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Psychological reactions to amniocentesis: A controlled study
Psychological reactions to amniocentesis: A controlled study GIOVANNI
A.
FAVA,
ROBERT
KELLNER,
LAURA
MICHELACCI,
GIANCARLO
M.D. M.D., M.D.
TROMBINI,
M.D.
DOROTHY
PATHAK,
PH.D.
CAMILLO
ORLANDI,
M.D.
LUCIANO
BOVICELLI,
BoloLpa,
Italic,
Albuquerque,
PH.D.
M.D. New
Mexico,
and Buffalo,
New
York
Fifty women who underwent amniocentesis and a matched control group of pregnant women were administered the Symptom Questionnaire to evaluate changes in distress. Anxiety, depression, and somatic symptoms had significantly decreased after the results of amniocentesis were communicated to the patient, but the decrease was similar in the normal control women. Hostility was higher in the amniocentesis group and decreased to normal levels after amniocentesis was performed, even before the results were communicated to the patient. (AM. J. OBSTET. GYNECOL. 143509,
1982.)
HAS BEEN a growing interest in the psychological aspects of amniocentesis.’ Since the procedure has become more common, there appears to be a need to understand its psychological impact. Several studies have been published. Finley and associates* studied 157 patients from a sample of 3 15 referred to a laboratory for prenatal genetic studies; those who were studied returned a mailed questionnaire. The majority of the women found the experience to be reassuring, would recommend it to others, and would seek it again themselves with a subsequent pregnancy. Chervin and associates3 also mailed a questionnaire to 67 patients who underwent amniocentesis and obtained 31 answers. The majority of patients expressed enthusiastic approval and appreciation for prenatal diagnosis. Most women (61%) reported only moderate anxiety about an abnormal baby before amniocentesis; 23% reported a high anxiety about the procedure itself, and 42% re-
THERE
From the II Chair of Obstetrics and Gynecology and the Chair of Psychosomatic Medicine, Unzuersity of Bologna School of Medicine; the Departments of Psychiatv and Family, Community and Emergency Medicine, Uniuersily of New Mexico School of Medicine; and the Department of Psychiatry, State UniuersiQ of New York at Buffnlo. Received for publication Accepted February
September
23, 1981.
I, 1982.
Reprint requests: G. Trombini, M.D., Istituto di Pricologia, Viale Berti Pichat 5, Bologna, Italy. 0002-9378/82/130509+05$00.50/0
0 1982 The C. V. Mosby
Co.
ported moderate anxiety. Astbury and Walters,’ using the State-Trait Anxiety Inventory,J studied 28 patients who had been referred for amniocentesis. Patients who were tested on two occasions showed a significant decrease in anxiety after the results of the procedure had been communicated to them. The authors concluded that amniocentesis makes a significant contribution to the psychological well-being of those pregnant women who are at greater risk of having an abnormal baby. Beeson and Golbus’ also studied anxiety related to amniocentesis by means of the State-Trait Anxiety Inventory, which was administered on several occasions to 36 couples. Women who had previously given birth to a child with a chromosomal disorder displayed higher levels of anxiety before amniocentesis than did women whose indication for the procedure was age. Dixson and associates7 interviewed and administered a questionnaire to 53 women who had elected to undergo genetic amniocentesis and 22 women who had declined this procedure. Most women who had amniocentesis felt reassured for the remainder of pregnancy. Those who refused the procedure had a significantly higher occurrence of concerns in regard to possible fetal injury or miscarriage. Bundey” explored the attitudes of 40-year-old college graduates toward amniocentesis. Seventeen percent of the women who responded to a questionnaire replied that they would refuse amniocentesis if it was 509
510
July I. 1982 Am. J. Obstet. C;vwol.
Fava et al.
