Perinatal smoking and depression in women with concurrent substance use

Predictors of cigarette smoking in pregnant women with substance use disorders

BACKGROUND

Cigarette smoking is common among pregnant women with substance use disorders (SUD) and may contribute to more adverse health consequences for the infant than alcohol and illicit drug use. However, most studies focused on stopping illicit drug use and paid little attention to cigarette smoking in pregnant women with SUD.

PURPOSE

To identify predictors of current smoking among pregnant women with SUD, given past-month psychological distress, alcohol use and illicit drug use, the receipt of past-year mental health and substance use treatment controlling for potential confounders.

METHODS

Secondary analysis of cross-sectional data from the National Survey on Drug Use and Health (NSDUH) 2015-2019 was conducted. The NSDUH included 3,540 pregnant women aged 18-44 years; among them were 195 lifetime smokers with SUD. Multiple logistic regression modeling was used to examine the probability of prenatal smoking.

RESULTS

Sixty-one percent of pregnant women with SUD reported current cigarette smoking. The likelihood of prenatal smoking increased with a higher level of past-month psychological distress (Adjusted Odds Ratio [AOR] 1.14; 95% Confidence Interval [CI]: 1.02-1.28), past-month illicit drug use (AOR: 5.68; 95% CI: 1.59-20.21), and past-year substance use treatment receipt (AOR: 5.73; 95% CI: 1.88-17.45).

CONCLUSION

The receipt of substance use treatment markedly increased the probability of smoking in pregnant women with SUD. Treatment and policy initiatives are required to address and integrate cigarette smoking within other substance use treatment modalities for pregnant women with SUD.

Systematic Review: Polysubstance Prevalence Estimates Reported during Pregnancy, US, 2009-2020

INTRODUCTION

The objective of this systematic review is to describe polysubstance studies and their prevalence estimates among pregnant people in the US.

METHODS

This review was not subject to protocol preparation or registration with the International Prospective Register of Systematic Reviews (PROSPERO) because outcome data were not reported. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) Checklist was followed. Four scientific literature databases were used to identify articles published from January 1, 2009 to June 3, 2020 reporting prenatal exposure to two or more substances in the US. A standardized process of title and abstract screening followed by a two-phase full-text review was used to assess study eligibility.

RESULTS

A total of 119 studies were included: 7 case-control studies, 7 clinical trials, 76 cohort studies, and 29 cross-sectional studies. Studies varied with respect to study design, time period, region, sampling and participant selection, substances assessed, and method of exposure ascertainment. Commonly reported polysubstance prevalence estimates among studies of pregnant people included combinations with alcohol, marijuana, and/or tobacco/nicotine. The range of prevalence estimates was wide (alcohol 1-99%; marijuana 3-95%; tobacco/nicotine 2-95%).

DISCUSSION

Polysubstance use during pregnancy is common, especially with alcohol, marijuana, and/or tobacco/nicotine. Future research to assess polysubstance use during pregnancy could help better describe patterns and ultimately help mitigate its effects on maternal and infant health outcomes.

Psychosocial factors and health practices in pregnancy: A cross-sectional study

AIM

The aim of this study was to investigate psychosocial, demographic and obstetric factors that affect health practices in pregnancy.

METHODS

This cross-sectional study was conducted with pregnant women selected by using random sampling in a public hospital in Turkey. The pregnant women (n = 383) completed the Health Practices Questionnaire in Pregnancy, the Center for Epidemiologic Studies Depression Scale, the Beck Anxiety Inventory and the Multidimensional Scale of Perceived Social Support. Multiple linear regression was used to examine predictors of participation in health practices. The variables were subjected to multiple linear regression analysis to estimate the effect of each independent variable (depression, anxiety, perceived social support, age, educational level, gestational week and parity) on the dependent variable (health practices).

RESULTS

Depression and anxiety were not significantly related to gestational health practices. The multiple linear regression model showed that inadequate social support, low education level, early gestational week and high parity were significant predictors of nonengagement in favourable health practices during pregnancy.

CONCLUSIONS

Pregnant women with inadequate social support and specific demographic and obstetric characteristics are less likely to participate in gestational health practices. This study suggests that more attention should be paid to these groups to improve the health practices of pregnant women.

