Psychiatric comorbidity among substance misusing mothers PAULA STRENGELL*, ILONA VÄISÄNEN*, MATTI JOUKAMAA, TIINA LUUKKAALA, KAIJA SEPPÄ
Strengell P,Väisänen I, Joukamaa M, Luukkaala T, Seppä K. Psychiatric comorbidity among substance misusing mothers. Nord J Psychiatry 2015;69:315–321. Background: Approximately half of patients suffering from a significant drug or alcohol related disorder also match the criteria of some other psychiatric disorder. Yet, little is known about comorbidity among substance misusing pregnant women. Aims: To estimate the prevalence of psychiatric diseases among mothers with substance misuse severe enough to end up in an assessment at a specialized addiction clinic and to compare their backgrounds to the controls. Methods: Between 1 June 2003 and 31 December 2005, the maternity clinics in Pirkanmaa health district were asked to refer mothers with possible substance misuse to Tampere University Addiction Psychiatric Clinic, where 119/217 patients were considered misusers. Of these, 49/119 (41.2%) participated in the whole study. At baseline, the assessment was made using the International Statistical Classification of Diseases and Related Health Problems (ICD-10) and at the end of the study, 6–12 months after delivery, with the Structured Clinical Interview for DSM-IV (SCID). The comparison group (n ⫽ 74) filled a postal survey concerning their background and substance use. Results: 57% of substance misusing pregnant women had psychiatric illnesses; 6–12 months after delivery the number of substance use-related diagnoses was 40%. However, the number, spectrum and severity of psychiatric diagnoses were high in this group. Conclusions: Psychiatric comorbidity is common among substance misusing mothers. Their social situation is often very difficult and support needs vary a lot. In order to offer them best possible treatment, diagnosing these disorders should be a routine part of evaluation during pregnancy. • Alcohol, Drugs, Pregnancy, SCID. Paula Strengell, Medical School, University of Tampere, Tampere, Finland, E-mail: paula. [email protected]; Accepted 16 October 2014.
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omorbidity in this study means that a patient has both a serious enough substance misuse to meet the criteria of either dependence or harmful use and a severe psychiatric condition like psychotic disorder, suicidal behaviour, major depression or personality disorder that complicates the patient’s life substantially. By definition, the psychiatric condition cannot only be a consequence of substance misuse. This definition was chosen because the concept of comorbidity is used variably in different studies and there is no well established use for it. The nature of the tight connection between substance misuse and psychiatric morbidity remains unclear. For example, antisocial personality disorder and substance misuse seem to have common grounds but alcoholism especially among women is more often a consequence of depression than a single reason for depression and
*Shared first authorship. © 2014 Informa Healthcare
anxiety disorders (1). According to the Epidemiologic Catchment Area (ECA) study, the population’s lifetime prevalence for substance misuse disorder is 16.7%. In drug misuse disorders, alcohol excluded, comorbidity is 53%, most commonly for anxiety and affective disorders. These figures are substantially higher than in the general population. About 25–30% of patients with a difficult psychiatric disease have an acute substance misuse disorder. Among schizophrenics, the rate is 47%, in affective disorders 32% and in anxiety disorders 24% (2, 3). According to different studies, 10–30% of depressed patients have a comorbid substance use problem, mostly with alcohol. The severity of psychiatric comorbidities is increased with the use of multiple substances (4). The National Comorbidity Survey found out that alcohol dependent women had 4.36 times the risk (95% CI 3.30–5.76) for affective disorder and 3.08 times (95% CI 2.20–4.30) for anxiety disorder than the population in DOI: 10.3109/08039488.2014.978892
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average (4). The ECA study showed that women with a lifelong drug abuse history had 4.5 times the risk for mental illness than those who had never used drugs (2). According to Finnish register based study, the comorbidity among substance misusing mothers is 85 times that among controls for schizophrenia class disorders (ICD 10–11; F20–F29) and 13 times for mood affective disorders (F30–F39) (5). Different studies afford the comorbidity prevalences for different substances and disorders. The information is therefore scattered and providing a uniform view is difficult. Despite the knowledge of the severe effects of alcohol and cigarettes on the infant, 10% of pregnant women exceed the limits of moderate alcohol consumption (one or two doses/week) and 16% continue smoking during pregnancy (5, 6). Nordic researches have shown that almost half of all pregnant women are occasionally drunk during pregnancy (7, 8). A lot is known about substance misusing mothers’ and their children’s health in general but there are only a few studies about pregnant women’s comorbidity and even less about their background characteristics. Pregnancy has mostly been seen as a protective agent towards psychiatric illnesses.
Aims The purpose of this study was to evaluate the psychiatric diagnoses among substance abusing mothers. The hypothesis was that they are at least as abundant as in other patient groups. The more accurate information is gathered after delivery (SCID), but also the clinically attained ICD-10 diagnostics of the first assessment is presented and compared with the finals. Substance abuse refers to dependence and harmful use according to DSM-IV and ICD-10 criteria, respectively. Alcohol, tranquilizers and drugs (cannabinoids stimulants, opioids, hallucinogens, inhalants) are all included. Additionally, the background characteristics of these patients are described and compared with controls when possible.
Material and methods Subjects Between 1 June 2003 and 31 December 2005, maternity clinics in Pirkanmaa health district were asked to refer mothers suspected of substance misuse to Tampere University Addiction Psychiatric Clinic. The referral criteria were any drug use including opioids, stimulants and hallucinogens during 1 year before pregnancy or when pregnant (during the first study year any drug use during lifetime), over 8 points in the Alcohol Use Disorders Identification Test (AUDIT) (9), alcohol use before pregnancy over 16 doses per week or over five doses per day, alcohol use during pregnancy over eight doses per week (during the first study year over 10 doses per week)
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or over five doses per day or abuse of tranquilizers. This was done as a part of a project aiming to establish a new treatment model for this patient group. With these criteria, 217 referrals (5600 children born annually on the area) were received and the patients were evaluated in the Addiction Clinic. First they were met by a nurse and a social worker and based on their decision also by an addiction psychiatrist. All workers have at least 10 years of experience in addiction psychiatry. Patients with a strong clinical suspicion of ongoing substance misuse were encouraged and asked to stay at the clinic. Thus the criterion for choosing patients was not a strict diagnostic category but a condition that affects the patient’s life substantially diminishing the performance capacity. Altogether, 119/217 patients fulfilled this criterion and were offered evaluation and treatment on the basis of their individual needs using both individual treatment and networking. Both substance misuse problems and mental diseases were noticed and social support was offered. Inpatient treatment was available when needed. Of that group, 49/119 (41.2%) followed the whole protocol and took part in the final diagnostic evaluation when the baby was 6–12 months old; 70/119 did not get that far for a variety of reasons, 20 did not want to take part in the study and 26 ended up with abortion. Other reasons were moving away and child being taken into custody. Detailed information on the backgrounds of this drop-out group cannot be given since these patients did not give their consent to the study. The comparison group was acquired from mothers who had given birth in the same hospital in 2006. Two hundred consequent mothers were sent a postal survey and 74 (35%) answered. Drug screening or medical records were not checked so information of their substance use was based on their literal answers only.