Anxietj~ Depression Somatic symptoms Hostilitb Relaxeri Contentetl Somatic wzll-being
:i.70 3.52 3.92 2.9x 3.3fi 3.32 3.90
t 33X) t3.81)
4.40 ( 2 4.22) 2.62 (3.16) 3.14 ( i 3.41))
t :I.:
1 .io
t I .93) + 1.X5) rt_1:13)
3.82 (-c I Al) 3.45 ( 2 I .76) :i..x ( ” 1XJ)
_f 4.9)
Time 1: The patient is toltf that amniowntesis is t-ecc)n~mentled.l’ilne is told the results of‘ the amniocentesis. NS= Not significant. *By pairecl t lest. tp < O.l)r,. $1’ < 0.00 I. 3p < O.(II.
offered because of the increased risk of mongolism at a late maternal age. The main reason given for refusal was dislike of abortion on religious or moral grounds. SilLestre and Fresco!’ explored, via interviews, the reactions 10 amniocentesis of 62 women and 25 of their husbands, and observed that during the first 1 months (before amniocentesis was carried out) the mothers were concerned about the pregnancy and possibility of abortion. The women began to look forward to the child only after the results of the amniocentesis were known, and sevrral waited for the results before announcing that thev were pregnant. These studies explored some of the attitudes and psychological changes before and after amniocentesis. ‘The results of’ several of’ the studies are difficult to evaluate; some were of a retrospective nature and liable to distortion of recall.‘. “. ’ and others dealt with samples which were. in part, self-selected (e.g., those women who chose to reply to a mailed questionnaire) and. therefore. mav have been biased. In one study, unstructured inter\icws were used and these were more liable to observer bias. In none of the studies were control groups of normal pregnant women used, so that it is difficult to assess whether the findings shotlId be attributed to the amniocentesis or reflect difftwnt stages of the pregnancy. Moreover, these studies dealt with anxiety only and nol with other important psychological symptoms, such as depression. The aims of the present study were to evaluate some of the psychological effects of amniocentesis and to replicate and to extend some of the previous findings. Methods Subjects.
women
A consecutive unselected series of 50 who underwent amniocentesis was matched fbr
(2
‘1.23)
t ss P
ss NS NS
2.46 1.34 2.34 1.42 4.68 5.02 4.48
2: Immetiiately after amniocentesis. Time 3: hfterthe patient
the week of their pregnancy with a control group of 50 healthy pregnant women. The control group included women who attended the outpatient clinic of the same department of obstetrics and gynecology and were seen by the obstetrician who counseled the other group about amniocentesis. All patients were married. The mean age of the patients who underwent amniocentesis was 32.96 years (k6.61); that of the control group was 28.28 (24.15) years. No significant differences existed between the two groups as to the number of previous pregnancies and abortions, and no significant differences in social class distribution on the basis of Goidthorpe and Hope’s” occupational classification. Amniocentesis was performed for one of the following reasons: maternal age of 35 years or older: history of a previous child with a chromosomal aberration; parent a known carrier of a translocation chromosome: history of a previous child with a detectable biochemical disorder; mother a known carrier of a detrimental X-linked gene; and family history of an open neural tube defect. All patients had been referred by physicians to the Laboratory ot Prenatal Pathophysiology, University of Bologna School of Medicine, where all the procedures were done. ,411 patients who had amniocentesis received counseling by an obstetrician about the nature of the investigation, the associated risks, and the implications if‘ an abnormal result was obtained: and all patients underwent A-scan and real-time ultrasonography,just before and immediately after amniocentesis. A second obstetrician performed amniocentesis without moving the mother from the ultrasound scanning table. .4 real-time scan was provided after the amniocentesis in order to reassure the mothers of a normal fetal heartbeat. The results concerning the fetal karyotype and amniotic fluid were known within 2 to 3
Volume Number
143 5
p Value* for changes from tzme 2 to timr’ 3
Psychological
p Value* for changes from time 1 to tinw 3
reactions
to amniocentesis
511
In the control group, the SQ was administered for the first time in the period between the eighth and twelfth weeks of pregnancy and between the twentieth and twenty-second weeks of pregnancy (periods one and three of the amniocentesis group). In both groups, informed consent was obtained verbally, as is customary in Italy. Statistical methods. The t test and analysis of covariance were used, with age, social class, previous pregnancies, and previous abortions as covariants, to evaluate differences between groups and changes with time.
