Reproductive patterns in psychotic patients,☆☆

https://doi.org/10.1016/j.schres.2010.05.018Get rights and content

Abstract

Context

Longitudinal epidemiological studies have shown worse outcomes in patients with psychotic disorder than in the general population. The reproductive pattern may be seen as a measure of outcome following psychotic disorder onset, and it may be measured as the rate of child births where the rate is a proxy measure of well-being.

Objective

To examine reproductive patterns following psychotic disorder onset by comparing the fertility rates of patients with schizophrenia and bipolar disorder with those of other psychiatric patients and the general population, taking into account parental status at disease-onset, time since onset, and the possible effect of abortions-rates.

Methods

A prospective register-based cohort study drawing on the entire Danish population born after 1950. Incidence Rate Ratios (IRRs) of fertility were analysed using survival analysis.

Results

Compared with the general population, the lowest first-child fertility rate was found among men (IRR = 0.10) and women (IRR = 0.18) with schizophrenia. In comparison, bipolar male patients had an IRR = 0.32 and female patients an IRR = 0.36, while male unipolar patients had an IRR = 0.46 and female patients an IRR = 0.57. In the group with other psychiatric disorders men had an IRR = 0.51 and women an IRR = 0.70.

Conclusions

The results of the present study show a selection process where persons with more severe disorders are less likely to become parents. The reduced fertility was strongly influenced by the time since psychiatric disorder onset; thus, the longer the time since onset, the higher the fertility.

Introduction

Longitudinal epidemiological studies have shown worse outcomes in patients with schizophrenia and bipolar disorder (psychotic disorders) than in patients with other psychiatric disorders and in the general population. These outcomes include markedly elevated mortality rates from all causes of death (Harris & Barraclough, 1998, Laursen et al., 2007b), suicide (Hiroeh et al., 2001), increased somatic and medical comorbidity (Laursen et al., 2009, Jeste et al., 1996), more unhealthy diets (Brown et al., 1999), higher rates of cigarette smoking (Itkin et al., 2001, Dalack et al., 1998, Jeste et al., 1996), and negative social consequences (Agerbo et al., 2004).

The reproductive pattern of a patient after psychotic disorder onset may also be considered an outcome measure. Men and women becoming parents have been shown to form a population segment that, among others, has a lower risk of cancer (Dalton et al., 2004) and psychiatric disorders (Munk-Olsen et al., 2006). Several studies have found reduced fertility rates among persons with schizophrenia or a combined measure of psychosis (McGrath et al., 1999, Haukka et al., 2003, Howard et al., 2002, Svensson et al., 2007, Bhatia et al., 2004), with only one recent study showing an opposite result (Nimgaonkar et al., 1997). A study detected no reduced fertility rates in patients with bipolar disorder (affective psychosis) (MacCabe et al., 2009). However, many of these studies are flawed because they have not duly considered the dimensions of ‘how’ and ‘when’ to measure reproduction. The average age at which schizophrenia sets in is in the early 20s, while bipolar disorders set in later (Laursen et al., 2007a). Common for the two disorders, and for many other psychiatric disorders, is that disease strikes during the primary reproductive period of both men's and women's lives. It should therefore be taken into account how many (if any) children the person has before disorder onset. Furthermore, women with psychotic disorders are often advised not to have children (Viguera et al., 2002a) and they may choose to have an induced abortion. The rates of induced abortion in women with psychotic disorders should therefore also be taken into account as a possible explanation for their reduced fertility.

The aim of the present study was to examine reproductive patterns following psychotic disorder onset by comparing the rates of childbirths in patients with schizophrenia and bipolar disorder with those of other psychiatric patients and members of the general population who had not been admitted to a psychiatric hospital, taking into account parental status at the time of onset of the disorder, time since onset of the disorder, and the possible effect of abortions.

Section snippets

Methods

We established a cohort study and obtained data on the vital status of the cohortees and their children. Information was drawn from the Danish Civil Registration System (Pedersen et al., 2006). We linked this information to the Danish Psychiatric Central Register (Munk-Jorgensen and Mortensen, 1997) from where we obtained information on inpatient psychiatric treatment, and to the The Danish National Hospital Register (Andersen et al., 1999) from where we obtained information about induced

Results

In the follow-up period from 1970 to 2006, a total of 2,819,941 cohort members were followed for 34,898,001 person-years during which 1,587,709 persons had at least one child.