Procedure A written informed consent was obtained from each patient at the SCID interview visit—this being the point of study entry. The consent was obtained from comparison group mothers by mail. Patients had the full choice of not taking part in the study or quitting in the middle while still receiving every treatment they needed. The research plan was approved by the ethical committee of the Pirkanmaa Hospital District. The 49 patients were evaluated during pregnancy and 6–12 months after delivery by an addiction psychiatrist (PS) co-working with a nurse or a social worker. The final evaluation was done 6–12 months after delivery in order to ensure that the possible postpartum depression and hormonal changes had gone over.
Measures The postal survey to the controls included questions about the social situation, substance use (smoking, alcohol and NORD J PSYCHIATRY·VOL 69 NO 4·2015
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different drugs), psychiatric treatment history, earlier prescribed drugs (antidepressants and antipsychotic drugs) and the AUDIT questionnaire. ICD-10 was used at the baseline diagnostic assessment of the patients (10). The final assessment 6–12 months after the delivery included the DSM-IV based SCID interview (11). Both methods were used to measure the present situation. In substance misuse, the timeframe is 1 year. Information about alcohol and drug use as well as social situation and former treatments was asked based on the European Addiction Severity Index (12). In this study, the focus was on Axis I diagnoses (depression, anxiety disorders and psychosis). Thus, personality disorders (Axis II) were listed, but their association to substance misuse disorders were not measured.
Statistical methods Statistical analyses were performed by IBM SPSS Statistics versions 7-19. Categorical background characteristics of substance misusing and non-selected control group of pregnant women were described by number of cases with percentages. Differences between groups were analysed by Pearson chi-square test or by Fisher’s exact test, if the expected values were too small. Normal distributed age was described by mean with range and tested by independent samples t-test. P-values less than 0.05 were considered statistically significant, but due to the small number of subjects, also some potentially important results below that value are reported (13) in addition to the statistically significant results (P ⬍ 0.05).
baby. Addictions and mental illnesses had been quite common in their childhood families. Even though many had drug problems, they mostly had not had any prison sentences. Most had sometimes used excessively alcohol but had stopped before pregnancy. About one fourth used intravenous drugs during pregnancy. More than half reported having ever used sedatives and about one fifth used them during pregnancy (Table 1). Cannabis was the most commonly used substance among the patients, second was alcohol, followed by amphetamine, sedatives and opioids. During pregnancy the order changed— opioids came first (because 10/14 of the users were on maintenance treatment), then sedatives, alcohol, amphetamine and cannabis. Hallucinogens and glues were almost always stopped before pregnancy. Even if all illicit substance use seemed to decrease during pregnancy, smoking increased three-fold. Almost one third of the patients had hepatitis C or some other hepatitis. Half of the patients had been in psychiatric outpatient or hospital treatment at least once before pregnancy. During pregnancy, 35 patients (72%) had been in psychiatric treatment. Antidepressants were the most commonly ever used psychiatric medicines (n ⫽ 36, 73%), sedatives came next (n ⫽ 21, 43%) and then antipsychotics (n ⫽ 15, 31%). Twenty-two of the patients (45%) had been in hospital for substance misuse treatment before and six (12%) during pregnancy. In this study group, 28 patients (57%) reported having had at least one drugrelated psychosis.
The ICD-10 diagnoses
Results Background characteristics of patients and controls The controls were significantly older and had significantly higher education than the patients (Table 1). All controls were in a permanent relationship and had several children more often than the patients. Only few of the controls used substances or smoked during pregnancy and none of them used amphetamine, cannabis, opioids or hallucinogens. In the AUDIT questionnaire 28 controls scored 0, 44 scored 1–4 and two scored ⬎ 4. Of the patients, 9/49 consumed alcohol during pregnancy (Table 2).
In-detail characteristics of the patients The pregnancies were usually not planned and violence at home was common (Table 2). Home help services and child custody services were often needed. The biological fathers of the unborn were also mostly addicted. Often the patients lived in bigger towns and some were homeless. None of the homeless lived on the street when pregnant but at their friends, parents or temporary shelters. During the treatment period, they were helped to get an apartment or some moved to supported homes with the NORD J PSYCHIATRY·VOL 69 NO 4·2015
In the entrance to the addiction clinic 21 patients (43%) were diagnosed as having only a substance use-related diagnosis and 14 (29%) as comorbid for both psychiatric and substance use. Eight (16%) were diagnosed having only a psychiatric disease, of whom four had only a personality disorder. Six patients (12%) got no diagnosis at all. The 49 patients had altogether 90 diagnoses. The most common was opioid use disorder (n ⫽ 15, 31%), then came alcohol (n ⫽ 14, 29%) and sedative (n ⫽ 10, 20%) use disorders. Personality disorders were found in 14 (29%). In the comorbid group (n ⫽ 14) there were altogether 40 diagnoses. Alcohol dependence was the most common diagnosis given to eight (57%), depression to six (43%) and anxiety disorders to five (36%). There were two psychosis diagnoses caused by undetermined substances.
The SCID diagnoses In the end of the study, 6–12 months after delivery, 12 patients (25%) had no diagnosis at all, nine (18%) had only alcohol or drug use-related diagnosis, 17 (35%) had only psychiatric diagnoses and 11 (22%) had double
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Table 1. Background characteristics of substance misusing and non-selected (control) pregnant women.
