Co-occurring psychiatric disorders in women with addictions

There is clinically important comorbidity between psychiatric and substance use disorders, particularly in women. Women with affective and anxiety disorders are more likely to present with alcohol or drug abuse/dependence. In turn, substance-abusing women are more likely to experience clinically significant depression and anxiety. Emerging evidence is pointing to an etiological role for anxiety disorders in the development of substance abuse/dependence; however, etiologic evidence is not as clear-cut for major depressive disorder. PTSD appears to be a particularly important factor for alcohol and drug dependence in women who have experienced childhood or adult sexual and or physical abuse. Although pharmacotherapy for affective or anxiety disorders is useful for ameliorating psychiatric symptoms, research is mixed on the effectiveness for improving alcohol- and drug-related outcomes. There is some limited evidence that women-specific services can improve treatment retention, substance use outcomes, and possibly psychosocial functioning compared with traditional mixed-gender programs. However, it is clear that women with co-occurring psychiatric and substance use problems are challenging to engage and retain in care. Physicians providing women's reproductive health services can serve a vital role in the identification and referral of substance-abusing women. Particular attention should be focused on screening and assessment of alcohol and drug use and problem severity among women who have identified psychiatric disorders or who are receiving antidepressant or anxiolytic medications. Recognition and referral for both psychiatric and substance use disorders are critical for long-term health and psychosocial improvement.     

Linking substance-abusing pregnant women to drug treatment services: a pilot program

Obiective : To conduct a pilot study to assist pregnant substance abusers to enter drug treatment.
Design : A nonexperimental design provided eligible women with outreach/home visits from a team led by a public health nurse.
Setting : All services for the women were provided in homes in the northeastern United States.
Participants : Ten pregnant substance-abusing women who were not in drug treatment upon entry into prenatal care enrolled in the project.
Interventions : Home visits by a public health nurse were provided to the women to jointly develop a plan of care targeted to each woman's needs. A substance abuse counselor was available as a consultant and for home visits. An interdisciplinary team met monthly to coordinate services, discuss therapeutic approaches and treatment strategies, and address needed changes in the health services system.
Main Outcome Measures : Rates of entry into substance abuse treatment, retention of custody of the index child, and scores on the Addiction Severity Index (ASI).
Results : Although the expected rate of entry into treatment was 10%, 90% of the women ( n = 9) entered treatment. All had full-term newborns. Eighty percent ( n - 8) retained custody of the index child. Upon the participants' enrollment, AS1 scores indicated a moderate to extreme problem with alcohol and drug use for all women, and moderate to extreme psychiatric problems for 89% of the women. Subsequent ASI scores demonstrated marked improvement in all three subscales.
Conclusion : This project provides strategies that nurses can use to assist substance-abusing pregnant women to enter drug treatment.     

Screening for substance use in pregnancy: a practical approach for the primary care physician

Our goal was to identify risk factors for substance use during pregnancy for primary care physicians so that we could assess a woman's risk of alcohol or illicit drug use. Participants were 2002 Medicaid-eligible pregnant women with < or =2 visits to prenatal care clinics in South Carolina and Washington State. Structured interviews were used to collect data. Logistic regressions and classification and regression trees identified predictors for pregnant women at high risk for substance use. Approximately 9% of the sample reported current use of either drugs or alcohol or both. Past use of alcohol or cigarettes, including during the month before pregnancy, most differentiated current drug or alcohol users from current nonusers. Our analysis suggests that primary care physicians can ask 3 questions in the context of a prenatal health evaluation to target women for referral to a full clinical assessment for drug and alcohol use.     

Hawaiian-style "Talkstory": Psychosocial Assessment and Intervention During and After Pregnancy

Standard health care services generally limit the psychosocial assessment and management provided for women during and after pregnancy. Recommendations for improving prenatal care include the need for evaluating different approaches for addressing culturally sensitive care. In an innovative prenatal and postpartum program developed by public health nurses in Hawaii, the use of local "talkstory" has been integrated successfully as a caregiving strategy for participating women from Asian and Pacific Islander ethnic groups. This article describes the use of talkstory for delivering psychosocial care and its application in the design of health care services for pregnant women in the general population.     

