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. Author manuscript; available in PMC: 2011 Jul 25.
Published in final edited form as: J Maint Addict. 2008 Jan 1;3(2-4):53–64. doi: 10.1300/J126v03n02_07

Suicidal Ideation Among Drug-Dependent Treatment-Seeking Inner-City Pregnant Women

Marc L Copersino 1, Hendrée Jones 2, Michelle Tuten 3, Dace Svikis 4
PMCID: PMC3142928  NIHMSID: NIHMS245817  PMID: 21796240

Abstract

The current retrospective study compared the psychiatric and lifestyle characteristics of two groups of treatment-seeking pregnant, opiate and/or cocaine dependent women admitted to the Center for Addiction and Pregnancy (CAP). Women reporting past and/or current suicidal ideation (SI) (46%; n = 35) were compared to women who did not report thoughts of suicidal ideation (NSI) (54%; n = 41). SI women were more likely to be homeless (p = .020), to report histories of emotional (p = .022), physical (p < 001), sexual abuse (p = .002) and psychiatric treatment (p < .001), and less likely to be married (p = .024) than NSI women. Psychiatrically, SI women were more likely to have co-morbid current and lifetime disorders than NSI women. These findings highlight the need to identify women with histories of suicidal ideation, recognize the potential relapse risk imposed by emotional distress, and confront these issues in treatment.

Keywords: Drug abuse, pregnancy, suicide, treatment, gender

INTRODUCTION

Suicide is a major public health problem in the United States. Much attention has been focused on identifying the risk factors of suicide in non-pregnant individuals. Suicide risk factors are numerous and include co-morbid mood and/or substance use disorders (Wilcox, Conner, & Caine, 2004; Phillips, Carpenter, & Nunes, 2004; Harris, & Barraclough, 1997; Aharonovich, Liu, Nunes, & Hasin, 2002; Dhossche, Meloukheia, & Chakravorty, 2000; Tondo, 1999), homelessness (Eynan, Langley, Tolomiczenko, Rhodes, Links, Wasylenki, & Goering, 2002), marital separation or divorce (Kposowa, 2000), lifetime sexual or physical abuse or assault (Ullman, 2004; Bartholomew, Rowan-Szal, Chatham, Nucatola, & Simpson, 2002), exposure to early trauma leading to a diagnosis of Post Traumatic Stress Disorder (Gladstone, Parker, Mitchell, Malhi, Wilhelm, & Austin, 2004), unemployment (Blakely, Collings, & Atkinson, 2003; Kposowa, 2003), low education and low socio-economic status and income (Kessler, Borges, & Walters, 1999). In contrast to the wealth of research focused on non-pregnant individuals, little research has focused on the report of suicidal ideation among pregnant substance abusers. This subpopulation of women deserves special attention given the potential impact of emotional distress on both the mother and the fetus. The present study sought to compare substance abusing pregnant women with and without a history of suicidal ideation.

Substance-abusing pregnant women often enter drug treatment with multiple risk factors for suicide. For example, substance dependence during pregnancy has been shown to be associated with comorbid mood disorders, homelessness, previous abuse (i.e., physical, sexual, and/or emotional abuse), unemployment, (Kissin, Svikis, Morgan, & Haug, 2001; Jansson, Svikis, Lee, Paluzzi, Rutigliano, & Hackerman, 1996; Finnegan, 1991), childhood sexual trauma, (Hill, Boyd, & Kortge, 2000) and post-traumatic stress disorder (PTSD) (Moylan, Jones, Haug, Kissin, & Svikis, 2001). Although previous studies have examined the relationship between suicidality and substance abuse in pregnant women, none have focused exclusively comparing drug dependent pregnant women with and without suicidal ideation. Thus, the purpose of the present study was to compare the psychiatric and psychosocial characteristics of treatment-seeking, drug-dependent, pregnant women who reported past and/or current suicidal ideation (SI) with the characteristics of women who did not report past and/or current suicidal ideation (NSI).

METHOD

Participants

Participants were 76 pregnant opioid (87%) and/or cocaine (67%) dependent women enrolled in the Center for Addiction and Pregnancy (CAP), a comprehensive care drug treatment program located on the Johns Hopkins Bayview Medical Center campus that services a predominantly inner-city urban population. Over half (64%) received methadone pharmacotherapy as a therapeutic adjunct. These women were predominately African American (75%), single (80%), and unemployed (95%), with a mean age of 31 years (SD = 5.3) and education of 11 years (SD = 1.8). This sample included women reporting past and/or current suicidal ideation (determined via Addiction Severity Index or Structured Clinical Interview for DSM-IV) (n = 35) and women reporting no past or current suicidal ideation (n = 41) (see Table 1). Participants were women taking part in a larger behavioral research study while attending treatment at CAP between April 4, 2000 and December 13, 2000. The study was approved by the Johns Hopkins Bayview Institutional Review Board for human research; volunteers gave written informed consent and were compensated for their participation.