Age, mean (range) Under 21 years, n (%) 21–34 years, n (%) Over 34 years, n (%) Education, n (%) Vocational school or less University Missing Working status, n (%) Not at work Studying or at work Mother’s marital status Marriage or common-law marriage Alone during pregnancy Divorced (incl. comm.-law marr.) Number of children One Two More than two Smoking, n (%) Never Before pregnancy During pregnancy Missing Sedatives Never Before pregnancy During pregnancy Missing Cannabis Never Before pregnancy During pregnancy Missing Amphetamine and stimulants Never Before pregnancy During pregnancy Missing Opioids Never Before pregnancy During pregnancy Missing Hallucinogens Never Before pregnancy During pregnancy Missing
Patients (n ⫽ 49)
Controls (n ⫽ 74)
25.2 (17–41) 11 (22) 37 (76) 1 (2)
30.8.2014 30.8 (22–41) 0 (0) 60 (81) 14 (19)
⬍ 0.001
⬍ 0.001 47 (100) 0 (0) 2
38 (51) 36 (49)
36 (74) 13 (27)
19 (26) 55 (74)
33 (67) 12 (25) 4 (8)
74 (100) 0 (0) 0 (0)
36 (74) 8 (16) 5 (10)
34 (46) 27 (37) 13 (18)
1 (3) 10 (25) 29 (73) 9
51 (85) 4 (7) 5 (8) 14
20 (42) 19 (40) 9 (19) 1
57 (95) 2 (3) 1 (2) 14
8 (16) 35 (71) 6 (12) 0
57 (95) 3 (5) 0 (0) 14
12 (25) 29 (60) 7 (15) 1
60 (100) 0 (0) 0 (0) 14
22 (45) 13 (27) 14 (29) 0
60 (100) 0 (0) 0 (0) 14
27 (55) 21 (43) 1 (2) 0
60 (100) 0 (0) 0 (0) 14
⬍ 0.001
⬍ 0.001
0.010
⬍ 0.001
⬍ 0.001
⬍ 0.001
⬍ 0.001
⬍ 0.001
⬍ 0.001
diagnosis. Thus, compared with the baseline situation assessed using ICD-10, the group with no diagnosis had increased and the number of drug- and alcohol-related diagnosed had decreased. However, the group with only a psychiatric diagnosis had increased. Six out of nine psychosis diagnoses had no drug-related origin.
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P
Those without a substance use-related diagnosis [(SA⫺), e.g. had no diagnosis at all or only had a psychiatric diagnosis, n ⫽ 29], at the end of the study were compared with those who had this diagnosis [(SA⫹), e.g. had either a substance use-related diagnosis alone or with a psychiatric diagnosis, n ⫽ 20]. The SA⫺ group NORD J PSYCHIATRY·VOL 69 NO 4·2015
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Table 2. Detailed characteristics of the substance misusing pregnant women, number of participants n with percentages (%).
Homeless, n (%) Conditional or unconditional sentence Addiction in childhood family Pregnancy planned Older children living away Home help services Child custody services at home Violence at home Father of the child addicted Alcohol use Never Before pregnancy During pregnancy Intravenous drug use Never Irregular use Regular use Use during pregnancy Opioid maintenance Never Begin during pregnancy Begin before pregnancy Hepatitis C Psych. hospital care during pregnancy Psych. outpatient care during pregnancy
Patients (n ⫽ 49)
Number of missing values
5 (10) 11 (22) 24 (49) 10 (22) 8 (16) 28 (57) 26 (53) 12 (25) 34 (69)
0 0 11 4 0 0 0 1 4 0 0 0 0 0
6 (12) 34 (69) 9 (18) 20 (41) 5 (10) 13 (27) 11 (22)
0 39 (80) 8 (16) 2 (4) 14 (30) 15 (31) 20 (41)
2 0
had more often been in earlier outpatient psychiatric care before (66% vs. 25%, P ⫽ 0.009) and also during pregnancy (55% vs. 20%, P ⫽ 0.019). SA⫹ group’s mothers had more often been in psychiatric hospital care during pregnancy (50% vs. 17%, P ⫽ 0.026). They had also had more drug psychoses during lifetime (79% vs. 46%, P ⫽ 0.036). Substance withdrawal outpatient treatment during pregnancy was more common in the SA⫹ group, too (80% vs. 41%, P ⫽ 0.009). Intravenous drugs during pregnancy were also more common in the SA⫹ than in the SA⫺ group (60% vs. 41%, P ⫽ 0.050). The final SCID-diagnoses of the comorbid mothers (n ⫽ 11) and mothers with only psychiatric diagnoses (n ⫽ 17) were compared (Table 3). The total number of diagnoses was 29/11 and 33/17, respectively. In the comorbid group alcohol was the most commonly used substance, next came various polydrug addictions, cannabis and finally opioids. There were no sedative or amphetamine users at the end of the study in this group. The most frequent psychiatric diagnoses were anxiety disorders, psychosis (acute, alcohol dependent, two undetermined) and mood disorders including bipolar disorder. Among mothers with only psychiatric diagnoses anxiety disorders, mood disorders and psychosis (one paranoid schizophrenia, one delusional disorder and two cases of acute psychosis) were most common. There was NORD J PSYCHIATRY·VOL 69 NO 4·2015
Table 3. Comparison of the final SCID-diagnoses between comorbid and ‘psychiatric only’ mothers.
Total number of diagnoses n, (%) Anxiety disorder Mood disorder Psychosis Alcohol Tetrahydrocannabinol Other drug Polydrug addiction Opioids Sedatives Amphetamine
SCID comorbid mothers (n ⫽ 11)
SCID “only psychiatric” mothers (n ⫽ 17)
29 (100) 8 (27) 5 (17) 4 (14) 5 (17) 2 (7) 2 (7) 2 (7) 1 (3) 0 (0) 0 (0)
33 (100) 18 (55) 10 (34) 5 (15) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0)
SCID, Structured Clinical Interview for DSM-IV.
no significant difference in the amount of psychoses between the groups. There were more different diagnostic groups and more psychiatric diagnoses among mothers with only psychiatric diagnoses compared with the comorbid mothers. A SCID-based personality disorder was diagnosed in 28 of the 49 patients. Altogether, there were 46 personality disorder diagnoses among the patients. At least two different personality disorders were found in 12 patients. Two patients had three, and two had four different personality disorders. Most prevalent were borderline (13/49) and antisocial (10/49) personality disorders.