Results weeks. In our sample, no abnormal results were found. The outcome of the amniocentesis was communicated by the obstetrician who had counseled the patient at the first interview. Husbands were generally present throughout the procedure (initial interview, amniocentesis, and communication of outcome). In all cases, the patient’s husband was present at least at some of the encounters. Psychological assessment. Psychological distress was assessed with the Symptom Questionnaire (SQ).” The SQ is a 92 item, self-rating scale of psychological distress, and consists of items which indicate symptoms and items which indicate well-being. The items are divided into symptom scales (anxiety, depression, somatic symptoms, and hostility based on factor analyses) and corresponding well-being scales (relaxed, contented, somatic well-being, and friendly). The subjects score one point for each symptom that they check “yes.” The questionnaire was designed to measure changes in distress in experiments in therapeutics, such as drug trials, and to compare levels of distress in various populations. The validation studies performed with this test,“. “’ and its precursor, the Symptom Rating Test,13 both in the United States and in Italy, suggested that it is a valid and reliable measure of distress. The questionnaire was administered in its validated Italian version.” Collection of data. The SQ was administered three times by the same obstetrician to the group of patients who underwent amniocentesis. 1. Eighth to tdfih werk (4 pregnancy In this phase, the women were interviewed by the obstetrician, who obtained a complete history and explained the procedure. The SQ was administered at the end of the interview. 2. Sixtprnth to rightpenth week. Amniocentesis was performed at this stage. The SQ was administered for the second time immediately after amniocentesis. .?. Tumtirth to tuvntpsucond werk. At this time, the outcome of the amniocentesis was communicated. Immediately afterward. the SQ was administered for the third time.
Differences between groups. The first comparison involved the SQ scores in the two groups before amniocentesis was performed (Time 1 in Table I) and at the first measurement of the control group (Time 1 of Table II). There were significant differences between the two groups in only the SQ subscales of hostility (p < 0.05) and somatic well-being (p < 0.001). even when differences were adjusted for age, social class, previous pregnancies, and previous abortions. Patients who had been offered amniocentesis were more hostile and reported less somatic well-being than the control group. After amniocentesis had been performed and the results were known (Time 3 in Table I), and at the same period of pregnancy in the control group (Time 2 in Table II), there were no significant differences between the groups, even when adjusted for the abovementioned covariants. Changes in psychological distress with time. Between the first measurement (before amniocentesis) and the second (after amniocentesis), there was a significant decrease in anxiety, depression, and hostility. Between the second and the third measurements (after communication of the outcome), there was a further significant decrease in anxiety and depression. and an increase in relaxation, contentment, and somatic wellbeing. Between the first and the third measurements, there was a significant improvement in all the SQ subscales, except the score for somatic well-being, which fluctuated (Table I). In the control group, there was a significant improvement in all the SQ subscales, also, except for hostility and its corresponding well-being scale, “friendly” (Table II).
Comment Contrary to expectations, changes in anxiety and depression (and the corresponding well-being scales) which occurred after amniocentesis did not differ significantly from changes in the control group from the first to the second trimester of pregnancy. Lubin and
512
Fava et al
Table
II. l’sychological
distress in normal
pregnant
women
Contented Somatic well-being
4.96 2.80 3.20 1.62 3.60 3.64
( k 2.92) (C2.81) (2 3.29) ( ? 2.63) ( k 1.fi3) (+ 1.50)
4.34
( k I .46)
Friendly
5.10 (t 1.11)
Anxiety Depression Somatic symptoms
Hostilit! Relaxed
2.08
(2
L
I .W)
t
I .6ti f C 1.X6) I .x4 ( 5 2.08) I.24 (“1.X) 4.38 ( t 1.OS) 5.16 (2 1.0”) 4.96 ( -t 1.4 I) 5.34 ( i- O.fi2)
i-
NS t
; t+ NS