A New Parental Mentalization Focused Ultrasound Intervention for Substance Using Pregnant Women. Effect on Self-reported Prenatal Mental Health, Attachment and Mentalization in a Randomized and Controlled Trial

The effect of a novel mentalization-based parenting intervention was explored on prenatal self-reported mentalization (P-PRFQ), attachment (MFAS), depression (EPDS) and anxiety (STAI) among women with substance use problems. The participants were 90 pregnant women referred to obstetric outpatient care due to recent or current substance use and randomized into intervention (n = 46) and control (n = 44) groups. The intervention group received three interactive 4D ultrasound sessions and a week-by-week pregnancy diary. The control condition was constituted of treatment-as-usual in obstetric care. Unfortunately, the efficacy of the intervention on maternal prenatal mental health, attachment, and parental mentalization was not substantiated. The negative results may be related to the small sample size, the patient-reported outcomes, or insufficient efficacy within this high-risk group. In the context of high psychosocial risks and follow-up by Child Welfare Services, the patient-reported outcomes may have underestimated prenatal adversity. The role of the research context, methodology, and possible sources of bias in the outcome assessment are discussed.

The trial registration number in the ClinicalTrials.gov: NCT03413631

Psychological interventions for co-occurring depression and substance use disorders

BACKGROUND

Comorbid depression and substance use disorders are common and have poorer outcomes than either disorder alone. While effective psychological treatments for depression or substance use disorders are available, relatively few randomised controlled trials (RCTs) have examined the efficacy of these treatments in people with these comorbid disorders.

OBJECTIVES

To assess the efficacy of psychological interventions delivered alone or in combination with pharmacotherapy for people diagnosed with comorbid depression and substance use disorders.

SEARCH METHODS

We searched the following databases up to February 2019: Cochrane Central Register of Controlled Trials, PubMed, Embase, CINAHL, Google Scholar and clinical trials registers. All systematic reviews identified, were handsearched for relevant articles.

SELECTION CRITERIA

The review includes data from RCTs of psychological treatments for people diagnosed with comorbid depression and substance use disorders, using structured clinical interviews. Studies were included if some of the sample were experiencing another mental health disorder (e.g. anxiety); however, studies which required a third disorder as part of their inclusion criteria were not included. Studies were included if psychological interventions (with or without pharmacotherapy) were compared with no treatment, delayed treatment, treatment as usual or other psychological treatments.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures expected by Cochrane.

MAIN RESULTS

Seven RCTs of psychological treatments with a total of 608 participants met inclusion criteria. All studies were published in the USA and predominately consisted of Caucasian samples. All studies compared different types of psychological treatments. Two studies compared Integrated Cognitive Behavioural Therapy (ICBT) with Twelve Step Facilitation (TSF), another two studies compared Interpersonal Psychotherapy for Depression (IPT-D) with other treatment (Brief Supportive Therapy (BST) or Psychoeducation). The other three studies compared different types or combinations of psychological treatments. No studies compared psychological interventions with no treatment or treatment as usual control conditions. The studies included a diverse range of participants (e.g. veterans, prisoners, community adults and adolescents). All studies were at high risk of performance bias, other main sources were selection, outcome detection and attrition bias. Due to heterogeneity between studies only two meta-analyses were conducted. The first meta-analysis focused on two studies (296 participants) comparing ICBT to TSF. Very low-quality evidence revealed that while the TSF group had lower depression scores than the ICBT group at post-treatment (mean difference (MD) 4.05, 95% confidence interval (CI) 1.43 to 6.66; 212 participants), there was no difference between groups in depression symptoms (MD 1.53, 95% CI -1.73 to 4.79; 181 participants) at six- to 12-month follow-up. At post-treatment there was no difference between groups in proportion of days abstinent (MD -2.84, 95% CI -8.04 to 2.35; 220 participants), however, the ICBT group had a greater proportion of days abstinent than the TSF group at the six- to 12-month follow-up (MD 10.76, 95% CI 3.10 to 18.42; 189 participants). There were no differences between the groups in treatment attendance (MD -1.27, 95% CI -6.10 to 3.56; 270 participants) or treatment retention (RR 0.95, 95% CI 0.72 to 1.25; 296 participants). The second meta-analysis was conducted with two studies (64 participants) comparing IPT-D with other treatment (Brief Supportive Psychotherapy/Psychoeducation). Very low-quality evidence indicated IPT-D resulted in significantly lower depressive symptoms at post-treatment (MD -0.54, 95% CI -1.04 to -0.04; 64 participants), but this effect was not maintained at three-month follow-up (MD 3.80, 95% CI -3.83 to 11.43) in the one study reporting follow-up outcomes (38 participants; IPT-D versus Psychoeducation). Substance use was examined separately in each study, due to heterogeneity in outcomes. Both studies found very low-quality evidence of no significant differences in substance use outcomes at post-treatment (percentage of days abstinent, IPD versus Brief Supportive Psychotherapy; MD -2.70, 95% CI -28.74 to 23.34; 26 participants) or at three-month follow-up (relative risk of relapse, IPT-D versus Psychoeducation; RR 0.67, 95% CI 0.30 to 1.50; 38 participants). There was also very low-quality evidence for no significant differences between groups in treatment retention (RR 1.00, 95% CI 0.81 to 1.23; 64 participants). No adverse events were reported in any study.

