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Am Fam Physician. 2001;63(11):2118-2129

to the editor: I would like to commend the authors of the article, “Acute and Post-traumatic Stress Disorder After Spontaneous Abortion.”1 I try to remain aware of the possibility of psychologic morbidity following spontaneous abortion but, admittedly, I had never considered the diagnosis of post-traumatic stress disorder (PTSD). As noted, there has not been much written about this subject, and I wonder if it is because the diagnosis is uncommon or underappreciated.

I agree that more investigation is needed to determine the incidence of and the most effective treatment for PTSD following spontaneous abortion. The authors state that as many as 10 percent of women may have acute stress disorder and up to 1 percent may have PTSD after spontaneous abortion, rates they derive from “anecdotal evidence.”1 Do the authors encounter this constellation of symptoms very often? The only article2 the authors cite that discusses the incidence of PTSD and spontaneous abortion found just one case of PTSD. This one case was in a study population different than the population with the more common first-trimester miscarriage; these were women who experienced a perinatal death between 16 weeks' gestation and seven days following delivery.

Correctly classifying patients who are having difficulties following a miscarriage may not be easy. Most studies describing the psychologic morbidity associated with miscarriage focus on depression, grief, bereavement and anxiety. The methods used to estimate prevalence vary widely because different terms and methods are used for the diagnosis, including the Diagnostic and Statistical Manual of Mental Disorders, 4th ed. (DSM-IV), Hamilton Anxiety Scale, Hospital Anxiety and Depression Scale, Perinatal Grief Scale and many others. Unless the patient has a classic PTSD feature like vivid dreams, hallucinations or flashbacks, many features of PTSD overlap with the diagnostic criteria for depression or anxiety. Alternatively, physicians or researchers in the past may also have misdiagnosed cases of PTSD as depression, anxiety or a mixed depression-anxiety.

Finally, regardless of the diagnosis, physicians need to be on the lookout for psychologic problems following miscarriage, sometimes proactively, and help the patient cope. The article1 discusses only the critical incident stressdebriefing process as treatment Other forms of psychotherapy and even hypnotherapy may be helpful. In addition, some pharmacologic treatments (antidepressants and anxiolytics) have been studied in the treatment of PTSD. I mention this to make two points: (1) physicians need to recognize the psychologic complications of miscarriage and do something to help their patients and (2) whether the diagnosis is clearly PTSD or not, one can offer psychotherapy and possibly medication. For persons who seem to have more depressive-type symptoms, antidepressants may be prescribed, while anxiolytics may be more helpful for those with more hypervigilant, anxious features.

to the editor: The authors of “Acute and Post-traumatic Stress Disorder After Spontaneous Abortion”1 make a meaningful contribution to the family practice literature by pointing out the association between significant stressors, such as spontaneous abortion, and traumatic stress disorders.

In December 1999, the U. S. Food and Drug Administration (FDA) approved labeling for sertraline (Zoloft) in the treatment of post-traumatic stress disorder (PTSD). Brief information about the approval can be found on the FDA's Web site:

A body of literature exists supporting the use of serotonergic antidepressants, including tricyclic antidepressants and selective serotonin reuptake inhibitors (SSRIs), for the treatment of patients with post-traumatic stress disorder (PTSD).2

Although only anecdotal in acute stress disorder, I have found low-dose serotonergic antidepressants (e.g., low-dose SSRIs) of benefit for the anxiety-type, hyperarousal component of this disorder. I find this no different from the use of SSRIs in the treatment of patients with generalized anxiety disorder. However, it is important to note that low doses are often sufficient to produce antianxiety effects; whereas, higher doses are usually necessary for antidepressant effects.

While family physicians may choose to counsel patients themselves or refer patients for counseling for these indications, many family physicians have experience and are comfortable with these classes of pharmacotherapeutic agents. Therefore, I thought this worth mentioning.

Of course, in the circumstance of the postabortion patient, issues related to medications and subsequent pregnancy planning would also be a pertinent issue for the physician and the patient to discuss.

in reply: Thank you for your observations and kind words regarding our article.1 You have raised some good points that were not addressed because of the limited focus of our article. The diagnosis for acute stress disorder2 (ASD) and post-traumatic stress disorder3 (PTSD) has been around for a relatively short time compared with depression, anxiety or pathologic grieving (the latter is not a diagnosis in the Diagnostic and Statistical Manual of Mental Disorders, 4th ed. [DSM-IV]).3 This is reflected in the limited writings on spontaneous abortion and negative emotional effects following this event.

We believe that the newness of this diagnosis, limited training and the lack of literature contribute to physicians overlooking this diagnosis when dealing with the aftereffects of spontaneous abortion. Additionally, we believe there is now a greater focus on psychologic issues in maternity care, which should increase research and literature in this area. In our own experiences in the departments of family practice, obstetrics-gynecology and behavioral medicine, we have observed these cases; however, as suggested, PTSD is rare while ASD is more likely observed in family practice or obstetrics-gynecology settings. Patients with PTSD are more likely to be referred for behavioral therapy, depending on the staff's level of awareness of this condition following spontaneous abortion. As has been aptly pointed out, psychotherapy and pharmacotherapy in this population may be of some benefit; however, we believe that in this subpopulation, pharmacotherapy may be of little benefit.

The concern with pharmacotherapy is the perceived risk these medications have on subsequent pregnancies. While a small percentage of subsequent pregnancies will end in another miscarriage, a woman taking a regular prescription medication often may assume that the medication had some role in the miscarriage or continue to harbor some increased apprehension about other untoward (teratogenic) effects if the pregnancy continues beyond the first trimester. Thus, most women prefer not to take a medication, if possible, when they begin attempting a subsequent pregnancy. Our focus in the article1 was to highlight the fact that when ASD is discovered, early preventive measures may reduce the traumatic experience and may prevent or reduce the symptomatology of PTSD. A psychotherapy referral may be in order if, after a brief intervention, the patient exhibits no symptomatic (or limited) relief.

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This series is coordinated by Kenny Lin, MD, MPH, deputy editor.

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