Discussion The present study shows that pregnant women with substance misuse disorders often have poor living conditions and a hard personal and family history. Some of them are homeless, which is very rare in Finland. They also suffer from a wide variety of psychiatric diseases, some of which are severe. Diagnosing these disorders is challenging especially at the beginning, when addictions still prevail. Despite the fact that substance misuse often begins at an early age and so forth may also affect the development of personality and is tied to other psychiatric problems, part of these patients could overcome the substance use at least temporarily. Our clinical experience is that the risk for beginning drugs or excessive alcohol use rises again after the breastfeeding period. Longer follow-up is needed especially because valuable information about the association between daily alcohol use before or during pregnancy and child custody actions already exists. Alcohol use is related to long-term custody actions but not to the early phase incidents (5). That might be because mothers and babies get substantial help in the beginning yet the entire problem is long-standing and recurrent in nature.
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Experience from Norway—where compulsory treatment for addicted mothers is possible—shows that about half of the patients taken into these actions manage to overcome their substance abuse. In Finland, optional social welfare and healthcare services are available for free to everybody who knows how to use them. The problem with substance abusers is that they often live on the edge of society and have strong presuppositions about officials. Most of them still go to maternity clinics and in bigger towns there are also special clinics for pregnant women with substance misuse. The challenge then is to provide patients with easy access services. There are certain limitations in this study. First, in spite of the long timeframe, the study group remained small and the participation rate was low. Low participation rates have troubled other comorbidity studies among pregnant women, too (14, 15). Because of the small study group, some significant results may have been missed. The high attrition rate also means that the results cannot be generalized. However, two thirds of the reasons for quitting were practical, such as moving or abortion, and the final third was due to poor coping, such as lack of participation or the child having been taken into custody. The reasons for abortions or moving are not known but the amount of abortions in this group is 10 times that of 20–24-year-old women on average in Finland (16). Most of the patients who did not want to take part in the study continued in the treatment anyway. It is possible that the most severely ill patients did not participate. This would mean that in reality the diagnoses are even more numerous and severe. Another limitation is that this study was done as a part of routine practice. Thus, for feasibility reasons it was impossible to collect exact diagnostic information of the control group mothers. The control group attrition rate was a bit higher so the difference between groups might not be as huge as it now seems. Control mothers were meant to represent the normal population and proved more sober than results from Northern countries have shown. In other words, it is likely that within the control group, the substance using mothers tended not to answer. A more representative control group could be attained from mothers that have been referred to psychiatric evaluation due to psychiatric problems without substance misuse. One limitation is that different diagnostic tools were used in the beginning (ICD-10) than in the end (SCID) of the study. This is also because the study followed the clinical routine in the beginning. Even so, the number of substance use-related diagnoses decreased during the treatment period and provided the possibility to make psychiatric diagnoses, the number of which increased. It is also confusing that in the beginning there were six mothers without ICD diagnosis. They had been taken in the study because of former substance misuse. Later it was confirmed that three of them did but three did not
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match the SCID lifetime criteria of abuse or dependence. Both the initial evaluation and the SCID diagnosis were made by the doctor also responsible for the treatment. Full medical records and clinical knowledge were usable then but so were, on the other hand, also the possible presuppositions. The background information gathered in the present study is basically in line with earlier results, indicating that when screening for comorbidity the focus of attention should be in young, lower educated, unemployed and unplanned pregnancies (14, 17, 18). In earlier studies, most biological fathers have had addictions and about one fourth have reported violence in their current families (14, 17). To support an adequate early mother–child relationship, it is important to ask the patients about their partners’ substance abuse and domestic violence. Even if about one fifth of the patients were misusing alcohol during pregnancy in the present study, alcohol was less of a problem compared with earlier studies (14, 17). Opioids, amphetamine and cannabis were relatively commonly used during pregnancy in the present study. Opioid use was mostly, but not completely, explained by the maintenance treatment. More focus should be put in hard drug abusers, because they have earlier been identified as a risk group for comorbidity (14, 15). The same applies for smoking which seems to be an independent risk factor for mothers’ mental illness, especially depression and psychotic symptoms (14, 19). In the NESARC’s sub-study, smokers had a higher risk for any mental disease compared with non-smokers (OR 1.64, 95% CI 1.03–2.62) and nicotine dependency was a risk factor for Axis 1 disease (OR 5.07, 95% CI 3.48–7.38) (20). According to the SCID, the comorbid mothers were often diagnosed as polydrug users as in Oei et al.’s study (17). Alcohol was the most commonly used substance, which fits the Finnish substance misuse profile in general (21). The psychiatric profiles between comorbid and “only psychiatric” mothers were almost identical and for example anxiety disorders and depression were common in both groups. Anxiety has been found to be strongly predictive for relapses in alcohol dependent non-pregnant women (22). In general, there were several psychoses in the present small study group. This is in line with another Finnish study, where the average amount of paranoid and psychotic symptoms were common and 30% of them scored over the psychiatric outpatient average. This suggests that when the substance abuse problems are treated it is possible to diagnose psychiatric conditions. It is known that personality disorders are very common among alcohol misusing patients and even more so among drug abusers—44% of alcohol misusers and 79% of opiate addicts suffer from them (23, 24). These disorders tend to make the addiction or psychiatric treatment very difficult (25). In the present population of NORD J PSYCHIATRY·VOL 69 NO 4·2015
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substance misusing mothers, a bit over half had at least one personality disorder. The decision of leaving personality disorders out of the analysis has also been made in a large epidemiological comorbidity review (25). This was because these disorders affect the patient’s life for a long time with no expected changes during the short study period. There is a need for better identification of co-morbidity and substance misuse among mothers. The present study provides important information on comorbid mothers’ characteristics and helps professionals to detect mothers in danger for comorbidity and related problems. Only one earlier SCID-based comorbidity study among pregnant women was found (17). This is why the present study provides us with new information regarding comorbid mothers’ diagnostic profiles and emphasizes the importance of tackling both problems in the treatment services. Declaration of interest The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the paper.
