmatic way in which we approach serious illnesses that happen to be mental illnesses. For purposes of today's hearing it may be useful to briefly discuss depression and psychosis in the context of the DSM.

Depression: When used to describe a mood, the word "depression" refers to feelings of sadness, despair, and discouragement. As such, depression may be a normal state of feelings which any person could experience from time to time. "Depression" is also a clinical and scientific term, and in these contexts may refer to a "symptom" seen in a variety of mental or physical disorders, or it may refer to a "mental disorder" itself. DSM-IV classifies depression by severity, recurrence, and association with mania.

Psychosis: Psychosis is part of a severe mental disorder and is characterized by a person's gross impairment in perceiving reality. A psychotic person may be delusional or may experience hallucinations, disorganized speech, or disorganized or catatonic behavior. Psychosis may show up, for example, in patients who are suffering from schizophrenia, delusional disorders, and some mood disorders including manic-depression or bipolar disorder.

Postpartum Psychiatric Disorders:

I was asked to focus most of my testimony on the question of post-abortion depression and psychosis, which I will do. Although others have addressed postpartum disorders, let me briefly talk about them. Mental disorders following childbirth was first mentioned over 400 years before the birth of Christ, by Hippocrates, who described the case of a woman in Cyzicus who "gave birth with difficult labor," became sleepless and wandered at night, eventually suffering great distress before becoming rational again.

Today we know from research that disturbances can occur in the postpartum period in the form of "baby blues," or more seriously as postnatal depression or psychosis. Onset of baby blues occurs within days of delivery and can impact a significant number (some suggest 28 to 80 percent) of mothers across cultures. Features include emotional lability unrelated to past history, but the disorder is self-limited. Women with baby blues benefit from reassurance that the symptoms are common and will quickly disappear, but should be advised to seek help if symptoms are severe or persist for more than two weeks.

Postpartum depression is an affective disorder lasting more than two weeks, typically with an onset beginning two to four weeks postpartum, the severity of which meets criteria for DSM-IV designation. Special attention to postpartum depression is warranted because - in addition to the impact on maternal health and mental health - it increases the risk of negative parenting behaviors and puts children at risk for adverse outcomes in social, emotional, and behavioral development. Many cases are missed because new mothers are discharged so quickly from the hospital, and thereafter most care is provided by physicians focused on the care and wellness of the infant. The literature shows risk factors including a previous history of depression, particularly depression occurring antepartum.

Postpartum psychoses are psychotic disorders arising after childbirth. These are acute, severe illnesses occurring after one or two of every 1,000 births. Symptoms include mood lability, severe agitation, confusion, thought disorganization, hallucinations and sleeplessness. Most researchers believe that postpartum psychosis is a manifestation of bipolar disorder. These episodes of psychotic illness are triggered by the biologic and psychological stresses of pregnancy and delivery. The results of misdiagnosed psychosis occurring postpartum or lack of access to effective treatment can be, frankly, horrific, with some mothers committing infanticide followed (in up to 62 percent of the cases) by suicide. Sadly, several such cases have occurred among Representative Rush's constituents.

One important factor in responding appropriately to postpartum disorders is to call attention to their existence. New mothers need to understand the difference between "the blues" and feelings of overwhelming and persistent sadness. Physicians can help by preparing their patients with some reassuring but straight talk about the fact that childbirth and new parenthood can indeed be stressful and reactions to motherhood can't always be predicted. Peripartum emotional support is important; families should be included in education efforts, assessment of possible risks, and in the provision of supports. In particular, efforts by policymakers to call attention to the problem are most welcome and helpful.

"Post-Abortion Depression and Psychosis:"

Advocates of a created designation of "post-abortion depression and psychosis" typically argue without foundation that abortions can have a long-term impact on the mental health of women who elect to terminate a pregnancy. Alleged symptoms include recurring sadness, persistent feelings of guilt and a host of other factors including eating disorders, substance abuse, suicidal ideation and promiscuity, to name a few.

