A review of psychiatric aspects for termination of pregnancy.

Referring to articles published by specialists in the field, the discussion focuses on the controversial and poorly reported subject of the psychiatric aspects of abortion. The views on this topic vary from country to country. The psychiatric morbidity occurring in pregnancy is examined as well as indications for abortion. A workable frame of reference indicating psychiatric illness, where abortion could be instituted, is presented. In Denmark and Sweden special laws, liberalizing abortion on psychiatric grounds, have been introduced. These include psychotic states, reactive depressions with psychotic states, reactive depressions with suicidal risks, psychasthenic conditions, as well as eugenic and social reasons. As puerperal psychoses have a good prognosis, Sim has stated that there are no psychiatric grounds for abortion. In Japan psychiatric indications for abortion need not be supported by medical evidence, but in Italy and Spain such indications however urgent are not permitted. In Britain the abortion act passed in 1967 liberalized the law in relation to psychiatric grounds for abortion. In a patient who has had a number of pregnancies each of which had precipitated exacerbations of schizophrenic illness, abortion could be recommended. Manic depressive illness has a good outcome with antidepressant medication, electroconvulsive therapy, lithium prophylaxis, and supportive therapy and would not by itself constitute grounds for abortion. Suicide is a very real threat in this group of diseases especially in the presence of agitation. Another problem would be a mother who has shown an aggressive psychopathic personality deviation. Patients who have had a psychotic or other obvious psychiatric illness constitute only a proportion of cases where a decision about therapeutic abortion may have to be considered. Often a psychiatrist would be called upon to express an opinion regarding therapeutic abortion in an unwed, neurotic, anxiety ridden mother, threatening suicide. The psychiatrist would then have to assess the seriousness of the suicidal threat. Suicidal acts are not rare in pregnancy. It is useful to obtain confirmation of serious suicidal inclinations from a close relative when assessing the mental states of patients. Ekblad following up 479 cases of abortion found that 11% expressed serious self reproach and 24% showed a mild form of guilt reaction, but these reactions are easily amenable to psychotherapy. If there is a grave risk to the mental health of the mother, if serious physical harm or death should ensue in an attempted suicide, or if there is a substantial risk that the child would develop a serious mental or physical handicap, then therapeutic abortion is justified. Another important legal consideration is the question of consent. In giving an opinion for abortion on psychiatric grounds obtaining a 2nd opinion of another psychiatrist is prudent. The laws in Sri Lanka do not recognize dangers to the mother's mental health or fetal deformities as indications for therapeutic abortion.