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DISTURBANCES ASSOCIATED
WITH 345 PREGNANCIES
IN 137 WOMEN
By
A. RYLE, D.M., D.Obst.R.C.O.G.
The Caversham
Tm@ late Dr. Vera Norris
Centre, London,
N. W.5
mental
hospital
admissions,
found that a London woman, at birth, has 0 . 8 chances in 1,000 ofbeing admitted
at some time in her life with a puerperal psychosis. This figure, based upon
hospital admissions, must be compared with Kline's (4) estimate that 5 per
cent.
of pregnant
women
have an associated
emotional
disturbance.
Clearly,
whether
admission
and
takes
place.
Estimates
of the incidence
the criteria
adopted
for attributing
illness
to the effects
of childbearing.
Opinion is divided concerning the nature of mental breakdowns
with childbearing,
occurring
in association
occurring
at other
of
of recent authors
with childbearing
times (Fondeur,
consider
associated
are indistinguishable
from those
(3)). Seager
(8)
has recently reviewed the literature and given an account of a series of puerperal
women admitted to a mental hospital who were compared with non-puerperal
admissions
and with
psychiatrically
normal
puerperal
women.
He concluded
that there was no evidence for a specific puerperal mental disorder, but that the
puerperium
acted
as a stress,
precipitating
breakdown
in the
predisposed
woman.
for a physiological
and in a physiological
effect is strongest
for those
disorders
change,
delivery.
The present paper reports a study carried out in general practice upon a
series of women
delivered
in recent
years.
was both
to
have
access
over
prolonged
periods
to
unselected
populations
in
the
way
that G.P.s have; in my own case the normal G.P.'s knowledge of his patients'
backgrounds and temperaments has been supplemented by a previous study
which has established the rates of psychiatric disturbances in the practice
population
possible
to compare
280
PSYCHOLOGICAL
DISTURBANCES
IN PREGNANCY
[March
METHOD
.4
The investigation has been carried out in general practice and is based
upon
an analysis
of the
records
of all women
who
have
been
confined
at least
once between January, 1955 and October, 1959 and who are still registered
with my practice. These patients have, of course, been under observation
throughout
Records were
traced by two methods : in the first place, the names of 80 women whom I had
personally cared for during pregnancy and labour were obtained from my
obstetric
7 patients registered
(1) Age at last confinement. (2) Parity at the time of the study. (3) History of
psychological disturbance starting (a) in pregnancy, (b) in first three post
partum
time.
months,
(4) Where
disorder
had
months,
occurred,
a record
was
made
if
it had at any time necessitated three or more consultations in the course of one
year, as this criterion had been used as a level of minimum severity for inclusion
in the practice prevalence survey. (5) The diagnosis was recorded. Three diag
nostic groups were employed, namely : (a) reactive disorders, (b) depression
with
downs.
endogenous
The
criteria
features,
for
(c) uncertain.
distinguishing
There
neurotic
were no schizophrenic
from
endogenous
break
depression
are still a subject for debate and this distinction presents particular difficulty
in mild cases.
In the present study where an attempt was being made to assess the relative
importanceof psychological
and physiological
features
two commonly used
criteriafor the diagnosisof endogenous depression,namely the association
or childbirth
as a socio-economic
burden;
(c) pregnancy
or child
is situated
in an
1961]
BY A. RYLE
281
Records
of
137
women
delivered
of
at
least
one
full-term
pregnancy
during the period of the investigation were traced ; by January, 1960 these
women had had, in all, 313 full-term pregnancies and 32 miscarriages. This
latter figure may be incomplete. Seventy-eight of this group of women had no
record of any psychiatric disturbance, 33 had a record of disturbance in preg
nancy or during the post-partum year and 26 had a record of disturbance at
other times. The parity and age distribution of these three groups are recorded
in Tables I and II. The marital history of the whole group, in so far as it is
TABLE I
I
17
2
39
3
16
4
6
5+
0
3
(5 each)
11
33
59
28
13
Wholegroup ..
..
.. 137
Average
Parity
21
Mis
car
riages
16
2 5
1 (10) 24
11
23
32
TABLE IL
Age
at Last
Confinement
of
137
Women
Classified
According
to Psychiatric
History
AgeatLastConfinement
Under
No psychiatric history
..
Number
..
78
20
3
or post-partum year
..
..
Psychiatric disturbance not in preg
nancy or post-partum year
..
Whole group
..
..
..
