The Intersection of Mental Health and Prenatal Substance Use

Pregnancy is often considered a time of joy and anticipation, yet for many individuals, it can also pose substantial emotional, physical, and psychological challenges and worsen existing mental health issues. Left unaddressed, these mental health challenges can increase the risk of substance use during pregnancy. Prenatal substance use, whether involving alcohol, drugs, or nicotine, poses risks not only to the mother’s well-being but also to the developing fetus, potentially leading to both short and long-term health complications, as well as increased mortality. Understanding the connections between mental health and prenatal substance use is critical for healthcare providers, families, and communities, as it can guide effective interventions and support.

The scope of the issue

A study published by Columbia University found that drug overdose deaths among pregnant and postpartum individuals increased by 81% between 2017 and 2020. While alcohol, tobacco, and marijuana are the substances most often used during pregnancy, opioid use during pregnancy has increased substantially. Individuals of reproductive age are clearly struggling with substance use disorders (SUD), but an SUD frequently also presents alongside additional mental health conditions such as depression, generalized anxiety, and trauma-related disorders. According to the American Psychiatric Association, each year, an estimated 500,000 pregnant women in the United States experience a mental health disorder before or during pregnancy, and nearly 1 in 4 pregnancy-related deaths can be attributed to mental health conditions, including substance use disorders. These co-occurring mental health and substance use disorders – sometimes called "dual diagnoses" – represent a significant public health concern. This intersection presents unique risks, as untreated mental health issues can fuel substance use, while substance use can exacerbate mental health symptoms, creating a vicious cycle. 

Studies show a substantially higher rate of mental illness in mothers who experience a substance use disorder. Depression, anxiety, and trauma-related disorders significantly influence substance use among pregnant women, as these mental health challenges often drive self-medication. Depression affects about 10-20% of pregnant women, and untreated symptoms – such as sadness, low energy, and hopelessness – can lead to increased use of substances like nicotine, alcohol, and marijuana. Anxiety disorders, including generalized anxiety disorder (GAD) and social anxiety, also correlate with increased substance use, especially nicotine, as some women use smoking to manage anxiety symptoms. Trauma-related disorders further elevate substance use risks, particularly among women with histories of abuse or violence. Trauma increases the likelihood of substance use as a coping mechanism, underscoring the importance of addressing mental health needs to reduce reliance on harmful substances during pregnancy. Research suggests that 50% of pregnant individuals who are referred to child protective services for prenatal substance use have four or more adverse childhood experiences (ACEs), reinforcing the idea that addressing underlying social-emotional health and intergenerational trauma is essential also to address problems relating to substance use.

Approaches to healthcare and intervention

The high prevalence of co-occurring mental health and substance use disorders in pregnancy has substantial implications for healthcare providers and policymakers. Effective interventions require a dual-focus approach that addresses both mental health conditions and substance use simultaneously. Research suggests that integrated treatment models – those combining prenatal care with mental health and substance use support – are the most effective at reducing substance use among pregnant women with co-occurring disorders. Integrated treatment links individuals to a range of providers that can deliver the coordinated, specialized, and personalized services needed. For example, it might link a person’s primary care provider, obstetrician, and behavioral health practitioner to coordinate effective care. The American College of Obstetricians and Gynecologists promotes the use of early, widespread universal screening for both substance use and mental health disorders as part of standard prenatal care. There is actually a push for universal screening for any individual who presents with behavioral health disorders – substance use or mental health – regardless of whether they present with only one or the other.

In addition to screening, pregnant individuals struggling with substance use and mental health issues can benefit from several support interventions:

• Cognitive behavioral therapy (CBT) helps manage anxiety, depression, and trauma, reducing reliance on substances. 

• Medication-assisted treatment (MAT) provides a safe alternative for those with opioid use disorder, using medications like methadone alongside counseling.

• Community support groups offer non-judgmental spaces for sharing experiences, helping reduce stigma and foster empowerment. 

Home visits and case management by healthcare workers ensure access to resources, prenatal care, and support in underserved areas, making it easier for women to prioritize health during pregnancy.

Barriers to treatment and support

Stigma: Despite the importance of mental health and substance use treatment during pregnancy, several barriers often prevent individuals from seeking or receiving help. Society’s perspective on mental health and substance use is improving, but the persistence of stigma, especially for pregnant individuals, remains a barrier for many. In some cases, societal stigma surrounding mental health issues prevents pregnant women from seeking therapy or counseling. Mental health stigma can make openly discussing struggles difficult, leading to self-medication with substances. This can create a cycle in which pregnant women with mental health struggles feel isolated and unsupported, making it harder to break away from harmful substance use patterns.

Pregnant women who struggle with substance use often experience intense guilt, shame, and fear of judgment from healthcare providers, family, and society. Additionally, the fear of legal repercussions, particularly for illicit drug use, can deter many women from seeking the support they need. Recognizing prenatal substance use as a health issue rather than a moral failing can reduce shame, allowing women to seek the support they need. Improved education, open dialogue, and access to integrated healthcare services are essential in breaking down these barriers.