*By paired t test. tp < 0.00 I. $p < 0.05. Pp < 0.01. associates,” in a study of 9?i pregnant women, found that anxiety showed significant variations over trimesters: it decreased in the second trimester and rose again to the initial level in the third trimester. The claim that amniocentesis decreases anxiety and improves the psychological well-being of the mothers’ is probably true for a few women (many women report the experience to have been reassuring), ‘. 3. 7 but this apparently dots not apply to a marked degree to the majority. The previously reported relief of anxiety after amniocentesis also occurs to a large extent in other pregnant women. It could be argued that women who undergo amniocentesis experience the same psychological changes as those of women with normal pregnancies. This is also probably true only for a few, because there were no substantial differences in the initial level of’ anxiety and depression between the women who were offered amniocentesis and the women with normal pregnancies. There was less somatic well-being immediateI) after amniocentesis; and this improved later. In previous studies of the psychological responses to amniocentesis, changes in hostility were not examined,‘~~. ((. 7. !) Silvestre and Fresco!’ noted that the physician was seen by many women as holding the power to either permit their child to be brought into the world,
REFERENCES
1. Boub, J.: Psychological aspects of‘ prenatal diagnosis, in Murken, J. P.. Stengel-Rutkowsky, S., and Schwinger, E.. editor: Prenatal Diagnosis, Stuttgart, 1979, Federike Enke. 2. Finley. S. C., Varner. P. D.. Vinson, P. C., and Finley, W. H.: Participants’ reaction to amniocentesis and prenatal genetic studies, JAMA 238:2377, 1977. 3. Chervin, A., Farnsworth, P. B., Freedman, D. W. I,.. Duncan, P. A., and Shapiro, L. R.: Amniocentesis for prenatal diagnosis, N. Y. State J. Med. 77:1406, 1977 4. Astbury, J.. and Walters, W. A. W.: Amniocentesis in the
or prevent such arrival. The scales used in the present studies do not indicate the target of hostility (which could be the physician or, perhaps, the husband). The decrease in hostility occurred after the procedure had been performed but before the patient was told the favorable outcome; this would suggest that the hostility was induced by the offer of the procedure rather than by the threat of having the pregnancy terminated. Possibly of course, the findings in this study are, in part, bound to the culture and will be different in other countries. On the basis of this reservation, the present study has yielded new information because of the methodology used. The amniocentesis sample was composed of a consecutive and unselected series of women who underwent the procedure at the same stage of pregnancy. The results were compared with those for a matched control group. Assessment of psychological distress was made with a \-alid scale, which was designed for this purpose and is free from observer bias. Patients in both groups were seen by the same obstetrician under relatively uniform conditions. In the groups which underwent amniocentesis, the timing of psychological tests allowed a differentiation between the effects of being told that amniocentesis was being offered and the effects of learning its outcome.
early
second
trimester
pregnancy
and
maternal
anxiety,
Aust. Fam. Physician 8:595. 1979. .5. Spielberger, C. D., Gorsuch, R. L., and Lushenb, R. E.: STAI Manual for the State-Trait Inventory. Palo Alto, 1970, Consulting Psychologists Press. 6. Beeson, D., and Golbus, M.: Anxiety engendered by amniocentesis, Birth Defects 15:191, 1979. 7. Dixson, B.. Richards, T. L., Reinsch, S., Edrich. V. B., Matson, M. R., and Jones, 0. W.: Midtrimester amniocentesis, J. Reprod. Med. 26:10, 1981. 8. Bundey, S.: Attitudes of 40-year-old college graduates towards amniocentesis, Br. Med. J. 2:1475, 1978.
Volume Number
143 5
9. Sihestre, D., and Fresco, N.: Reactions to prenatal diagnosis, Am. J. Orthopsychiatry 50:610, 1980. 10. Goldthorpe, J. H., and Hope, K.: The Social Grading of Occupations, London, 1974, Oxford University Press. 11. Kellner, R.: Abridged Manual of the Symptom Questionnaire, Albuquerque, 1981, University of New Mexico. 12. Fava, G. A., Kellner, R., Perini, G. I., Fava, M., Michelacci, L.. Munari, R., Pasquali Evangelisti, L., Grandi. S..
Psychological
reactions
to amniocentesis
513
and Bernardi, M.: Italian validation of the Symptom Rating Test (SRT) and the Symptom Questionnaire (SQ), Can. J. Psychiatry. In press. 13. Kellner, R., and Sheffield, B. F.: A self-rating scale of distress, Psychol. Med. 3:88, 1973. 14. Lubin, B., Gardener, S. H., and Roth, A.: Mood and somatic symptoms during pregnancy, Psychosom. Med. 37:136, 1975.
