Pregnancy, drugs & alcohol, emotional instability: what nightmares are made of

July 15, 2001

The majority of alcohol research to date has focused primarily on men, or on combined samples of men and women. Even fewer psychopathological studies - which examine emotional, behavioral and psychological problems - have focused exclusively on women with drug dependencies. Of those that have, the focus has been on single substances of abuse, such as cocaine. A study in the July issue of Alcoholism: Clinical & Experimental Research examines the psychopathology of pregnant women with co-occurring alcohol and drug dependencies.

"Pregnant drug-dependent women present for treatment with a variety of medical, psychosocial and emotional problems," said Donna R. Miles, postdoctoral fellow in the Department of Pharmacology and Toxicology at Virginia Commonwealth University, and lead author of the study. "Rates of homelessness, poverty, unemployment, and prostitution are high in this patient population. Many of these women have histories of emotional, physical and sexual abuse. Yet societal stigmatization typically prompts pregnant women to conceal substance use, which makes identification and intervention difficult. In fact, many alcohol- and drug-abusing women avoid prenatal care altogether. Furthermore, in many states, delivery of a drug-positive infant results in legal sanctions that include termination of parental rights and criminal prosecution. Taken together, this myriad of problems and concerns make pregnant drug-dependent women a very vulnerable population in need of more intensive, user-friendly services that focus not only on their alcohol and drug problems, but their other needs and concerns as well."

"Pregnancy can have multiple effects on alcohol/drug-dependent women," added Roy W. Pickens, associate vice president for research, and professor of psychiatry, at Virginia Commonwealth University. "On the one hand, concern about the effects of alcohol/drug use may cause a pregnant woman to be more willing to seek and complete treatment. On the other hand, pregnancy adds to the unfounded social stigma of being alcohol/drug dependent, which may keep a woman from entering treatment."

In the study, the psychopathology of 170 pregnant women in treatment for drug dependency was measured using the Minnesota Multiphasic Personality Inventory - Revised (MMPI-2). The MMPI-2 uses 567 self-report items to measure different aspects of psychopathology, including depression, anxiety, impulsivity, aggression and suspiciousness. The majority of the women (79%) were drug dependent only; less than one quarter (21%) were both alcohol and drug dependent.

"Our findings show that cocaine- and/or heroin-dependent pregnant women who also have problems with alcohol come into treatment with more psychological problems than those who don't also have alcohol problems," said Miles. "Specifically, they had more symptoms of depression and anxiety as well as problems controlling impulsivity and aggression. They were also more likely to misinterpret life experiences and react in atypical ways to their environment. These findings emphasize the need for universal screening for alcohol problems in drug-using pregnant women and, for those who screen positive, to make sure treatment is offered and tailored to meet their needs."

"These findings illustrate that all drug-dependent individuals are not the same," agreed Pickens. "In fact, these differences are sometimes important in the selection of treatment approaches. The study suggests that alcohol dependence, in particular, is a factor related to psychiatric/personality disorders in the drug dependent individual. This difference needs to be recognized by treatment providers, the individuals' relatives, and the general public."

It is unclear exactly how many pregnant women use alcohol and/or drugs during pregnancy, or how many seek help for their dependencies. Alcohol dependence affects more than one in five women in general, according to Miles. U.S. Department of Health and Human Services 1996 data reveal that 5.5 percent of women used illicit drugs during pregnancy, while 18.8 percent reported alcohol use during pregnancy. Pickens said a more recent study found that a similar proportion (5 to 6%) of women had used illicit drugs during pregnancy, while a greater proportion (25%) had used alcohol. Because research consistently shows that alcohol use during pregnancy is the leading known cause of mental retardation, said Miles, its use should not be overlooked, even when women are using other drugs.

"The rates at which pregnant drug-using women seek treatment vary widely," said Miles, "depending upon availability of services, practitioner attitudes and legal consequences." For example, prior to the creation of the Baltimore Center for Addiction and Pregnancy (CAP), where this research was conducted, less than five percent of pregnant drug-abusing women followed through with an initial referral to "standard" drug treatment. (CAP uses what is considered an "intensive" approach: residential treatment followed by 6.5 hours per day of outpatient treatment for the duration of pregnancy.) Subsequent to CAP's establishment, Miles estimated that approximately 50 percent of the pregnant drug-dependent women referred to CAP actually followed through with the referral.

"The women seeking treatment at CAP have severe cocaine and/or opiate dependence as well as limited financial, family/social and medical resources," said Miles. "They are also older women with several previous pregnancies." Most of the women were also single (75%), African American (80%), and had a mean age of 29 years. Miles noted there were difficulties generalizing the study's findings to younger women with more varied sociodemographic characteristics.

"This kind of program is often so focused on illicit drug use," said Miles, "that alcohol problems often go undetected or receive less emphasis in treatment. Yet this study found that alcohol seems to be uniquely associated with greater psychopathology. The women with co-occurring alcohol and drug problems present for treatment with more emotional problems such as depression and anxiety, and such problems are associated with poorer treatment participation, retention and outcome. We need to intensify efforts to keep these women in care. One strategy would be to provide residential treatment for a longer period of time, perhaps even for the duration of pregnancy. This would allow greater opportunities for maintaining abstinence from alcohol and other drugs while at the same time providing a safe and supportive environment that may aid in reducing their emotional distress. Unless we recognize the unique psychological and emotional symptoms associated with different drugs of choice, the end result is likely to be premature treatment dropout and potentially negative outcomes for both mother and baby."
Co-authors of the Alcoholism: Clinical & Experimental Research paper included: Dace S. Svikis of the Medical College of Virginia at the Virginia Commonwealth University, and the Johns Hopkins University School of Medicine; Jody L. Kulstad of the Medical College of Virginia at the Virginia Commonwealth University; and Nancy A. Haug of the Johns Hopkins University School of Medicine. The study was funded by the National Institute on Alcohol Abuse and Alcoholism, and the National Institute on Drug Abuse.

Contact: Donna R. Miles, Ph.D.
Virginia Commonwealth University

Add'l Contact: Roy W. Pickens, Ph.D.

Alcoholism: Clinical & Experimental Research

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