Criminalization: Another deterrent to pregnant women seeking support is the criminalization associated with prenatal and postnatal substance use and mental illness. Many fear that social services will get involved if a substance use disorder is revealed. Punitive policies such as fines, loss of custody, and incarceration for substance use in pregnancy deter women from accessing support services, though states with punitive policies have higher rates of infants who suffer from neonatal abstinence syndrome (NAS). Much of the drug criminalization stems from historical inequitable policies that disproportionately impact Black and Brown communities.

Gaps in provider education: The American Psychiatric Association notes that mental health and substance use disorders “remain largely undiagnosed, untreated, or undertreated” in pregnant individuals. In part, the lack of adequate treatment is attributed to gaps in behavioral health provider knowledge regarding how to deliver care appropriate to this particular demographic. Additional training could begin to close these gaps in knowledge and improve both prenatal and postnatal outcomes.

Lack of awareness: Many women are unaware of the dangers of certain substances during pregnancy or may underestimate the impact of their use. These misunderstandings and lack of knowledge are especially common with substances like alcohol, nicotine, and cannabis, which are often perceived as less harmful.

Limited access to healthcare: Many expectant mothers, particularly those from historically marginalized or low-income communities, lack access to healthcare services. Economic barriers, lack of transportation, and limited availability of specialized prenatal care contribute to this gap. More than one-third of all Americans live in what’s designated as a Mental Health Professional Shortage Area, which disproportionally impacts marginalized communities.

Moving forward

The complex relationship between mental health and substance use in pregnancy emphasizes the importance of comprehensive, compassionate care. Addressing both mental health conditions and substance use through integrated treatment models can significantly reduce risks for both mothers and their babies. With proper care, understanding, and support, pregnant women experiencing co-occurring disorders can find healthier pathways for themselves and their children.

References

• American Psychiatric Association. (2023). Perinatal mental and substance use disorders. https://www.psychiatry.org/getmedia/344c26e2-cdf5-47df-a5d7-a2d444fc1923/APA-CDC-Perinatal-Mental-and-Substance-Use-Disorders-Whitepaper.pdf

• Bruzelius, E., & Martins, S. S. (2022). US trends in drug overdose mortality among pregnant and postpartum persons, 2017-2020. JAMA, 328(21), 2159. https://doi.org/10.1001/jama.2022.17045

• Chang, G. (2020). Maternal substance use: Consequences, identification and interventions. Alcohol Research: Current Reviews, 40(2). https://doi.org/10.35946/arcr.v40.2.06

• Echols, A., Collins, S., Sanaa Akbarali, Ramya Dronamraju, & Uesugi, K. (2023). Public health approaches to perinatal substance use: An overview of strategic directions. Maternal and Child Health Journal, 27(S1), 1–4. https://doi.org/10.1007/s10995-023-03792-4

• Faherty, L. J., Kranz, A. M., Russell-Fritch, J., Patrick, S. W., Cantor, J., & Stein, B. D. (2019). Association of punitive and reporting state policies related to substance use in pregnancy with rates of neonatal abstinence syndrome. JAMA Network Open, 2(11), e1914078. https://doi.org/10.1001/jamanetworkopen.2019.14078

• Hirschtritt, M. E., Avalos, L. A., Sarovar, V., Ridout, K. K., Goler, N. C., Ansley, D. R., Satre, D. D., & Young-Wolff, K. C. (2022). Association between prenatal cannabis use and psychotropic medication use in pregnant patients with depression and anxiety. Journal of Addiction Medicine, 16(4). https://doi.org/10.1097/adm.0000000000000946

• Louw, K.-A. (2018). Substance use in pregnancy: The medical challenge. Obstetric Medicine, 11(2), 54–66. https://doi.org/10.1177/1753495X17750299

• Prince, M. K., & Ayers, D. (2023, July 21). Substance use in pregnancy. PubMed; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK542330/

• Rodriguez, J. J., & Smith, V. C. (2019). Epidemiology of perinatal substance use: Exploring trends in maternal substance use. Seminars in Fetal and Neonatal Medicine, 24(2), 86–89. https://doi.org/10.1016/j.siny.2019.01.006

• Serino, MA, D., Peterson, MD, B. S., & Rosen, MD, T. S. (2018). Psychological functioning of women taking illicit drugs during pregnancy and the growth and development of their offspring in early childhood. Journal of Dual Diagnosis, 14(3), 158–170. https://doi.org/10.1080/15504263.2018.1468946

• Substance Abuse and Mental Health Services Administration. (2022). The case for screening and treatment of co-occurring disorders. Www.samhsa.gov. https://www.samhsa.gov/co-occurring-disorders

• Tong, V. T., Farr, S. L., Bombard, J., DʼAngelo, D., Ko, J. Y., & England, L. J. (2016). Smoking before and during pregnancy among women reporting depression or anxiety. Obstetrics & Gynecology, 128(3), 562–570. https://doi.org/10.1097/aog.0000000000001595

• Volkow, N. (2023, February 15). Pregnant people with substance use disorders need treatment, not criminalization. National Institute on Drug Abuse. https://nida.nih.gov/about-nida/noras-blog/2023/02/pregnant-people-substance-use-disorders-need-treatment-not-criminalization