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Strengell P,Väisänen I, Joukamaa M, Luukkaala T, Seppä K. Psychiatric comorbidity among substance misusing mothers. Nord J Psychiatry 2015;69:315–321. Background: Approximately half of patients suffering from a significant drug or alcohol related disorder also match the criteria of some other psychiatric disorder. Yet, little is known about comorbidity among substance misusing pregnant women. Aims: To estimate the prevalence of psychiatric diseases among mothers with substance misuse severe enough to end up in an assessment at a specialized addiction clinic and to compare their backgrounds to the controls. Methods: Between 1 June 2003 and 31 December 2005, the maternity clinics in Pirkanmaa health district were asked to refer mothers with possible substance misuse to Tampere University Addiction Psychiatric Clinic, where 119/217 patients were considered misusers. Of these, 49/119 (41.2%) participated in the whole study. At baseline, the assessment was made using the International Statistical Classification of Diseases and Related Health Problems (ICD-10) and at the end of the study, 6–12 months after delivery, with the Structured Clinical Interview for DSM-IV (SCID). The comparison group (n ⫽ 74) filled a postal survey concerning their background and substance use. Results: 57% of substance misusing pregnant women had psychiatric illnesses; 6–12 months after delivery the number of substance use-related diagnoses was 40%. However, the number, spectrum and severity of psychiatric diagnoses were high in this group. Conclusions: Psychiatric comorbidity is common among substance misusing mothers. Their social situation is often very difficult and support needs vary a lot. In order to offer them best possible treatment, diagnosing these disorders should be a routine part of evaluation during pregnancy. • Alcohol, Drugs, Pregnancy, SCID. Paula Strengell, Medical School, University of Tampere, Tampere, Finland, E-mail: paula. [email protected]; Accepted 16 October 2014.
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omorbidity in this study means that a patient has both a serious enough substance misuse to meet the criteria of either dependence or harmful use and a severe psychiatric condition like psychotic disorder, suicidal behaviour, major depression or personality disorder that complicates the patient’s life substantially. By definition, the psychiatric condition cannot only be a consequence of substance misuse. This definition was chosen because the concept of comorbidity is used variably in different studies and there is no well established use for it. The nature of the tight connection between substance misuse and psychiatric morbidity remains unclear. For example, antisocial personality disorder and substance misuse seem to have common grounds but alcoholism especially among women is more often a consequence of depression than a single reason for depression and
*Shared first authorship. © 2014 Informa Healthcare
anxiety disorders (1). According to the Epidemiologic Catchment Area (ECA) study, the population’s lifetime prevalence for substance misuse disorder is 16.7%. In drug misuse disorders, alcohol excluded, comorbidity is 53%, most commonly for anxiety and affective disorders. These figures are substantially higher than in the general population. About 25–30% of patients with a difficult psychiatric disease have an acute substance misuse disorder. Among schizophrenics, the rate is 47%, in affective disorders 32% and in anxiety disorders 24% (2, 3). According to different studies, 10–30% of depressed patients have a comorbid substance use problem, mostly with alcohol. The severity of psychiatric comorbidities is increased with the use of multiple substances (4). The National Comorbidity Survey found out that alcohol dependent women had 4.36 times the risk (95% CI 3.30–5.76) for affective disorder and 3.08 times (95% CI 2.20–4.30) for anxiety disorder than the population in DOI: 10.3109/08039488.2014.978892
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average (4). The ECA study showed that women with a lifelong drug abuse history had 4.5 times the risk for mental illness than those who had never used drugs (2). According to Finnish register based study, the comorbidity among substance misusing mothers is 85 times that among controls for schizophrenia class disorders (ICD 10–11; F20–F29) and 13 times for mood affective disorders (F30–F39) (5). Different studies afford the comorbidity prevalences for different substances and disorders. The information is therefore scattered and providing a uniform view is difficult. Despite the knowledge of the severe effects of alcohol and cigarettes on the infant, 10% of pregnant women exceed the limits of moderate alcohol consumption (one or two doses/week) and 16% continue smoking during pregnancy (5, 6). Nordic researches have shown that almost half of all pregnant women are occasionally drunk during pregnancy (7, 8). A lot is known about substance misusing mothers’ and their children’s health in general but there are only a few studies about pregnant women’s comorbidity and even less about their background characteristics. Pregnancy has mostly been seen as a protective agent towards psychiatric illnesses.
Aims The purpose of this study was to evaluate the psychiatric diagnoses among substance abusing mothers. The hypothesis was that they are at least as abundant as in other patient groups. The more accurate information is gathered after delivery (SCID), but also the clinically attained ICD-10 diagnostics of the first assessment is presented and compared with the finals. Substance abuse refers to dependence and harmful use according to DSM-IV and ICD-10 criteria, respectively. Alcohol, tranquilizers and drugs (cannabinoids stimulants, opioids, hallucinogens, inhalants) are all included. Additionally, the background characteristics of these patients are described and compared with controls when possible.
Material and methods Subjects Between 1 June 2003 and 31 December 2005, maternity clinics in Pirkanmaa health district were asked to refer mothers suspected of substance misuse to Tampere University Addiction Psychiatric Clinic. The referral criteria were any drug use including opioids, stimulants and hallucinogens during 1 year before pregnancy or when pregnant (during the first study year any drug use during lifetime), over 8 points in the Alcohol Use Disorders Identification Test (AUDIT) (9), alcohol use before pregnancy over 16 doses per week or over five doses per day, alcohol use during pregnancy over eight doses per week (during the first study year over 10 doses per week)
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or over five doses per day or abuse of tranquilizers. This was done as a part of a project aiming to establish a new treatment model for this patient group. With these criteria, 217 referrals (5600 children born annually on the area) were received and the patients were evaluated in the Addiction Clinic. First they were met by a nurse and a social worker and based on their decision also by an addiction psychiatrist. All workers have at least 10 years of experience in addiction psychiatry. Patients with a strong clinical suspicion of ongoing substance misuse were encouraged and asked to stay at the clinic. Thus the criterion for choosing patients was not a strict diagnostic category but a condition that affects the patient’s life substantially diminishing the performance capacity. Altogether, 119/217 patients fulfilled this criterion and were offered evaluation and treatment on the basis of their individual needs using both individual treatment and networking. Both substance misuse problems and mental diseases were noticed and social support was offered. Inpatient treatment was available when needed. Of that group, 49/119 (41.2%) followed the whole protocol and took part in the final diagnostic evaluation when the baby was 6–12 months old; 70/119 did not get that far for a variety of reasons, 20 did not want to take part in the study and 26 ended up with abortion. Other reasons were moving away and child being taken into custody. Detailed information on the backgrounds of this drop-out group cannot be given since these patients did not give their consent to the study. The comparison group was acquired from mothers who had given birth in the same hospital in 2006. Two hundred consequent mothers were sent a postal survey and 74 (35%) answered. Drug screening or medical records were not checked so information of their substance use was based on their literal answers only.