Prenatal Care Outcomes in Women with Substance Use Disorders: A Retrospective Cohort Study

ObjectiveThis study sought to examine and compare the characteristics and prenatal care and pregnancy outcomes of women with and without substance use disorder (SUD). It also examined whether there were differences in prenatal care and pregnancy outcomes within the population of substance-using women based on the stability of their SUD during pregnancy.MethodsThis retrospective cohort study involved pregnant women with and without SUD who accessed care through the Maternity Centre of Hamilton between 2015 and 2017. Cases and controls were matched 1:1 for gravidity, parity, ethnicity, smoking status, and postal code.ResultsFifty-five pregnant women with SUD were identified and matched to 55 pregnant women without SUD. When analyzed by stability of substance use, women with stable SUD had similar outcomes to those of women without SUD. Women with unstable SUD received the poorest prenatal care and were more likely to have their infants removed from their care. There was significant movement towards stability of maternal substance use over the course of pregnancy in our integrated prenatal and addiction care model.ConclusionWomen with unstable SUD had poorer prenatal care and higher rates of custody loss than those with stable substance use disorders or those without substance use disorders. The disparate outcomes among women with unstable SUD may indicate a need to identify patients requiring greater support at entry into prenatal care and to target services accordingly. This integrated prenatal and addiction care model was effective in reducing maternal substance use in pregnancy.     

Group Prenatal Care for Women Receiving Medication‐Assisted Treatment for Opioid Use Disorder in Pregnancy: An Interprofessional Approach

Opioid use disorder among pregnant women is common and rapidly increasing nationwide. Group prenatal care is an innovative alternative to individual care for pregnant women and has been shown to improve women's and health care providers’ satisfaction and adherence to care. We describe a novel group prenatal care program colocated in an opioid treatment program that integrates prenatal care, substance use disorder counseling, and medication‐assisted treatment. Our interprofessional model draws on the unique contributions of physicians, midwives, nurses, and mental health professionals to address the complex needs of pregnant women with opioid use disorder. Participants reported increased trust and engagement with health care providers and peers, improved prenatal care and birth experience, and increased resilience for relapse prevention. Group prenatal care is an accepted and promising model for women with opioid use disorder in pregnancy and has the potential to improve outcomes for women and newborns.     

Models of care for opioid dependent pregnant women

As the opioid crisis continues to exist in the United States, opioid use in pregnancy is becoming a more common occurrence. Left untreated, it may result in an increased risk for adverse outcomes for both the mother and her unborn child. Unfortunately, women with opioid use disorders often face numerous barriers when trying to access prenatal care services including limited availability or treatment options, stigma, legal consequences, co-morbid psychiatric disorders, and trauma exposure. A care model that integrates prenatal care, medication assisted treatment and behavioral health services delivered in a trauma-informed environment can improve prenatal care attendance and thus have far-reaching positive implications for both the woman and her newborn child.     

Characteristics of Women Who Do Not Seek Prenatal Care and Implications for Prevention

Objectives: To describe characteristics of women without prenatal care and their reasons for not seeking prenatal care.
Design: Retrospective record review.
Setting: Urban, academic medical center.
Participants: Women without prenatal care whose pregnancies reached the third trimester, who presented to the hospital for delivery or immediately postpartum for a 7 year period.
Methods: Records were reviewed for factors including socio-demographic factors, history of pregnancy/miscarriage/abortion, social supports, abuse history, history of substance use, toxicology results, history of mental illness or mental retardation, and the reason for lack of prenatal care.
Results: Among 211 women with no prenatal care, the primary reasons were noted: 30% had problems with substance use; 29% experienced denial of pregnancy; 18% had financial reasons; 9% concealed pregnancy; and 6% believed they did not need prenatal care due to multiparity. Women with substance use disorders were significantly more likely to be older, unemployed multigravidas.
Conclusions: Nurses should target specific groups of women for education and intervention based on their rationale for not seeking prenatal care.     

Referrals for dental care during pregnancy

Oral health is essential to overall health in the prenatal period. Pregnancy is not a time to delay dental care. Several studies have shown an association between periodontal disease and poor pregnancy outcomes including preterm birth. Interventions to provide periodontal treatment to pregnant women yield inconsistent results regarding preterm birth but have established the safety of periodontal therapy during pregnancy. Postpartum women in poor dental health readily transmit the tooth decay pathogen Streptococcus mutans from their saliva to their infants, resulting in increased risk of early childhood caries. Preventive services and treatment for acute problems should be recommended, fears allayed, and women referred. Dental radiographs may be performed safely with the use of appropriate shielding. Nonemergent interventions are best provided between 14 and 20 weeks' gestation for comfort and optimal fetal safety. Most gravid women do not seek dental care. Increased interprofessional communication to encourage dentists to treat pregnant women will reduce the number of women without care. In states where it is available, Medicaid coverage of dental services for pregnant women is typically allowed during pregnancy and for 2 months postpartum. Women's health providers should understand the importance of protecting oral health during pregnancy and educate their patients accordingly.     