A.
FAVA,
ROBERT
KELLNER,
LAURA
MICHELACCI,
GIANCARLO
M.D. M.D., M.D.
TROMBINI,
M.D.
DOROTHY
PATHAK,
PH.D.
CAMILLO
ORLANDI,
M.D.
LUCIANO
BOVICELLI,
BoloLpa,
Italic,
Albuquerque,
PH.D.
M.D. New
Mexico,
and Buffalo,
New
York
Fifty women who underwent amniocentesis and a matched control group of pregnant women were administered the Symptom Questionnaire to evaluate changes in distress. Anxiety, depression, and somatic symptoms had significantly decreased after the results of amniocentesis were communicated to the patient, but the decrease was similar in the normal control women. Hostility was higher in the amniocentesis group and decreased to normal levels after amniocentesis was performed, even before the results were communicated to the patient. (AM. J. OBSTET. GYNECOL. 143509,
1982.)
HAS BEEN a growing interest in the psychological aspects of amniocentesis.’ Since the procedure has become more common, there appears to be a need to understand its psychological impact. Several studies have been published. Finley and associates* studied 157 patients from a sample of 3 15 referred to a laboratory for prenatal genetic studies; those who were studied returned a mailed questionnaire. The majority of the women found the experience to be reassuring, would recommend it to others, and would seek it again themselves with a subsequent pregnancy. Chervin and associates3 also mailed a questionnaire to 67 patients who underwent amniocentesis and obtained 31 answers. The majority of patients expressed enthusiastic approval and appreciation for prenatal diagnosis. Most women (61%) reported only moderate anxiety about an abnormal baby before amniocentesis; 23% reported a high anxiety about the procedure itself, and 42% re-
THERE
From the II Chair of Obstetrics and Gynecology and the Chair of Psychosomatic Medicine, Unzuersity of Bologna School of Medicine; the Departments of Psychiatv and Family, Community and Emergency Medicine, Uniuersily of New Mexico School of Medicine; and the Department of Psychiatry, State UniuersiQ of New York at Buffnlo. Received for publication Accepted February
September
23, 1981.
I, 1982.
Reprint requests: G. Trombini, M.D., Istituto di Pricologia, Viale Berti Pichat 5, Bologna, Italy. 0002-9378/82/130509+05$00.50/0
0 1982 The C. V. Mosby
Co.
ported moderate anxiety. Astbury and Walters,’ using the State-Trait Anxiety Inventory,J studied 28 patients who had been referred for amniocentesis. Patients who were tested on two occasions showed a significant decrease in anxiety after the results of the procedure had been communicated to them. The authors concluded that amniocentesis makes a significant contribution to the psychological well-being of those pregnant women who are at greater risk of having an abnormal baby. Beeson and Golbus’ also studied anxiety related to amniocentesis by means of the State-Trait Anxiety Inventory, which was administered on several occasions to 36 couples. Women who had previously given birth to a child with a chromosomal disorder displayed higher levels of anxiety before amniocentesis than did women whose indication for the procedure was age. Dixson and associates7 interviewed and administered a questionnaire to 53 women who had elected to undergo genetic amniocentesis and 22 women who had declined this procedure. Most women who had amniocentesis felt reassured for the remainder of pregnancy. Those who refused the procedure had a significantly higher occurrence of concerns in regard to possible fetal injury or miscarriage. Bundey” explored the attitudes of 40-year-old college graduates toward amniocentesis. Seventeen percent of the women who responded to a questionnaire replied that they would refuse amniocentesis if it was 509
510
July I. 1982 Am. J. Obstet. C;vwol.
Fava et al.