Procedure A written informed consent was obtained from each patient at the SCID interview visit—this being the point of study entry. The consent was obtained from comparison group mothers by mail. Patients had the full choice of not taking part in the study or quitting in the middle while still receiving every treatment they needed. The research plan was approved by the ethical committee of the Pirkanmaa Hospital District. The 49 patients were evaluated during pregnancy and 6–12 months after delivery by an addiction psychiatrist (PS) co-working with a nurse or a social worker. The final evaluation was done 6–12 months after delivery in order to ensure that the possible postpartum depression and hormonal changes had gone over.
Measures The postal survey to the controls included questions about the social situation, substance use (smoking, alcohol and NORD J PSYCHIATRY·VOL 69 NO 4·2015
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different drugs), psychiatric treatment history, earlier prescribed drugs (antidepressants and antipsychotic drugs) and the AUDIT questionnaire. ICD-10 was used at the baseline diagnostic assessment of the patients (10). The final assessment 6–12 months after the delivery included the DSM-IV based SCID interview (11). Both methods were used to measure the present situation. In substance misuse, the timeframe is 1 year. Information about alcohol and drug use as well as social situation and former treatments was asked based on the European Addiction Severity Index (12). In this study, the focus was on Axis I diagnoses (depression, anxiety disorders and psychosis). Thus, personality disorders (Axis II) were listed, but their association to substance misuse disorders were not measured.
Statistical methods Statistical analyses were performed by IBM SPSS Statistics versions 7-19. Categorical background characteristics of substance misusing and non-selected control group of pregnant women were described by number of cases with percentages. Differences between groups were analysed by Pearson chi-square test or by Fisher’s exact test, if the expected values were too small. Normal distributed age was described by mean with range and tested by independent samples t-test. P-values less than 0.05 were considered statistically significant, but due to the small number of subjects, also some potentially important results below that value are reported (13) in addition to the statistically significant results (P ⬍ 0.05).
baby. Addictions and mental illnesses had been quite common in their childhood families. Even though many had drug problems, they mostly had not had any prison sentences. Most had sometimes used excessively alcohol but had stopped before pregnancy. About one fourth used intravenous drugs during pregnancy. More than half reported having ever used sedatives and about one fifth used them during pregnancy (Table 1). Cannabis was the most commonly used substance among the patients, second was alcohol, followed by amphetamine, sedatives and opioids. During pregnancy the order changed— opioids came first (because 10/14 of the users were on maintenance treatment), then sedatives, alcohol, amphetamine and cannabis. Hallucinogens and glues were almost always stopped before pregnancy. Even if all illicit substance use seemed to decrease during pregnancy, smoking increased three-fold. Almost one third of the patients had hepatitis C or some other hepatitis. Half of the patients had been in psychiatric outpatient or hospital treatment at least once before pregnancy. During pregnancy, 35 patients (72%) had been in psychiatric treatment. Antidepressants were the most commonly ever used psychiatric medicines (n ⫽ 36, 73%), sedatives came next (n ⫽ 21, 43%) and then antipsychotics (n ⫽ 15, 31%). Twenty-two of the patients (45%) had been in hospital for substance misuse treatment before and six (12%) during pregnancy. In this study group, 28 patients (57%) reported having had at least one drugrelated psychosis.
The ICD-10 diagnoses
Results Background characteristics of patients and controls The controls were significantly older and had significantly higher education than the patients (Table 1). All controls were in a permanent relationship and had several children more often than the patients. Only few of the controls used substances or smoked during pregnancy and none of them used amphetamine, cannabis, opioids or hallucinogens. In the AUDIT questionnaire 28 controls scored 0, 44 scored 1–4 and two scored ⬎ 4. Of the patients, 9/49 consumed alcohol during pregnancy (Table 2).
In-detail characteristics of the patients The pregnancies were usually not planned and violence at home was common (Table 2). Home help services and child custody services were often needed. The biological fathers of the unborn were also mostly addicted. Often the patients lived in bigger towns and some were homeless. None of the homeless lived on the street when pregnant but at their friends, parents or temporary shelters. During the treatment period, they were helped to get an apartment or some moved to supported homes with the NORD J PSYCHIATRY·VOL 69 NO 4·2015
In the entrance to the addiction clinic 21 patients (43%) were diagnosed as having only a substance use-related diagnosis and 14 (29%) as comorbid for both psychiatric and substance use. Eight (16%) were diagnosed having only a psychiatric disease, of whom four had only a personality disorder. Six patients (12%) got no diagnosis at all. The 49 patients had altogether 90 diagnoses. The most common was opioid use disorder (n ⫽ 15, 31%), then came alcohol (n ⫽ 14, 29%) and sedative (n ⫽ 10, 20%) use disorders. Personality disorders were found in 14 (29%). In the comorbid group (n ⫽ 14) there were altogether 40 diagnoses. Alcohol dependence was the most common diagnosis given to eight (57%), depression to six (43%) and anxiety disorders to five (36%). There were two psychosis diagnoses caused by undetermined substances.
The SCID diagnoses In the end of the study, 6–12 months after delivery, 12 patients (25%) had no diagnosis at all, nine (18%) had only alcohol or drug use-related diagnosis, 17 (35%) had only psychiatric diagnoses and 11 (22%) had double
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Table 1. Background characteristics of substance misusing and non-selected (control) pregnant women.