Maternity Care for Pregnant Women with Opioid Use Disorder: A Review

Opioid misuse is a problem that is complex and widespread. Opioid misuse rates are rising across all US demographics, including among pregnant women. The opioid epidemic brings a unique set of challenges for maternity health care providers, ranging from ethical considerations to the complex health needs and risks for both woman and fetus. This article addresses care for pregnant women during the antepartum, intrapartum, and postpartum periods through the lens of the opioid epidemic, including screening and counseling, an interprofessional approach to prenatal care, legal considerations, and considerations for care during labor and birth and postpartum. Providers can be trained to identify at‐risk women through the evidence‐based process of Screening, Brief Intervention, and Referral to Treatment (SBIRT) and connect them with the appropriate care to optimize outcomes. Women at moderate risk of opioid use disorder can be engaged in a brief conversation with their provider to discuss risks and enhance motivation for healthy behaviors.  Women with risky opioid use can be given a warm referral to pharmacologic treatment programs, ideally comprehensive prenatal treatment programs where available (a warm referral is a term used when a provider, with the patient's permission, contacts another provider or another service him or herself rather than providing a phone number and referral number). Evidence regarding care for the pregnant woman with opioid use disorder and practical clinical recommendations are provided.     

Source of prenatal care and infant birth weight: the case of a North Carolina county

The impact of a comprehensive prenatal care program on the birth weights of infants born to low-income women is assessed. Women receiving care through the prenatal program of a large county public health department were compared to pregnant Medicaid-eligible women in the same county, who received prenatal care primarily from private-practice physicians. The percentage of low birth weight was 8.3 for the health department women compared with 19.3 for the Medicaid women. After differences between the two groups in race, marital status, participation in the Special Supplemental Food Program for Women, Infants, and Children (WIC), quantity of prenatal care, and other risk factors were statistically controlled, the chance of a Medicaid woman having a low-weight birth was still more than twice as great (p = 0.007). A case-management approach and greater use of services ancillary to basic obstetric medical care appear to contribute to the better birth weight outcomes in the health department.     

Antepartum and postpartum depression

Psychiatric mood disorders can and do occur in pregnant women. Women with antepartum depression have a risk of poor nutrition, substance abuse, and prenatal noncompliance. Careful assessment of risk and benefits to the pregnant woman and to the unborn child must be made before pharmacologic therapy is initiated. The three postpartum mood disorders--postpartum "blues," postpartum depression, and postpartum psychosis--are common, and education is an important instrument in the treatment of these disorders.     

The effect of integrating substance abuse treatment with prenatal care on birth outcome.

OBJECTIVE: To determine whether engaging pregnant substance abusers in an integrated program of prenatal care and substance abuse treatment would improve neonatal outcomes. STUDY DESIGN: The subjects were women who voluntarily enrolled in Project Link, an intensive outpatient substance abuse treatment program at Women and Infants Hospital, Providence, RI. A total of 87 women received substance abuse treatment in conjunction with their prenatal care; the comparison group of 87 women received equivalent prenatal care but did not enroll in the substance abuse treatment program until after they delivered. The two groups of women were similar demographically and socioeconomically and had similar substance abuse histories. Univariate and multivariate analyses were performed. The key outcomes were gestational age at delivery, birth weight, preterm delivery, Apgar scores, and neonatal intensive care admission rate. Factors controlled in the multivariate models included demographics, socioeconomic status, parity, and prenatal care. RESULTS: Infants born to women who enrolled prenatally were 400 gm heavier (p < 0.001), and their gestational age was 2 weeks longer (p < 0.001) than infants of mothers enrolled postpartum. In addition, they were approximately one-third as likely to be born with a low birth weight (p < 0.01) and approximately one-half as likely to be admitted to the neonatal intensive care unit (p < 0.05). CONCLUSION: Neonatal outcome is significantly improved for infants born to substance abusers who receive substance abuse treatment concurrent with prenatal care compared with infants born to substance abusers who enter treatment postpartum.     