AUTHORS' CONCLUSIONS

The conclusions of this review are limited due to the low number and very poor quality of included studies. No conclusions can be made about the efficacy of psychological interventions (delivered alone or in combination with pharmacotherapy) for the treatment of comorbid depression and substance use disorders, as they are yet to be compared with no treatment or treatment as usual in this population. In terms of differences between psychotherapies, although some significant effects were found, the effects were too inconsistent and small, and the evidence of too poor quality, to be of relevance to practice.

Influence of smoking habits on mental status in Japanese women during the first trimester of pregnancy

PURPOSE

We examined the relation between smoking habits and maternal mental status such as depression and anxiety during the first trimester of pregnancy.

MATERIAL AND METHODS

Between July 2016 and June 2018, we examined the increased odds of depressive and anxiety symptoms in the women with smoking habits during prepregnancy with and without smoking cessation during the first trimester of pregnancy in comparison with those without smoking habits using self-administered questionnaires.

RESULTS

The rate of depressive and anxiety symptom in the women with smoking habits during prepregnancy (46.4 and 47.3%, respectively) was higher than those in the women without smoking habits during the first trimester of pregnancy irrespective of smoking cessation. The rate of depressive or anxiety symptom during the first trimester of pregnancy did not change significantly by smoking cessation in the women with smoking habits during prepregnancy (depressive symptom: 44.6 versus 53.7%, p = .13; anxiety symptom: 45.3 versus 55.2%, p = .17).

CONCLUSIONS

Smoking habits during prepregnancy seemed to be associated with the increased perinatal mental disorders irrespective of smoking cessation.

Temporal trends of co-diagnosis of depression and/or anxiety among female maternal and non-maternal hospitalizations: Results from Nationwide Inpatient Sample 2004-2013

Perinatal depression/anxiety is considered the most underdiagnosed pregnancy complication in the US and is associated with poor maternal and fetal outcomes. However, despite its prevalence, most women who present with depressive symptoms are not screened and do not receive adequate treatment. We examined the clinical co-diagnosis of depression and/or anxiety among maternal and non-maternal hospitalizations among females aged 14-49 from the Nationwide Inpatient Sample (NIS) between 2004 and 2013 (n = 83,472,775). Meta-regression was used to determine annual change and presence of temporal trends. Survey logistic regression was used to examine the association with sociodemographic factors. Rates of diagnosis of depression and/or anxiety disorders demonstrated a temporal increase from 2004-2013, and this increase was mainly driven by non-maternal hospitalizations compared to maternal. Furthermore, non-maternal hospitalizations demonstrated a greater prevalence of depression and/or anxiety diagnoses compared to maternal hospitalizations over the same time period (21•7% versus 2•8%). Among all female hospitalizations, whites were roughly twice as likely as minorities to have a diagnosis of depression and/or anxiety. These results add to the evidence suggestive of the underdiagnosed depression/anxiety present among women of reproductive age, particularly pregnant women and minorities, and underscore the critical role of obstetricians in treating both physical and mental health.