Age, mean (range) Under 21 years, n (%) 21–34 years, n (%) Over 34 years, n (%) Education, n (%) Vocational school or less University Missing Working status, n (%) Not at work Studying or at work Mother’s marital status Marriage or common-law marriage Alone during pregnancy Divorced (incl. comm.-law marr.) Number of children One Two More than two Smoking, n (%) Never Before pregnancy During pregnancy Missing Sedatives Never Before pregnancy During pregnancy Missing Cannabis Never Before pregnancy During pregnancy Missing Amphetamine and stimulants Never Before pregnancy During pregnancy Missing Opioids Never Before pregnancy During pregnancy Missing Hallucinogens Never Before pregnancy During pregnancy Missing
Patients (n ⫽ 49)
Controls (n ⫽ 74)
25.2 (17–41) 11 (22) 37 (76) 1 (2)
30.8.2014 30.8 (22–41) 0 (0) 60 (81) 14 (19)
⬍ 0.001
⬍ 0.001 47 (100) 0 (0) 2
38 (51) 36 (49)
36 (74) 13 (27)
19 (26) 55 (74)
33 (67) 12 (25) 4 (8)
74 (100) 0 (0) 0 (0)
36 (74) 8 (16) 5 (10)
34 (46) 27 (37) 13 (18)
1 (3) 10 (25) 29 (73) 9
51 (85) 4 (7) 5 (8) 14
20 (42) 19 (40) 9 (19) 1
57 (95) 2 (3) 1 (2) 14
8 (16) 35 (71) 6 (12) 0
57 (95) 3 (5) 0 (0) 14
12 (25) 29 (60) 7 (15) 1
60 (100) 0 (0) 0 (0) 14
22 (45) 13 (27) 14 (29) 0
60 (100) 0 (0) 0 (0) 14
27 (55) 21 (43) 1 (2) 0
60 (100) 0 (0) 0 (0) 14
⬍ 0.001
⬍ 0.001
0.010
⬍ 0.001
⬍ 0.001
⬍ 0.001
⬍ 0.001
⬍ 0.001
⬍ 0.001
diagnosis. Thus, compared with the baseline situation assessed using ICD-10, the group with no diagnosis had increased and the number of drug- and alcohol-related diagnosed had decreased. However, the group with only a psychiatric diagnosis had increased. Six out of nine psychosis diagnoses had no drug-related origin.
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P
Those without a substance use-related diagnosis [(SA⫺), e.g. had no diagnosis at all or only had a psychiatric diagnosis, n ⫽ 29], at the end of the study were compared with those who had this diagnosis [(SA⫹), e.g. had either a substance use-related diagnosis alone or with a psychiatric diagnosis, n ⫽ 20]. The SA⫺ group NORD J PSYCHIATRY·VOL 69 NO 4·2015
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Table 2. Detailed characteristics of the substance misusing pregnant women, number of participants n with percentages (%).
Homeless, n (%) Conditional or unconditional sentence Addiction in childhood family Pregnancy planned Older children living away Home help services Child custody services at home Violence at home Father of the child addicted Alcohol use Never Before pregnancy During pregnancy Intravenous drug use Never Irregular use Regular use Use during pregnancy Opioid maintenance Never Begin during pregnancy Begin before pregnancy Hepatitis C Psych. hospital care during pregnancy Psych. outpatient care during pregnancy
Patients (n ⫽ 49)
Number of missing values
5 (10) 11 (22) 24 (49) 10 (22) 8 (16) 28 (57) 26 (53) 12 (25) 34 (69)
0 0 11 4 0 0 0 1 4 0 0 0 0 0
6 (12) 34 (69) 9 (18) 20 (41) 5 (10) 13 (27) 11 (22)
0 39 (80) 8 (16) 2 (4) 14 (30) 15 (31) 20 (41)
2 0
had more often been in earlier outpatient psychiatric care before (66% vs. 25%, P ⫽ 0.009) and also during pregnancy (55% vs. 20%, P ⫽ 0.019). SA⫹ group’s mothers had more often been in psychiatric hospital care during pregnancy (50% vs. 17%, P ⫽ 0.026). They had also had more drug psychoses during lifetime (79% vs. 46%, P ⫽ 0.036). Substance withdrawal outpatient treatment during pregnancy was more common in the SA⫹ group, too (80% vs. 41%, P ⫽ 0.009). Intravenous drugs during pregnancy were also more common in the SA⫹ than in the SA⫺ group (60% vs. 41%, P ⫽ 0.050). The final SCID-diagnoses of the comorbid mothers (n ⫽ 11) and mothers with only psychiatric diagnoses (n ⫽ 17) were compared (Table 3). The total number of diagnoses was 29/11 and 33/17, respectively. In the comorbid group alcohol was the most commonly used substance, next came various polydrug addictions, cannabis and finally opioids. There were no sedative or amphetamine users at the end of the study in this group. The most frequent psychiatric diagnoses were anxiety disorders, psychosis (acute, alcohol dependent, two undetermined) and mood disorders including bipolar disorder. Among mothers with only psychiatric diagnoses anxiety disorders, mood disorders and psychosis (one paranoid schizophrenia, one delusional disorder and two cases of acute psychosis) were most common. There was NORD J PSYCHIATRY·VOL 69 NO 4·2015
Table 3. Comparison of the final SCID-diagnoses between comorbid and ‘psychiatric only’ mothers.
Total number of diagnoses n, (%) Anxiety disorder Mood disorder Psychosis Alcohol Tetrahydrocannabinol Other drug Polydrug addiction Opioids Sedatives Amphetamine
SCID comorbid mothers (n ⫽ 11)
SCID “only psychiatric” mothers (n ⫽ 17)
29 (100) 8 (27) 5 (17) 4 (14) 5 (17) 2 (7) 2 (7) 2 (7) 1 (3) 0 (0) 0 (0)
33 (100) 18 (55) 10 (34) 5 (15) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0)
SCID, Structured Clinical Interview for DSM-IV.
no significant difference in the amount of psychoses between the groups. There were more different diagnostic groups and more psychiatric diagnoses among mothers with only psychiatric diagnoses compared with the comorbid mothers. A SCID-based personality disorder was diagnosed in 28 of the 49 patients. Altogether, there were 46 personality disorder diagnoses among the patients. At least two different personality disorders were found in 12 patients. Two patients had three, and two had four different personality disorders. Most prevalent were borderline (13/49) and antisocial (10/49) personality disorders.