Caring for Pregnant Women with Opioid Use Disorder in the USA: Expanding and Improving Treatment

Purpose of the Review

Opioid use disorder in the USA is rising at an alarming rate, particularly among women of childbearing age. Pregnant women with opioid use disorder face numerous barriers to care, including limited access to treatment, stigma, and fear of legal consequences. This review of opioid use disorder in pregnancy is designed to assist health care providers caring for pregnant and postpartum women with the goal of expanding evidence-based treatment practices for this vulnerable population.

Recent Findings

We review current literature on opioid use disorder among US women, existing legislation surrounding substance use in pregnancy, and available treatment options for pregnant women with opioid use disorder. Opioid agonist treatment (OAT) remains the standard of care for treating opioid use disorder in pregnancy. Medically assisted opioid withdrawal (“detoxification”) is not recommended in pregnancy and is associated with high maternal relapse rates. Extended release naltrexone may confer benefit for carefully selected patients. Histories of trauma and mental health disorders are prevalent in this population; and best practice recommendations incorporate gender-specific, trauma-informed, mental health services. Breastfeeding with OAT is safe and beneficial for the mother-infant dyad.

Summary

Further research investigating options of OAT and the efficacy of opioid antagonists in pregnancy is needed. The US health care system can adapt to provide quality care for these mother-infant dyads by expanding comprehensive treatment services and improving access to care.

     

Perinatal Behavioral Health,the COVID-19 Pandemic,and a Social Determinants of Health Framework

The United States has greater prevalence of mental illness and substance use disorders than other developed countries, and pregnant women are disproportionately affected. The current global COVID-19 pandemic, through the exacerbation of psychological distress, unevenly affects the vulnerable population of pregnant women. Social distancing measures and widespread closures of businesses secondary to COVID-19 are likely to continue for the foreseeable future and to further magnify psychosocial risk factors. We propose the use of a social determinants of health framework to integrate behavioral health considerations into prenatal care and to guide the implementation of universal and comprehensive psychosocial assessment in pregnancy. As the most numerous and well-trusted health care professionals, nurses are ideally positioned to influence program and policy decisions at the community and regional levels and to advocate for the full integration of psychosocial screening and behavioral health into prenatal and postpartum care as core components.     

Psychiatric disorders in pregnancy

Psychiatric disorders are common in pregnancy and can be associated with a range of adverse outcomes, including maternal death. Early identification and, where appropriate, referral to a specialist mental health service, is the key to successful management. Women with more severe psychiatric disorders, such as bipolar affective disorder, schizophrenia and moderate to severe depression, benefit from a shared management approach involving obstetric, primary care and specialist mental health services, formalized within a written perinatal care plan. Large numbers of women take psychotropic medication during pregnancy, but when it represents an appropriate alternative to medication, timely psychological treatment is the preferred approach for a range of psychiatric disorders. When medication is used, it should be based on a risk/benefit analysis that takes appropriate notice of the dangers of stopping or avoiding medication as well as any risk to the exposed fetus. All decisions about the management of a psychiatric disorder should involve the pregnant women as a fully informed partner in a shared decision-making approach. This review summarizes general guidance on management for the obstetrician and issues arising in relation to a number of specific psychiatric disorders and specific psychiatric treatments.     

Women's perspectives on maternity services in Sweden: processes, problems, and solutions

Most measures of health care quality focus on medical outcomes rather than patients' assessments of quality. Drawing on data from a national survey of Swedish women, this study describes women's opinions about what is important to them during pregnancy and birth. This qualitative study is based on responses of 827 pregnant women to an open question completed in the second trimester. In total, 2061 separate statements were analyzed. Using content analysis, these statements were clustered into 4 themes: desirable characteristics of midwife, prenatal care during pregnancy, care during labor and birth, and care after birth. Within those themes, 13 categories were found. Findings suggest areas for improvement in maternity services including: the timing and length of prenatal visits, making parent education classes available to all women, prelabor visits to the maternity ward, continuous information about the progress of labor, flexibility in time of discharge, and postpartum support for families. Women also stated that characteristics of the midwife, such as being supportive, friendly, attentive, respectful, and nonjudgemental, were important. A patient-centered and individualized approach, with women and their partners as the subjects rather than the objects of care, would increase satisfaction and the overall quality of maternity services in Sweden.     