Anxietj~ Depression Somatic symptoms Hostilitb Relaxeri Contentetl Somatic wzll-being
:i.70 3.52 3.92 2.9x 3.3fi 3.32 3.90
t 33X) t3.81)
4.40 ( 2 4.22) 2.62 (3.16) 3.14 ( i 3.41))
t :I.:
1 .io
t I .93) + 1.X5) rt_1:13)
3.82 (-c I Al) 3.45 ( 2 I .76) :i..x ( ” 1XJ)
_f 4.9)
Time 1: The patient is toltf that amniowntesis is t-ecc)n~mentled.l’ilne is told the results of‘ the amniocentesis. NS= Not significant. *By pairecl t lest. tp < O.l)r,. $1’ < 0.00 I. 3p < O.(II.
offered because of the increased risk of mongolism at a late maternal age. The main reason given for refusal was dislike of abortion on religious or moral grounds. SilLestre and Fresco!’ explored, via interviews, the reactions 10 amniocentesis of 62 women and 25 of their husbands, and observed that during the first 1 months (before amniocentesis was carried out) the mothers were concerned about the pregnancy and possibility of abortion. The women began to look forward to the child only after the results of the amniocentesis were known, and sevrral waited for the results before announcing that thev were pregnant. These studies explored some of the attitudes and psychological changes before and after amniocentesis. ‘The results of’ several of’ the studies are difficult to evaluate; some were of a retrospective nature and liable to distortion of recall.‘. “. ’ and others dealt with samples which were. in part, self-selected (e.g., those women who chose to reply to a mailed questionnaire) and. therefore. mav have been biased. In one study, unstructured inter\icws were used and these were more liable to observer bias. In none of the studies were control groups of normal pregnant women used, so that it is difficult to assess whether the findings shotlId be attributed to the amniocentesis or reflect difftwnt stages of the pregnancy. Moreover, these studies dealt with anxiety only and nol with other important psychological symptoms, such as depression. The aims of the present study were to evaluate some of the psychological effects of amniocentesis and to replicate and to extend some of the previous findings. Methods Subjects.
women
A consecutive unselected series of 50 who underwent amniocentesis was matched fbr
(2
‘1.23)
t ss P
ss NS NS
2.46 1.34 2.34 1.42 4.68 5.02 4.48
2: Immetiiately after amniocentesis. Time 3: hfterthe patient
the week of their pregnancy with a control group of 50 healthy pregnant women. The control group included women who attended the outpatient clinic of the same department of obstetrics and gynecology and were seen by the obstetrician who counseled the other group about amniocentesis. All patients were married. The mean age of the patients who underwent amniocentesis was 32.96 years (k6.61); that of the control group was 28.28 (24.15) years. No significant differences existed between the two groups as to the number of previous pregnancies and abortions, and no significant differences in social class distribution on the basis of Goidthorpe and Hope’s” occupational classification. Amniocentesis was performed for one of the following reasons: maternal age of 35 years or older: history of a previous child with a chromosomal aberration; parent a known carrier of a translocation chromosome: history of a previous child with a detectable biochemical disorder; mother a known carrier of a detrimental X-linked gene; and family history of an open neural tube defect. All patients had been referred by physicians to the Laboratory ot Prenatal Pathophysiology, University of Bologna School of Medicine, where all the procedures were done. ,411 patients who had amniocentesis received counseling by an obstetrician about the nature of the investigation, the associated risks, and the implications if‘ an abnormal result was obtained: and all patients underwent A-scan and real-time ultrasonography,just before and immediately after amniocentesis. A second obstetrician performed amniocentesis without moving the mother from the ultrasound scanning table. .4 real-time scan was provided after the amniocentesis in order to reassure the mothers of a normal fetal heartbeat. The results concerning the fetal karyotype and amniotic fluid were known within 2 to 3
Volume Number
143 5
p Value* for changes from tzme 2 to timr’ 3
Psychological
p Value* for changes from time 1 to tinw 3
reactions
to amniocentesis
511
In the control group, the SQ was administered for the first time in the period between the eighth and twelfth weeks of pregnancy and between the twentieth and twenty-second weeks of pregnancy (periods one and three of the amniocentesis group). In both groups, informed consent was obtained verbally, as is customary in Italy. Statistical methods. The t test and analysis of covariance were used, with age, social class, previous pregnancies, and previous abortions as covariants, to evaluate differences between groups and changes with time.