In fact, the vast majority of women have abortions without psychiatric sequelae, or secondary, consequences. A study of a national sample of more than 5,000 women in the U.S. followed for eight years concluded that the experience of abortion did not have an independent relationship to women's well-being.

The most powerful predictor of a woman's mental state after an abortion is her mental state before the abortion. The psychological outcome of abortion is optimized when women are able to make decisions on the basis of their own values, beliefs and circumstances, free from pressure or coercion, and to have those decisions, whether to terminate or continue a pregnancy, supported by their families, friends and society in general.

As a practicing psychiatrist, I have seen a 15-year-old girl who was pregnant as a result of being raped by a family friend, her grades falling and depression descending as she and her mother sought funds to pay for an abortion to avoid compounding the trauma of the assault. I have seen a young woman who had an abortion in her teens without support from family or friends, and who did not have the opportunity to talk about her feelings until entering psychotherapy for other reasons later in her life. There, she concluded that the decision had been painful but correct and went on to have and cherish several healthy children. I worked with a woman who had an abortion early in her life and had to come to grips, decades later, with the fact that she might never have a child, and in the process, reaffirmed that she had made the right decision when she was younger.

My professional experience reflects the scientific findings: women do best when they can decide for themselves whether to take on the responsibility of motherhood at a particular time, and when their decisions are supported. No one can make the decision better than the woman concerned. Mental illnesses can increase the risk of unwanted pregnancy, but again, abortion does not cause mental illness.

President Ronald Reagan appointed C. Everett Koop, M.D., as the Surgeon General of the United States and asked him to produce a report on the effects of abortion on women in America. Dr. Koop was known to be opposed to abortion, but he insisted upon hearing from experts on all sides of the issue. The American Psychiatric Association assigned me to present the psychiatric data to Dr. Koop. I reviewed the literature and gave my testimony. Later, I went on to publish two books and a number of articles based upon the scientific literature.

Dr. Koop, though personally opposed to abortion, testified that "the psychological effects of abortion are miniscule from a public health perspective." It is the public health perspective which with we are concerned in this hearing, and Dr. Koop's conclusion still holds true today.

Despite the challenges inherent in studying a medical procedure about which randomized clinical trials cannot be performed, and despite the powerful and varying effects of the social milieu on psychological state, the data from the most rigorous, objective studies are clear: abortions are not a significant cause of mental illness.

I am submitting for the record under separate cover some of the excellent scientific articles, published in the world's most prestigious medical journals, upon which I base my professional conclusions. These articles speak for themselves.

The fact that there is no psychiatric syndrome following abortion, and that the vast majority of women suffer no ill effects, does not mean that there are no women who are deeply distressed about having had abortions. Some are members of communities that strongly disapproved of abortion and some were unaware of or unable to access other options. It was difficult in the past for some of these women to discuss their negative feelings. Some are now actively organized to affirm and underscore those feelings and to publish and publicize their accounts. These accounts, however, are not scientific studies, which cannot rely on self-selected populations, or those specifically recruited because of negative feelings.

It's important to understand that an unwanted pregnancy is a major stressor in a woman's life. According to Burt and Hendrick, research suggests that for women "who have undergone an elective first-trimester abortion, the strongest predictor of poor postabortion psychological outcome is a prepregnancy history of depression." Other factors can include medical or genetic factors (that is, that the pregnancy is terminated because of medical or genetic risks or complications), and a feeling that the decision to abort was not freely made. Again, the literature shows that freely chosen abortion does not result in postabortion psychopathology. Notably, in an article published in 2000 in the Archives of General Psychiatry assessing the psychological consequences of first-trimester abortions, the rate of reported posttraumatic stress disorder in the subjects was lower than the rate in a general female population matched by age.

Some articles and statements aimed at the public have gone so far as to claim the existence of an "abortion trauma syndrome." We are all familiar with posttraumatic stress disorder, or PTSD, a condition tragically brought to public attention by the horrific events of September 11, 2001. "Abortion trauma syndrome" does not exist in the psychiatric literature and is not recognized as a psychiatric diagnosis.