Guideline No. 405: Screening and Counselling for Alcohol Consumption During Pregnancy

ObjectiveTo establish national standards of care for screening and counselling pregnant women and women of child-bearing age about alcohol consumption and possible alcohol use disorder based on current best evidence.Intended UsersHealth care providers who care for pregnant women and women of child-bearing age.Target PopulationPregnant women and women of child-bearing age and their families.EvidenceMedline, EMBASE, and CENTRAL databases were searched for “alcohol use and pregnancy.” The results were filtered for a publication date between 2010 and September 2018. The search terms were developed using Medical Subject Headings terms and keywords, including pre-pregnancy, pregnant, breastfeeding, lactation, female, women, preconception care, prenatal care, fetal alcohol spectrum disorder, prenatal alcohol exposure, drinking behavior, alcohol abstinence, alcohol drinking, binge drinking, alcohol-related disorders, alcoholism, alcohol consumption, alcohol abuse, benzodiazepines, disulfiram, naltrexane, acamprosate, ondansetron, topiramate, cyanamide, calcium carbimide, alcohol deterrents, disease management, detoxification, Alcoholics Anonymous, alcohol counselling, harm reduction, pre-pregnancy care, prenatal care, incidence, prevalence, epidemiological monitoring, and brief intervention. Evidence was included from clinical trials, observational studies, reviews, systematic reviews and meta-analyses, guidelines, and conference consensus.Validation MethodsThe content and recommendations in this guideline were drafted and agreed upon by the authors. The Board of Directors of the Society of Obstetricians and Gynaecologists of Canada approved the final draft for publication. The quality of evidence was rated using the criteria described in the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) methodology framework.Benefits, Harms, CostsImplementation of the recommendations in these guidelines using validated screening tools and brief intervention approaches may increase obstetrical care provider recognition of alcohol consumption and problematic alcohol use among women of child-bearing age and those who are pregnant. It is anticipated that health care providers will become confident and competent in managing and supporting these women so they can achieve optimal health and pregnancy outcomes.SUMMARY STATEMENTS (GRADE ratings in parentheses)

• 1Alcohol is a known teratogen (high).
• 2The current evidence cannot establish a safe threshold for alcohol consumption in pregnancy (high).
• 3Abstaining from alcohol during pregnancy is the safest option (high).
• 4Abstaining from alcohol while breastfeeding is the safest option (high).

RECOMMENDATIONS (GRADE ratings in parentheses)

• 1All pregnant women should be questioned about alcohol use by asking a single question (in a nonjudgmental way) to determine use. If women consume alcohol, one of the following screening tools should be used: AUDIT-C or T-ACE, or another evidence-based screening tool available in the provincial/territorial prenatal record. If women consume alcohol, pattern of use should be established to screen for binge drinking (strong, high).
• 2If screening identifies an alcohol use disorder, brief intervention should be provided at the same time screening is completed (strong, high).
• 3When a maternal alcohol use disorder is diagnosed, it should be documented in the infant's medical record after delivery (strong, low). Carers should be encouraged to discuss in utero alcohol exposure with their child's health care provider (strong, low).
• 4Every clinical encounter is an opportunity to discuss alcohol use. All women of child-bearing age should be periodically screened for problematic alcohol use. Screening, brief intervention, and referral to treatment can be brief or in depth depending on the context. Health care providers should incorporate screening for problematic alcohol use into routine women's health screening and information sharing and include screening, brief intervention, and referral to treatment where needed (strong, high).
• 5Brief interventions and, if needed, coordinated referral and follow-up should accompany screening for alcohol use. A nonjudgmental, supportive approach is important to encourage disclosure of alcohol use and accessing of services (strong, high).
• 6If a woman continues to use alcohol during pregnancy, harm reduction, treatment, and social support strategies should be encouraged (strong, high).
• 7Health care providers should be knowledgeable on providing brief interventions and be aware of referral pathways (strong, moderate).
• 8Women need to be able to participate in brief interventions and treatment without undue risk of loss of child custody; where universal screening and brief interventions are implemented, policies must be aligned so that support and treatment can be encouraged by providers and accessed by women without fear (appropriate attention must still be given to the safety of the child) (strong, moderate).
• 9Specialized, community-based interventions need to be available and accessible to women with problematic drinking and related health and social concerns (strong, moderate).

     

Association of preconceptional health care utilization and early initiation of prenatal care.