Results weeks. In our sample, no abnormal results were found. The outcome of the amniocentesis was communicated by the obstetrician who had counseled the patient at the first interview. Husbands were generally present throughout the procedure (initial interview, amniocentesis, and communication of outcome). In all cases, the patient’s husband was present at least at some of the encounters. Psychological assessment. Psychological distress was assessed with the Symptom Questionnaire (SQ).” The SQ is a 92 item, self-rating scale of psychological distress, and consists of items which indicate symptoms and items which indicate well-being. The items are divided into symptom scales (anxiety, depression, somatic symptoms, and hostility based on factor analyses) and corresponding well-being scales (relaxed, contented, somatic well-being, and friendly). The subjects score one point for each symptom that they check “yes.” The questionnaire was designed to measure changes in distress in experiments in therapeutics, such as drug trials, and to compare levels of distress in various populations. The validation studies performed with this test,“. “’ and its precursor, the Symptom Rating Test,13 both in the United States and in Italy, suggested that it is a valid and reliable measure of distress. The questionnaire was administered in its validated Italian version.” Collection of data. The SQ was administered three times by the same obstetrician to the group of patients who underwent amniocentesis. 1. Eighth to tdfih werk (4 pregnancy In this phase, the women were interviewed by the obstetrician, who obtained a complete history and explained the procedure. The SQ was administered at the end of the interview. 2. Sixtprnth to rightpenth week. Amniocentesis was performed at this stage. The SQ was administered for the second time immediately after amniocentesis. .?. Tumtirth to tuvntpsucond werk. At this time, the outcome of the amniocentesis was communicated. Immediately afterward. the SQ was administered for the third time.
Differences between groups. The first comparison involved the SQ scores in the two groups before amniocentesis was performed (Time 1 in Table I) and at the first measurement of the control group (Time 1 of Table II). There were significant differences between the two groups in only the SQ subscales of hostility (p < 0.05) and somatic well-being (p < 0.001). even when differences were adjusted for age, social class, previous pregnancies, and previous abortions. Patients who had been offered amniocentesis were more hostile and reported less somatic well-being than the control group. After amniocentesis had been performed and the results were known (Time 3 in Table I), and at the same period of pregnancy in the control group (Time 2 in Table II), there were no significant differences between the groups, even when adjusted for the abovementioned covariants. Changes in psychological distress with time. Between the first measurement (before amniocentesis) and the second (after amniocentesis), there was a significant decrease in anxiety, depression, and hostility. Between the second and the third measurements (after communication of the outcome), there was a further significant decrease in anxiety and depression. and an increase in relaxation, contentment, and somatic wellbeing. Between the first and the third measurements, there was a significant improvement in all the SQ subscales, except the score for somatic well-being, which fluctuated (Table I). In the control group, there was a significant improvement in all the SQ subscales, also, except for hostility and its corresponding well-being scale, “friendly” (Table II).
Comment Contrary to expectations, changes in anxiety and depression (and the corresponding well-being scales) which occurred after amniocentesis did not differ significantly from changes in the control group from the first to the second trimester of pregnancy. Lubin and
512
Fava et al
Table
II. l’sychological
distress in normal
pregnant
women
Contented Somatic well-being
4.96 2.80 3.20 1.62 3.60 3.64
( k 2.92) (C2.81) (2 3.29) ( ? 2.63) ( k 1.fi3) (+ 1.50)
4.34
( k I .46)
Friendly
5.10 (t 1.11)
Anxiety Depression Somatic symptoms
Hostilit! Relaxed
2.08
(2
L
I .W)
t
I .6ti f C 1.X6) I .x4 ( 5 2.08) I.24 (“1.X) 4.38 ( t 1.OS) 5.16 (2 1.0”) 4.96 ( -t 1.4 I) 5.34 ( i- O.fi2)
i-
NS t
; t+ NS