Let me make a few specific observations about many of the primary arguments put forward by some who support the nomenclature of "post abortion depression" and "post abortion psychosis."

§ The terms confuse emotions with psychiatric illnesses. As stated earlier, the term "depression" can be used for both a passing mood and a disease. Sadness, grief and regret follow some abortions, for very understandable reasons. These are not diseases. There is no evidence that women regret deciding to have abortions more than they regret making other decisions, including having and raising children, or allowing their babies to be adopted by others. We have a 50 percent divorce rate in this country. One might conclude that many or most of those 50 percent regret having gotten married, but as a nation, we are working to promote marriage, not to make it difficult.

§ Supporters of the would-be created nomenclature do not distinguish women who terminate unwanted pregnancies from those who have to terminate wanted pregnancies because of threats to their own health or serious malformations in their fetuses. Those circumstances can cause terrible disappointment, a sense of failure, and concern over the possibility of future pregnancies, all of which are stressors independent of the abortion itself.

§ The arguments overlook an obvious reality: only pregnant women have abortions. They fail to compare the aftereffects of abortion with the aftereffects of pregnancy, labor, and childbirth. Full-term pregnancy is associated with considerably greater medical and psychiatric risk than is abortion. The incidence of psychiatric illness after abortion is the same or less than after birth. One study reports that for each 1,000 women in the population, 1.7 were admitted to a psychiatric inpatient unit for psychosis after childbirth, and 0.3 were admitted after an abortion.

§ Assertions that abortion causes mental illness do not take into account the reasons women become pregnant when not intending to have babies, and the reasons pregnant women decide to have abortions. Pre-existing depression and other mental illnesses can make it more difficult for women to obtain and use contraception, to refuse sex with exploitative or abusive partners, and to insist that sexual partners use condoms. Poverty, past and current abuse, incest, rape, lack of education, abandonment by partners, and other ongoing overwhelming responsibilities are in themselves stressors that increase the risk of mental illness and increase the risk of unintended pregnancy.

§ Likewise, they do not account for the mental health of the woman before she has an abortion. Pre-existing mental state is the single most powerful predictor of post-abortion mental state. As we all learned in school, association does not mean causation. Having a serious mental illness at a given time may make some women decide that it would not be appropriate to become mothers at that time. The scientific literature indicates that the best mental health outcomes prevail when women can make their own decisions and receive support from loved ones and society whether they decide to continue or terminate a pregnancy.

§ Some articles I have seen assume that all women who have abortions require mental health intervention. There is no evidence that women seeking abortions need counseling or psychological help any more than people facing other medical procedures. Standard medical practice demands that patients be informed of the nature of a proposed medical procedure, including its risks, benefits and alternatives, and that they be allowed to make their own decisions. Of course this applies to abortion as well. Because the circumstances and decision can be stressful, most facilities where abortions are performed make formal counseling a routine part of patient care.

§ Over 30 percent of women in the United States have abortions at some time in their lives, and very few of these seek or need psychiatric help related to the procedure - either before or after. Our role, as mental health professionals, when patients do seek our consultation under those circumstances, is to help each patient review her own experiences, situation, plan, values, and beliefs, and make her own decision.

§ There is little attempt made to address the impact of barriers to abortion, social pressure, and misinformation on the mental health of women who have abortions. Imagine being in a social milieu where your pregnancy is stigmatized and abortion is frowned upon, having to make excuses for your absence from home, work, or school, travel a great distance to have the procedure, endure a waiting period, perhaps without funds for food or shelter. Imagine having to face and go through a crowd of demonstrators in order to enter a medical facility. Finally, imagine being told that the medical procedure you are about to undergo is very likely to cause mental and physical health problems -although this is not true. Any stress or trauma caused by these external factors should not be confused with reactions to the abortion itself.