OBJECTIVE: To assess whether women having preconceptional health care utilization were more likely to have early initiation of prenatal care than were women not having preconceptional health care utilization. STUDY DESIGN: In this cohort study, data were collected prospectively from a population-based Perinatal Health Care Surveillance System in China. The analysis included 195 796 women who delivered single live births in 13 cities/counties during 1997 to 2000. Mantel-Haenszel test was employed to calculate risk ratios and 95% confidence intervals (CI). Multivariate logistic regression was conducted to assess the association between preconceptional health care utilization and early initiation of prenatal care after controlling for maternal residence, age at delivery, educational attainment, occupation, parity, preconceptional medical disorders, and high-risk medical experiences during the first trimester. SPSS 11.5 (SPSS Inc.) was employed for data analysis. RESULTS: Women having preconceptional health care utilization were 2.6 times (95%CI: 2.5 to 2.6) more likely to have early initiation of prenatal care compared with women not having preconceptional health care utilization. When stratified by maternal residence, age at delivery, educational attainment, occupation, parity, preconceptional medical disorder, high-risk medical experiences during the first trimester, and preconceptional medical disorders, this association still existed. After controlling for stratification factors mentioned above and the interaction of maternal age, educational attainment, and parity, women having preconceptional health care utilization were 2.7 times (95%CI: 2.6 to 2.8) more likely to have early initiation of prenatal care than were women not having preconceptional health care utilization. CONCLUSION: Women who had preconceptional health care utilization were more likely to have early prenatal care than were women not having preconceptional health care utilization.     

Demographic and psychosocial characteristics of substance-abusing pregnant women

Women who abuse drugs and alcohol during pregnancy are an elusive population who often remain unidentified to practitioners and researchers and hence have not been well studied. In trying to understand better the characteristics of women who use drugs during pregnancy, the present article relies extensively on information gathered in studies of women in substance abuse treatment who, as epidemiologic studies show, may be more severely impaired than other substance-abusing women and, therefore, may not be typical of substance-abusing women identified in the course of obstetric practice. Yet, those pregnant women who are actually identified by medical providers as substance users are often those whose behavior raises concerns with health providers (such as presenting for labor having had no prenatal care) and thus also may represent only a relatively impaired group of substance-abusing women. The most objective picture available of the universe of women who use drugs during pregnancy comes from blinded urine toxicology screens conducted at samples of representative hospitals across states and across the country. The startling finding to emerge from these studies is that common perceptions of substance abuse as a problem of poor, ethnic minority, and young individuals is inaccurate and that this perception may all too often be acted on by medical providers in a prejudicial manner. These studies show similar rates of substance use during pregnancy by women of different racial, social class, and age categories. Demographic features are only related to type of substance used, with black women and poorer women more likely to use illicit substances, particularly cocaine, and white women and better educated women more likely to use alcohol, the substance whose teratogenic effects have been most clearly documented. Despite the even distribution of substance use across demographic categories, poor women and women of color are far more likely to be reported to health and child welfare authorities for use of substances during pregnancy than are other women, even when their base rates for use of illicit drugs are considered. Data from both epidemiologic studies and samples of women seeking treatment for substance abuse problems indicate that the lives of substance-abusing women are fraught with difficulties past and present. Substance-abusing women are likely to have been raised by parents who were substance abusers, particularly alcoholics. Although the intergenerational patterns of substance abuse may have some genetic basis, there is also ample evidence suggesting problematic relationships in families with a substance-abusing parent that raises concerns about intergenerational transmission of problematic parenting behavior. Perhaps the most startling research finding reported in studies reviewed in this article is the high proportion of substance-abusing women who have experienced early sexual abuse. Although most studies have not had adequate comparison groups of non-substance-abusing women, the fact remains that most studies suggest a third to a half of substance abusing women experienced some kind of sexual abuse during childhood. Substance-abusing women's lives remain complicated as adults. They are commonly involved with men who are also users of drugs, they are often the victims of domestic violence, and they suffer from a variety of psychiatric disorders. Studies of epidemiologic and treatment populations indicate that the majority of substance-abusing women have one or more types of comorbid mental disorders, with depression being the most common and the most elevated compared with substance-abusing men, but antisocial personality being extremely high compared with samples of non-substance-abusing women. These findings are of great concern given a growing body of research with non-substance-abusing women, suggesting that family violence and maternal psychopathology can have a profound effect on women's parenting and development o