*By paired t test. tp < 0.00 I. $p < 0.05. Pp < 0.01. associates,” in a study of 9?i pregnant women, found that anxiety showed significant variations over trimesters: it decreased in the second trimester and rose again to the initial level in the third trimester. The claim that amniocentesis decreases anxiety and improves the psychological well-being of the mothers’ is probably true for a few women (many women report the experience to have been reassuring), ‘. 3. 7 but this apparently dots not apply to a marked degree to the majority. The previously reported relief of anxiety after amniocentesis also occurs to a large extent in other pregnant women. It could be argued that women who undergo amniocentesis experience the same psychological changes as those of women with normal pregnancies. This is also probably true only for a few, because there were no substantial differences in the initial level of’ anxiety and depression between the women who were offered amniocentesis and the women with normal pregnancies. There was less somatic well-being immediateI) after amniocentesis; and this improved later. In previous studies of the psychological responses to amniocentesis, changes in hostility were not examined,‘~~. ((. 7. !) Silvestre and Fresco!’ noted that the physician was seen by many women as holding the power to either permit their child to be brought into the world,
REFERENCES
1. Boub, J.: Psychological aspects of‘ prenatal diagnosis, in Murken, J. P.. Stengel-Rutkowsky, S., and Schwinger, E.. editor: Prenatal Diagnosis, Stuttgart, 1979, Federike Enke. 2. Finley. S. C., Varner. P. D.. Vinson, P. C., and Finley, W. H.: Participants’ reaction to amniocentesis and prenatal genetic studies, JAMA 238:2377, 1977. 3. Chervin, A., Farnsworth, P. B., Freedman, D. W. I,.. Duncan, P. A., and Shapiro, L. R.: Amniocentesis for prenatal diagnosis, N. Y. State J. Med. 77:1406, 1977 4. Astbury, J.. and Walters, W. A. W.: Amniocentesis in the
or prevent such arrival. The scales used in the present studies do not indicate the target of hostility (which could be the physician or, perhaps, the husband). The decrease in hostility occurred after the procedure had been performed but before the patient was told the favorable outcome; this would suggest that the hostility was induced by the offer of the procedure rather than by the threat of having the pregnancy terminated. Possibly of course, the findings in this study are, in part, bound to the culture and will be different in other countries. On the basis of this reservation, the present study has yielded new information because of the methodology used. The amniocentesis sample was composed of a consecutive and unselected series of women who underwent the procedure at the same stage of pregnancy. The results were compared with those for a matched control group. Assessment of psychological distress was made with a \-alid scale, which was designed for this purpose and is free from observer bias. Patients in both groups were seen by the same obstetrician under relatively uniform conditions. In the groups which underwent amniocentesis, the timing of psychological tests allowed a differentiation between the effects of being told that amniocentesis was being offered and the effects of learning its outcome.
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Aust. Fam. Physician 8:595. 1979. .5. Spielberger, C. D., Gorsuch, R. L., and Lushenb, R. E.: STAI Manual for the State-Trait Inventory. Palo Alto, 1970, Consulting Psychologists Press. 6. Beeson, D., and Golbus, M.: Anxiety engendered by amniocentesis, Birth Defects 15:191, 1979. 7. Dixson, B.. Richards, T. L., Reinsch, S., Edrich. V. B., Matson, M. R., and Jones, 0. W.: Midtrimester amniocentesis, J. Reprod. Med. 26:10, 1981. 8. Bundey, S.: Attitudes of 40-year-old college graduates towards amniocentesis, Br. Med. J. 2:1475, 1978.
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9. Sihestre, D., and Fresco, N.: Reactions to prenatal diagnosis, Am. J. Orthopsychiatry 50:610, 1980. 10. Goldthorpe, J. H., and Hope, K.: The Social Grading of Occupations, London, 1974, Oxford University Press. 11. Kellner, R.: Abridged Manual of the Symptom Questionnaire, Albuquerque, 1981, University of New Mexico. 12. Fava, G. A., Kellner, R., Perini, G. I., Fava, M., Michelacci, L.. Munari, R., Pasquali Evangelisti, L., Grandi. S..
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and Bernardi, M.: Italian validation of the Symptom Rating Test (SRT) and the Symptom Questionnaire (SQ), Can. J. Psychiatry. In press. 13. Kellner, R., and Sheffield, B. F.: A self-rating scale of distress, Psychol. Med. 3:88, 1973. 14. Lubin, B., Gardener, S. H., and Roth, A.: Mood and somatic symptoms during pregnancy, Psychosom. Med. 37:136, 1975.