Firstly, we examined the IRRs of having the first child among cohort members with no children and found that men (IRR = 0.10; 95% CI (0.09, 0.11)) and women (IRR = 0.18; 95% CI (0.17, 0.20)) with schizophrenia had the lowest observed fertility compared with their respective counterparts with no psychiatric admission (Table 1).

Key findings

We found a reduced fertility among both women and men with psychiatric disorders. Persons with schizophrenia had the lowest fertility followed by bipolar disorder, unipolar disorder, and the remaining disorders. The reduced fertility was most pronounced among cohortees with a psychiatric disorder when having the first child was used as the outcome. Furthermore, reproductive rates rose with time since the first psychiatric admission, and men with a psychiatric disorder had a lower fertility than

Conclusion

Drawing on the entire Danish population, we were able to describe reproductive patterns in patients with psychotic disorders. Fertility rates among persons with a psychiatric disorder are highly dependent on diagnosis. Compared with the part of the population with no psychiatric hospitalization, persons with schizophrenia had the lowest rates of childbirths. Persons with bipolar disorder had lower rates than persons with unipolar disorder and persons in the group consisting of the remaining

Role of funding source

The Stanley Medical Research Institute and The Danish Medical Research Council had no further role in study design; in the collection, analysis and interpretation of data; in the writing of the report; and in the decision to submit the paper for publication.

Contributors

Dr. Thomas Munk Laursen (TML) designed the study and wrote the protocol. Authors TML and Trine Munk-Olsen managed the literature searches and analyses. Author TML undertook the statistical analysis, and author TML wrote the first draft of the manuscript. All authors contributed to and have approved the final manuscript.

Conflict of interest

None.

Acknowledgments

This study was supported by The Stanley Medical Research Institute. Dr. T Munk-Olsen has received financial support from The Danish Medical Research Council (Reference number: 09-063642/FSS).

References (35)

  • G.W. Dalack et al.

    Nicotine dependence in schizophrenia: clinical phenomena and laboratory findings

    Am. J. Psychiatry

    (1998)
  • S.O. Dalton et al.

    Risk for cancer in parents of patients with schizophrenia

    Am. J. Psychiatry

    (2004)
  • E.C. Harris et al.

    Excess mortality of mental disorder

    Br. J. Psychiatry

    (1998)
  • J. Haukka et al.

    Fertility of patients with schizophrenia, their siblings, and the general population: a cohort study from 1950 to 1959 in Finland

    Am. J. Psychiatry

    (2003)
  • L.M. Howard et al.

    The general fertility rate in women with psychotic disorders

    Am. J. Psychiatry

    (2002)
  • O. Itkin et al.

    Smoking habits in bipolar and schizophrenic outpatients in southern Israel

    J. Clin. Psychiatry

    (2001)
  • K.D. Jakobsen et al.

    Reliability of clinical ICD-10 schizophrenia diagnoses

    Nord. J. Psychiatry

    (2005)
  • Cited by (88)

    • Long-term development and outcome of early-onset psychosis

      2023, Adolescent Psychosis: Clinical and Scientific Perspectives
    • Altered working memory-related brain activity in children at familial high risk for psychosis: A preliminary study

      2022, Schizophrenia Research
      Citation Excerpt :

      This likely limited our ability to show more subtle changes in WM-related activation of other brain regions and establish brain-behavior relationships, although these can be difficult to show even in larger samples. We note that it is challenging to collect (large) samples of young FHR children as individuals with a psychotic disorder tend to have fewer offspring (Laursen and Munk-Olsen, 2010; MacCabe et al., 2009). Given these challenges, we believe that the current findings represent a valuable addition to current literature, despite our modest sample size.

    • Altered resting-state functional connectivity in young children at familial high risk for psychotic illness: A preliminary study

      2020, Schizophrenia Research
      Citation Excerpt :

      The first and principal limitation is the small size of our sample. Children with a parent or sibling diagnosed with schizophrenia are difficult to recruit, particularly in the young age range of our sample, due to issues such as reduced fecundity in patients and the disorganization of families as a result of the illness (Laursen and Munk-Olsen, 2010; Power et al., 2013). Given our small sample size, we suggest that our results are taken as preliminary evidence of abnormal STG functional connectivity in pre-adolescent children with a familial vulnerability for schizophrenia.

    View all citing articles on Scopus

    Dr. TM Laursen had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analyses.

    ☆☆

    This study was approved by the Danish Data Protection Agency.

    View full text