§ With respect to parental consent issues, one important study involved adolescents who had negative pregnancy tests with those who were pregnant and carried to term and those who were pregnant and had terminated the pregnancy. All three groups had higher levels of anxiety than they showed one or two years later. But, the interesting result was that two years later, the adolescents who had abortions had better life outcomes - including school, income, and mental health - and had a significantly more positive psychological profile, meaning lower anxiety, higher self-esteem and a greater sense of internal control than those who delivered and those were not pregnant. As all of us support planned pregnancies and parenthood and healthy families, we need to better understand and respond to issues such as postpartum and maternal-/parenting-related depression so that women who continue their pregnancies are not at greater risk.

§ With respect to health issues, there is much misinformation about medical sequelae of abortion. Breast cancer is a good example. But here's what the National Cancer Institute wrote in its May 2003 report, "Abortion, Miscarriage, and Breast Cancer Risk": "The relationship between induced and spontaneous abortion and breast cancer risk has been the subject of extensive research beginning in the late 1950s. Until the mid-1990s, the evidence was inconsistent. Since then, better-designed studies have been conducted. These newer studies examined large numbers of women, collected data before breast cancer was found, and gathered medical history information from medical records rather than simply from self-reports, thereby generating more reliable findings. The new studies consistently showed no association between induced and spontaneous abortions and breast cancer risk."

The most highly regarded and methodologically sound study on the purported link between abortion and breast cancer - Melbye's "Induced Abortion and the Risk of Breast Cancer," which appeared in the New England Journal of Medicine in 1997 - indicates that there is no relationship between induced abortion and breast cancer. In contrast with most of the studies in this area, this study contains a large study sample (1.5 million women) and relies on actual medical records rather than women's recollection, which can be influenced by fear and the attitudes of their communities.

In February 2003, the National Cancer Institute, a part of the U.S. Department of Health and Human Services, brought together more than 100 of the world's leading experts on pregnancy and breast cancer risk. Workshop participants reviewed existing population-based, clinical, and animal studies on the relationship between pregnancy and breast cancer risk, which included studies of induced and spontaneous abortions. This workshop "concluded that having an abortion does not increase a woman's subsequent risk of developing breast cancer." The World Health Organization, which conducted its own review of the subject, came to the same conclusion.

In plain language, there is no medical basis for the claim that abortion increases the risk of breast cancer. This position, shared by the National Cancer Institute and the American Cancer Society, is based on a thorough review of the relevant body of research. Among studies that show abortion to be associated with a higher incidence of breast cancer, most are unreliable due to recall bias and other methodological flaws. By contrast, studies that were designed to avoid such biases show no relationship. It is irresponsible for politicians to develop public policy that is based upon false medical allegations.

Conclusion:

Mr. Chairman, as a woman, as a physician, and particularly as a psychiatrist, I have great sympathy and compassion for all of my patients, women and men, adults and adolescents, who struggle with mental illnesses. In order to ensure state of the art treatment, we need to ensure that the scientific process that is the foundation of our reference for diagnostic criteria - the DSM - is maintained at the highest levels. Above all else, what the women I treat need is access to mental health care.

Today, patients in our great country who seek treatment for mental illnesses all too often find that they lack access to adequate mental health services as a direct result of the discrimination in insurance coverage for mental disorders. If this Congress wants to take one single action that would make a world of difference for all women - for all persons - seeking treatment for mental disorders, I respectfully suggest that the right action would be to enact a federal law requiring non-discriminatory coverage of treatment of mental illnesses as part of all insurance. It is time to end the artificial mind/ body split in insurance coverage. Well over half the House of Representatives and more than two-thirds of the Senate have cosponsored legislation to achieve this result. On behalf of my patients, I respectfully urge you to address the unmet mental health needs of the nation's women, and men, children and adolescents, by enacting non-discriminatory coverage of treatment of mental illnesses.

Thank you again for the opportunity to speak with you today. I would be happy to answer any questions you or other members of the Subcommittee may have.