Three
others
40
33
11
14
26
137
3
8
7
35
7
38
8
54
eventful.
are separated
3 have stable
but non-legal
unionsand 1 isunmarried,living
with her family.Fourteenof theremainder
have consulted
two
of
the
33
who
had
some
relating
psychological
to marital
disturbance
stress. Twenty
during
preg@
nancy and the post-partum year were classified as reactive disorders and in
the majority of this group (17 cases) the illness represented a reaction to a
situation or relationship connected with the pregnancy. In 6 of these cases the
problems were socio-economic; in the remainder they were emotional and in
nearly every case associated with a disturbed marriage relationship.
Seven
patientspresentedwith depressionwith endogenous features.
In 4 patients
there was inadequate information for classification.
In order to demonstrate the effect of childbearing upon mental health the
rate of disturbance associated with it must be compared to the rate amongst
282
@
[March
women in the same population who have not borne children. For this purpose
the one-year prevalence rates for women aged 2039for the practice population
as a whole can be used, although naturally these rates include women who have
borne
children.
These
rates
have
been
calculated
for two
separate
periods
(July, 1957 to July, 1958 and JanuaryDecember, 1960) (Ryle (7)). The rates
for these two periods were very similar ; those for the latter period are as
follows : annual female prevalence rate (aged 2039)for reactive disorders,
95 per I ,000 ; endogenous
the calculation
3
or
more
depression,
of these rates cases were only included where there had been
consultations
in
the
course
of
one
year.
By
adopting
this
same
criterion for the women in this present study, a rate of illness can be calculated
(as episodes
per patient-year)
either
conception
or for the
post-partum year. The total number of episodes of illness meeting this criterion
occurring in the pregnancy or the post-partum year is 27, of which 23 were
associated with the 313 full-term pregnancies and 4 were associated with the
32
miscarriages.
diagnosis,
@
@
The
is presented
time
of
presentation
of
these
disorders,
classified
by
of illness occurred
TABLE III
Episodes of Psychiatric Disorders Related to 313 Full-term Pregnancies and 32
Miscarriages, Classified According to Time of Presentation and Diagnosis, Excluding
Cases in Whom there were Fewer than 3 Consultations
Reactive
Time of Presentation
During pregnancy
..
..
03months after delivery
..
312months after delivery . .
Disorders
..
7
..
3
..
3
miscarriage . .
After miscarriage
..
..
..
..
Total
Endogenous
Depression
0
6
2
Uncertain
1
1
0
Total
8
10
5
3
0
0
1
0
0
3
1
16
27
the present paper). Further support for the view that childbirth precipitates
endogenous depression
isobtainedfrom a studyof the time of development
of symptoms.
The post-partum
three months
represents
period associated
with pregnancy
studied in the present
one-seventh
investigation.
of the
Three
out of 13 episodes of reactive disorder first presented during this period but,
of the 8 episodes of endogenous depression, no fewer than 6 occurred within
three
months
of delivery.
CASE HISTORIES
are given
to illustrate
of patients
who consulted
the principles
upon
which
has
1961]
@
BY A. RYLE
been based.
All patients
considered
283
to show evidence
of endogenous
depression
are reported. No examples are given from the group in which the pregnancy
appeared irrelevant to the disturbance.
(a) Reactive Disorder:
Pregnancy
as a Socio-economic
Froblem
Case 6
By the age of25 this patient had five children. They lived in a dark, damp basement. She had
@-
occasional
mild
depressive
spells
and
when
her
youngest
child
was
she
had
more
pro
nounced depression with sleep disturbance and some episodes of depersonalization. At this
stage she became pregnant after a contraceptive failure ; she became increasingly depressed
and made a not very determined suicidal attempt by gas. Termination of the pregnancy and
sterilization was carried out on psychiatric advice. This patient was diagnosed as a neurotic
depression in an hysterical personality. Her symptoms did not return after operation.
Case 9
A girl of 18 whose husband was called up ten weeks after her delivery, leaving her alone in
her mother-in-law's house, became depressed. A few weeks later she was discovered to be
pregnant again, became very depressed and lost much weight. She recovered when her husband
obtained a home posting.
painful
attempts
at induction
and
a long
labour.
to a man
of rigid
religious views who provided very little emotional support. She became unintentionally
pregnant two years after her first delivery and reacted to the pregnancy with much depression
and rejection, both because ofher husband's attitudes and because ofher fear ofa repetition of
the complications of her first pregnancy. She threatened suicide, but a psychiatrist who was
consulted did not feel that there was a real danger of this. She was treated with reassurance and
support
and
an undertaking
on my part
to carry
out
the confinement
which
was,
in fact,
un
eventful. She has continued to have phases of mild anxiety and depression since from time to
time. This case was regarded as a neurotic depression, precipitated by pregnancy, occurring
in the context ofan unsatisfactory marriage.