Clusters of Behavioral Health and Psychosocial Risk for Childbearing Women in Four Virginia Communities

Introduction Four Virginia communities participated in a community services enhancement pilot to centralize intake and referral for childbearing women eligible for home visiting support through the Maternal, Infant and Early Childhood Home Visiting (MIECHV) program. Methods As an aspect of the study, project-trained intake workers administered behavioral health and psychosocial risk screening (including emotional health, substance use, interpersonal violence, and smoking) during intake eligibility assessment. Participants identified as at-risk were referred for community intervention concurrently with referral to MIECHV services. Results In the study sample (N = 1515), emotional health was identified as the most common single risk factor (n = 326, 21.5%) and clusters of 2 or more behavioral health risks were identified for 223 (14.7%) of women. Among those with two or more behavioral health risks, smoking was significantly related to all other areas of behavioral health risk. Conclusion Findings from this multi-site pilot emphasize concomitant behavioral health and psychosocial risks in childbearing women and reinforce the importance of embedding comprehensive public health interventions in community systems of care.

Effects of Maternal Mental Health on Engagement in Favorable Health Practices During Pregnancy

INTRODUCTION

A woman's health practices during pregnancy are associated with maternal and neonatal outcomes. Yet limited research has examined predictors of a woman's engagement in favorable health practices, particularly in pregnant women at greatest risk for adverse outcomes. We examined the role of mental health on engagement in favorable health practices during pregnancy in a sample of pregnant, low-income, predominantly African American women.

METHODS

A convenience sample of pregnant women was obtained from 3 obstetric clinics within a large Mid-Atlantic academic health system. Pregnant women (N = 166) completed measures of depression, social support, and engagement in favorable health practices during their second trimester. Six domains of health practices (ie, balance of rest and exercise, safety measures, nutrition, substance use, health care access, access to pregnancy-related information) were assessed by the Health Practices in Pregnancy Questionnaire-II. Multiple linear regression was used to examine predictors of engagement in favorable health practices.

RESULTS

Fifty-nine percent of the study participants experienced depressive symptomatology during pregnancy. Multivariate linear regression modeling demonstrated that increased depressive symptoms, decreased social support, young age, and prepregnancy overweight or obesity were significant predictors of nonengagement in favorable health practices during pregnancy.

DISCUSSION

Findings suggest that pregnant women with poor mental health (eg, depressive symptomatology, poor social support) and specific sociodemographic characteristics (eg, young age, prepregnancy overweight or obesity) were less likely to engage in favorable health practices during pregnancy. Health care providers are uniquely positioned to assess a woman's mental health and related indicators to optimize pregnancy and neonatal outcomes.

Intrauterine Tobacco Smoke Exposure and Congenital Heart Defects

Tobacco use and second-hand smoke exposure during pregnancy are linked to a host of deleterious effects on the pregnancy, fetus, and infant. Health outcomes improve when women quit smoking at any time during the pregnancy. However, the developing heart is vulnerable to noxious stimuli in the early weeks of fetal development, a time when many women are not aware of being pregnant. Congenital heart defects are the most common birth defects. Research shows an association between maternal tobacco exposure, both active and passive, and congenital heart defects. This article presents recent evidence supporting the association between intrauterine cigarette smoke exposure in the periconceptional period and congenital heart defects and discusses clinical implications for practice for perinatal and neonatal nurses.

A pilot study of home-based smoking cessation programs for rural, appalachian, pregnant smokers

OBJECTIVE

To evaluate a web-based contingency management program (CM) and a phone-delivered cessation counseling program (Smoking Cessation for Healthy Births [SCHB]) with pregnant smokers in rural Appalachia who were ≤12 weeks gestation at enrollment.

DESIGN

Two group randomized design.

SETTING

Home-based cessation programs in rural Appalachia Ohio and Kentucky.

PARTICIPANTS

A community sample of pregnant smokers (N = 17).

METHODS

Participants completed demographic and smoking-related questionnaires and were assigned to CM (n = 7) or SCHB (n = 10) conditions. Smoking status was assessed monthly using breath carbon monoxide and urinary cotinine.

RESULTS

For CM, two of seven (28.57%) of the participants achieved abstinence, and three of 10 (30%) of those enrolled in SCHB were abstinent by late in pregnancy. Participants in CM attained abstinence more rapidly than those in SCHB. However, those in SCHB experienced less relapse to smoking, and a greater percentage of these participants reduced their smoking by at least 50%.

CONCLUSION

Based on this initial evaluation, the web-based CM and SCHB programs appeared to be feasible for use with rural pregnant smokers with acceptable program adherence for both approaches. Future researchers could explore combining these programs to capitalize on the strengths of each, for example, rapid smoking cessation based on CM incentives and better sustained cessation or reductions in smoking facilitated by the counseling support of SCHB.