TABLE 1.

Study Participant Demographic, Psychosocial, and Psychiatric Characteristics

Suicidal
Ideation
(n=35)		 No Suicidal
Ideation
(n=41)		 OR (95% CI) †† p value*
% n % n
1Age
  ≥30 years of age 57 20 56 23 1.08(0.43,2.74) .866
2Education
  Less than 12 years 49 17 42 17 1.33(0.54. 3.31) .535
3Unemployed 93 33 95 39 2.43(0.44, 13.39) .309
4Married 11 4 27 11 4.24(1.21. 14.86) .024
5Race:
  African American 71 25 78 32 0.69 (0.23, 2.06) .511
Methadone Maintenance 58 19a 69 27b 0.60(0.23, 1.59) .307
Homelessness 26 9 5 2 6.75(1.35, 33.79) .020
Current Drug Dependence:
  Alcohol 42 14a 33 13b 1.47 (0.56, 3.84) .428
  Opioid 79 26a 95 37b 0.20 (0.04, 1.04) .056
  Cocaine 82 27a 54 21b 3.86 (1.30, 11.42) .015
  6Multiple 79 26a 61 26b 1.86 (0.64, 5.40) .256
Lifetime Abuse
  Emotional 77 27 51 21 3.21 (1.18, 8.73) .022
  Physical 74 26 29 12 6.98 (2.53, 19.24) .000
  Sexual 46 16 12 5 6.06 (1.92, 19.11) .002
Past or Current Diagnosis
  Major Depression 73 24a 38 15b 4.27 (1.57, 11.62) .005
  9Anxiety 3 1a 3 1b 1.19 (0.07, 19.75) .905
  10PTSD 69 22d 41 16b 3.16 (1.18, 8.45) .022
  11Comorbid 91 29a 61 24b 6.04 (1.56, 23.36) .009
Psychiatric History
  7Dual Diagnosis 97 32d 90 35b 3.66 (0.39, 34.46) .257
  8Psychiatric Treatment 73 25c 15 6 16.20 (5.11, 51.35) .000
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††

OR (95% CI) = unadjusted odds ratio bracketed by 95% Wald confidence interval. Odds ratio indicates the risk for SI versus NSI for each characteristic. Reference category for odds ratio on dichotomous variables is the negative response.

1

Mean [SD] age 31 [4.7] years for SI and 31 [5.8] years for NSI.

2

Mean [SD] years education 11 [2.1] years for SI and 11 [1.5] years for NSI.

3

Among remaining SI, 6% were in controlled environments. Among remaining NSI, 12% were retired or disabled and 5% had missing data.

4

Marital status categories were: Never Married, Married, Widowed, Divorced, Separated, or Unknown. The new category “Married” collapses the categories Married and Separated.

5

Race categories include: African-American, Caucasian, Asian, Alaskan, American Indian, and Other. Among remaining SI, 26% were Caucasian and 3% were in the Other category. Among remaining NSI, 19% were Caucasian and 2% were American Indian.

6

Multiple = more than one current drug dependence diagnosis.

7

Dual diagnosis = 2 or more of any Axis I diagnoses, including 2 or more dependence disorder diagnoses.

8

Psychiatric treatment = any lifetime inpatient or outpatient psychiatric treatment or hospitalization.

9

Anxiety = current Generalized Anxiety Disorder (GAD) only

10

PTSD = Post Traumatic Stress Disorder

11

Comorbid mood and drug or alcohol dependence diagnoses

a

Based on n = 33

b

Based on n = 39

c

Based on n = 34

d

Based on n = 32

*

Probability value for Pearson's chi-square statistic; values in bold are statistically significant.

Procedures/Instruments

All research participants completed an intake assessment battery during their first seven days of residential treatment and following stabilization on methadone and minimal signs of withdrawal. All assessments were administered by a group of similarly trained staff in the respective treatment settings. The assessment battery included the Addiction Severity Index–Fifth Edition (ASI; McLellan, Kushner, Metzger, Peters, Smith, Grissom, Pettinati, & Argeriou, 1992) and the Structured Clinical Interview for DSM-IV Axis I Disorders, Research Version (SCID-I; First, Gibbon, Spitzer, Williams, 1996).