Case 19
This patient, after a long series of miscarriages, conceived at the age of 34 for the ninth
time and on this occasion the pregnancy was successful. Ten weeks after her confinement, the
husband announced his intention of leaving her for a woman with whom he had been un
faithful; the patient thereupon took an overdose of barbiturates and was admitted to hospital
in coma. She was successfully resuscitated. The marital situation remained unsatisfactory for a
further two years, but there were no further suicidal attempts. This patient was regarded as
having a severe neurotic depression occurring as the result of her husband's threatened defec
tion soon after the successful conclusion of a long awaited pregnancy.
Case 20
p
This
patient
was
married
at
the
age
of
17
and
had
three
children
in
the
course
of
the
next
four years. The third pregnancy was unintentional and was strongly rejected initially. During
the year following the third confinement she complained of depression, fatigue, feelings of
unreality and depersonalization. She tended to ruminate over dreadful things and became frigid.
Her personality was obsessional and she had some compulsive rituals. She then conceived for
thefourth
timeandbecameseverely
depressed;
forthefirst
timesheexpressed
hostility
towards
her husband; she felt she had married too young and that she was tied down to the house while
her husband gambled and was seldom in. She was referred for psychiatric opinion and termina
tion was advised and carried out. She developed a post-operative pyrexia and was nursed in
isolation and developed a brief agitated depression at this stage, but has remained reasonably
well during the six months since. This case was diagnosed as a neurotic depression exacer
bated by an unwanted pregnancy in a woman of predisposed personality whose marriage
was unsatisfactory.
284
@
PSYCHOLOGICAL
DISTURBANCES
IN PREGNANCY
[March
husband and children is good. A month after the birth ofher second child, when she was 27, she
developed an acute fear that she had Hodgkin's disease, and over the following six months
she had a series of similar acute panics. She felt humiliated by her fears, was generally low
spirited, could not concentrate and felt heavy
in the morning, although she usually slept well.
Her mother had been staying in the house since the birth of the child and the patient felt
(but did not express) a good deal of resentment at the mother's tendency to take over the
running of the household and children. The condition improved gradually after the mother's
departure, but it was more than a year before she felt really well. Three years later she had a
third child, delivery being complicated by a profuse P.P.H. There was no depression after this
birth but a year later a further pregnancy ended in a miscarriage with very heavy loss neces
sitating transfusion, and shortly after this she became depressed again and expressed the fear
that she was developing the same type of illness as she had had after her second confinement
She became frigid and could not sleep for more than three or four hours. Her mother had run
the house on her return from hospital and reiterated how she had previously advised against
further pregnancies. The depression graduallylifted over the ensuing months.
Case 25
At the age of 18 this patient developed insomnia, a fear of madness and anxiety, following
the V.2 rocket attacks on London. She saw a psychiatrist, who thought she had a schizoid
personality. She recovered after a few months' psychotherapy. Her father had had similar
illnesses after the 1914-18 war and in 1941. She had a first child at the age of 26 and was rather
depressed after the confinement but did not see a doctor for this. She was delivered of her
second child when she was 31. Four days after delivery she became tearful and she became
increasingly
depressed
returned
to her parents'
in ensuing
weeks.
She had
house for her confinement.
recently
moved
to the suburbs
but had
On returning
to her own home her depres
sion became worse; she could not go out for any distance alone, especially not past the local
mental
hospital.
Rather
than
where her depression
improved
go to the psychiatrist
there she returned
to her parents'
home
after nocturnal
sedation
and methyl amphetamine
by day and
some supportive psychotherapy. She complained for some time of disturbed sleep (early
waking) and she said she had not got any real feeling for the baby. Her depression improved
steadily, but she developed panic attacks while out shopping and, after some trial returns to her
new house, abandoned the idea ofliving there and moved back into the parental home. In the
two years since she has had minor anxiety symptoms only; she works as a catering manageress
part-time and enjoys her children.
Case 26
This patient conceived before marriage at the age of 19. Ten months after delivery she
complained of headaches, premenstrual depression and lack of energy ; she wept easily. Three
years later
depression
she presented
in her sexual
with headaches,
feelings.