Discussion The present study shows that pregnant women with substance misuse disorders often have poor living conditions and a hard personal and family history. Some of them are homeless, which is very rare in Finland. They also suffer from a wide variety of psychiatric diseases, some of which are severe. Diagnosing these disorders is challenging especially at the beginning, when addictions still prevail. Despite the fact that substance misuse often begins at an early age and so forth may also affect the development of personality and is tied to other psychiatric problems, part of these patients could overcome the substance use at least temporarily. Our clinical experience is that the risk for beginning drugs or excessive alcohol use rises again after the breastfeeding period. Longer follow-up is needed especially because valuable information about the association between daily alcohol use before or during pregnancy and child custody actions already exists. Alcohol use is related to long-term custody actions but not to the early phase incidents (5). That might be because mothers and babies get substantial help in the beginning yet the entire problem is long-standing and recurrent in nature.
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Experience from Norway—where compulsory treatment for addicted mothers is possible—shows that about half of the patients taken into these actions manage to overcome their substance abuse. In Finland, optional social welfare and healthcare services are available for free to everybody who knows how to use them. The problem with substance abusers is that they often live on the edge of society and have strong presuppositions about officials. Most of them still go to maternity clinics and in bigger towns there are also special clinics for pregnant women with substance misuse. The challenge then is to provide patients with easy access services. There are certain limitations in this study. First, in spite of the long timeframe, the study group remained small and the participation rate was low. Low participation rates have troubled other comorbidity studies among pregnant women, too (14, 15). Because of the small study group, some significant results may have been missed. The high attrition rate also means that the results cannot be generalized. However, two thirds of the reasons for quitting were practical, such as moving or abortion, and the final third was due to poor coping, such as lack of participation or the child having been taken into custody. The reasons for abortions or moving are not known but the amount of abortions in this group is 10 times that of 20–24-year-old women on average in Finland (16). Most of the patients who did not want to take part in the study continued in the treatment anyway. It is possible that the most severely ill patients did not participate. This would mean that in reality the diagnoses are even more numerous and severe. Another limitation is that this study was done as a part of routine practice. Thus, for feasibility reasons it was impossible to collect exact diagnostic information of the control group mothers. The control group attrition rate was a bit higher so the difference between groups might not be as huge as it now seems. Control mothers were meant to represent the normal population and proved more sober than results from Northern countries have shown. In other words, it is likely that within the control group, the substance using mothers tended not to answer. A more representative control group could be attained from mothers that have been referred to psychiatric evaluation due to psychiatric problems without substance misuse. One limitation is that different diagnostic tools were used in the beginning (ICD-10) than in the end (SCID) of the study. This is also because the study followed the clinical routine in the beginning. Even so, the number of substance use-related diagnoses decreased during the treatment period and provided the possibility to make psychiatric diagnoses, the number of which increased. It is also confusing that in the beginning there were six mothers without ICD diagnosis. They had been taken in the study because of former substance misuse. Later it was confirmed that three of them did but three did not
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match the SCID lifetime criteria of abuse or dependence. Both the initial evaluation and the SCID diagnosis were made by the doctor also responsible for the treatment. Full medical records and clinical knowledge were usable then but so were, on the other hand, also the possible presuppositions. The background information gathered in the present study is basically in line with earlier results, indicating that when screening for comorbidity the focus of attention should be in young, lower educated, unemployed and unplanned pregnancies (14, 17, 18). In earlier studies, most biological fathers have had addictions and about one fourth have reported violence in their current families (14, 17). To support an adequate early mother–child relationship, it is important to ask the patients about their partners’ substance abuse and domestic violence. Even if about one fifth of the patients were misusing alcohol during pregnancy in the present study, alcohol was less of a problem compared with earlier studies (14, 17). Opioids, amphetamine and cannabis were relatively commonly used during pregnancy in the present study. Opioid use was mostly, but not completely, explained by the maintenance treatment. More focus should be put in hard drug abusers, because they have earlier been identified as a risk group for comorbidity (14, 15). The same applies for smoking which seems to be an independent risk factor for mothers’ mental illness, especially depression and psychotic symptoms (14, 19). In the NESARC’s sub-study, smokers had a higher risk for any mental disease compared with non-smokers (OR 1.64, 95% CI 1.03–2.62) and nicotine dependency was a risk factor for Axis 1 disease (OR 5.07, 95% CI 3.48–7.38) (20). According to the SCID, the comorbid mothers were often diagnosed as polydrug users as in Oei et al.’s study (17). Alcohol was the most commonly used substance, which fits the Finnish substance misuse profile in general (21). The psychiatric profiles between comorbid and “only psychiatric” mothers were almost identical and for example anxiety disorders and depression were common in both groups. Anxiety has been found to be strongly predictive for relapses in alcohol dependent non-pregnant women (22). In general, there were several psychoses in the present small study group. This is in line with another Finnish study, where the average amount of paranoid and psychotic symptoms were common and 30% of them scored over the psychiatric outpatient average. This suggests that when the substance abuse problems are treated it is possible to diagnose psychiatric conditions. It is known that personality disorders are very common among alcohol misusing patients and even more so among drug abusers—44% of alcohol misusers and 79% of opiate addicts suffer from them (23, 24). These disorders tend to make the addiction or psychiatric treatment very difficult (25). In the present population of NORD J PSYCHIATRY·VOL 69 NO 4·2015
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substance misusing mothers, a bit over half had at least one personality disorder. The decision of leaving personality disorders out of the analysis has also been made in a large epidemiological comorbidity review (25). This was because these disorders affect the patient’s life for a long time with no expected changes during the short study period. There is a need for better identification of co-morbidity and substance misuse among mothers. The present study provides important information on comorbid mothers’ characteristics and helps professionals to detect mothers in danger for comorbidity and related problems. Only one earlier SCID-based comorbidity study among pregnant women was found (17). This is why the present study provides us with new information regarding comorbid mothers’ diagnostic profiles and emphasizes the importance of tackling both problems in the treatment services. Declaration of interest The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the paper.
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