Case27
This patient had some psychotherapy at the age of 16, at which time she was under stress
as a result of her parents'
objection
to her association
man. Eventually
her parents accepted the association and the couple have lived since in the parents' home. At the
age of 24 she became pregnant ; the pregnancy was welcomed but she became rather anxious
and, as a result of a fear of hospitals, booked for a home confinement. In fact she had to go
into hospital for induction, but labour was otherwise uneventful. Two weeks later she became
irritable, tearful, forgetful and fatiguable; she began to have difficulty in getting off to sleep
and woke early and was noticeably more depressed in the mornings. She did not feel as warmly
towards the child as she had expected to. In the ensuing weeks she was treated with methyl
amphetamine by day with nocturnal sedation and supportive psychotherapy. Sheremained very
irritable, especiallytowards her mother who tended to try to take over the baby's management.
She was frigid for six months after her confinement.
Case 28
This patient first became pregnant at the age of 19. She had an ante-natal admission for
A.P.H., a premature labour and a P.P.H. Four weeks after her confinement she became very
depressed and was referred to a psychiatrist, who gave intensive supportive therapy and seda
tion. She was much improved after four weeks. Her second pregnancy resulted in the birth
of twins, one of whom died soon after birth and the other of whom died some months later
without having ever left the hospital. She became severelydepressed soon after her deliveryand
while under out-patient treatment she attempted suicide and was admitted to a mental hospital.
Her condition at that time was described as retarded
and bewildered. She expressed a
delusional idea about being incredibly filthy and deserving to be in prison. She recovered after
E.C.T. Sterilization was recommended but not carried out, and this was perhaps fortunate, for
4
shehashad two further
pregnancies,
including
thesuccessful
delivery
of twins,
without
further breakdown.
1961]
@-
BY A. RYLE
285
Case29
This patient committed suicide in 1956 and records are not available. She was aged about
30, married, against family opposition, to an Indian clerical worker. She had had a stillbirth one
year before the delivery of her child. She had no untoward psychological reaction to this, but
soon after delivery of her child she became depressed and self-accusatory and was admitted
to hospital and treated by E.C.T. Soon after her discharge from hospital, about six months after
delivery,
shejumped
under
a train
DIScuSsION
in pregnancy
or the post-partum
year is lower
than
the equivalent
overall rate for women of similar age in the practice population. This lower rate
conceals a markedly higher rate for depression with endogenous features. The
patients with endogenous
depressions,
within three months of delivery.
factor
in the provocation
population.
This could
presented
symptoms
of the neurotic
symptoms.
None
be explained
to the
as an effect of selection,
women
who bear children being, as a group, more stable and satisfied than their sisters.
Evidence
for a specific
depression
frequency
@
significant
effect
with endogenous
of childbearing
is apparent,
however,
in that
disturbance
is
also
It is noteworthy
present
deliveries,
in
most
cases.
turbances
are included for study, childbirth
has apparently
precipitated
genous depression
in about 3 per cent. of confinements.
4 .4 per cent.
dis
endo
of the
women having been affected at some time. Roth (6) estimates that 10 per cent
of the population are liable to endogenous depression, and this figure of 4.4
per cent. in a population nearly all below the age of 40 is in reasonable
accordance
with this estimate. It would seem that the role of childbirth
must
be provocative
rather than causative,
for hospital admission
rates for endo
genous depression
rise steadily with age (Brooke (I)) and my own practice
prevalence
figures, though based on few largely mild cases, show a similar
tendency.
If childbearing
caused the disease to occur in those who would not
otherwise
be afflicted one would expect a peak incidence in the childbearing
era. The fact that recurrence with each delivery is not automatic and the presence
of the depressive
illness.
suicide,
diagnosis
occurring
to
the
after
normal
childbirth
fatigues
is often
of
efficiency
caring
unrecognized,
for
of treatment,
small
make
symptoms
children.
The
it desirable
being
risk
of
that
the
286
in pregnancy or the post-partum year. The rate for reactive disorders in the
year after delivery was 19 per 1,000, about one-fifth the one-year prevalence
rate for women of similar age in the practice population as a whole. The rate
for depression with endogenous features during this year was 26 per 1,000,
about five times the equivalent annual prevalence rate and nearly all the attacks
occurred within three months of delivery. There is some evidence that delivery
precipitates endogenous depression.
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