The ASI is a standardized semi-structured clinical interview for assessing psychosocial severity in seven potential problem areas (Medical, Employment, Alcohol, Drug, Legal, Family/Social, and Psychological). There is a body of literature demonstrating good reliability and validity of the standard Fifth Edition of the ASI (see Leonhard, Mulvey, Gastfriend, & Shwartz, 2000 for review).

The SCID-I is a structured clinical interview that assesses lifetime and current DSM-IV Axis I psychiatric disorders. The SCID-I was used to make current (within the past 12 months) DSM-IV drug dependence diagnoses for opioids, cocaine, and alcohol; and to make current and lifetime mood disorder diagnoses. Previous assessments of the reliability and validity of various structured and semi-structured DSM-IV substance use disorder diagnostic interviews indicates very good reliability and validity for dependence diagnoses (Üstün, Compton, Mager, Babor, Baiyewu, Chatterji, Cottler, Gögüs, Mavreas, Peters, Pull, Saunders, Smeets, Stipec, Vrasti, D. Hasin, Room, Van den Brink, Regier, Blaine, Grant, Sartorius, 1997; Feingold & Rounsaville, 1995). Reliability of the mood disorder diagnoses assessed via the SCID-I ranges from good to fair inter-rater agreement. Kappa values for the mood disorder diagnoses range from .88 for Post Traumatic Stress Disorder, .80 for Major Depression, .76 for Dysthymic Disorder, and .63 for Generalized Anxiety Disorder (Zanarini, Skodol, Bender, Dolan, Sanislow, Schaefer, Morey, Grilo, Shea, McGlashan, & Gunderson, 2000). Adapted versions of the SCID-I have also demonstrated cross-cultural utility in identifying mood disorders in women during pregnancy and post-partum (Gorman, O’Hara, Figueiredo, Hayes, Jacquemain, Kammerer, Klier, Rosi, Seneviratne, Sutter-Dallay, & TCS-PND Group, 2004).

Interviewer Training

Didactic training on both the ASI and SCID-I was provided regarding the intent and purpose of each item on both instruments. Interviewers were also required to view training videotapes provided by the test makers of both interviews. A two-step training approach was used to ensure inter-rater reliability. This approach involved the trainee observing and co-rating five or more consecutive interviews administered by an expert interviewer, followed by the trainee conducting at least five consecutive interviews that are co-rated by the expert interviewer with one-hundred percent inter-rater agreement.

Data Analysis

Odds ratios (ORs) and 95% confidence intervals (CI) were calculated to estimate the odds of membership in the SI versus the NSI group across the various demographic, psychosocial, and drug use characteristics. The reference category for ORs on dichotomous (“yes” versus “no”) variables was the negative response. Age was dichotomized as over or under 30 years of age and education as above or below a twelfth grade education. Logistic regression was used to compare individuals with and without suicidal ideation for all variables. Probability values were calculated using Pearson’s chi-square statistic, and were considered significant at p < .05. All data analyses were conducted using SPSS version 12.0.0 for Windows.

RESULTS

Demographics

As shown in Table 1, the two groups did not differ in age, education levels, employment status, race, or substance dependence. Women did differ with respect to marital status, such that women reporting NSI were about 4 times more likely to be married than women in the SI group.

Psychosocial, Drug Use and Psychiatric Characteristics

As shown in Table 1, women reporting past and/or current suicidal ideation (SI) presented to treatment with more severe problems in a variety of life areas. SI women were seven times more likely than NSI women to be homeless. SI women had more severe co-morbid substance abuse problems than did NSI women. They were significantly more likely to be currently dependent on cocaine and diagnosed with comorbid mood and drug or alcohol dependence diagnoses than those in the NSI group. Women with SI reported significantly higher rates of emotional, physical and sexual abuse compared to women who did not report suicidal ideation. The SI group was also more likely to be diagnosed with Major Depression, have PTSD (current or lifetime) and previously received psychiatric treatment than the NSI group.

DISCUSSION

Out of a sample of 76 pregnant drug-abusing women, 46% (n = 35) reported suicidal ideation; which is three-and-a-half times greater than what has been reported in the general population of treatment-seeking, drug-dependent adults (Chatham, Knight, Joe, & Simpson, 1995). The alarming rate of suicidal ideation in this population clearly indicates a need for specialized interventions to address the psychosocial impairment of pregnant women entering drug treatment.

Housing instability was striking among the SI group, and this finding is similar to results previously reported from work done at this facility (Tuten, Jones, & Svikis, 2003) and extends previous work in no-pregnant individuals which reported homelessness as a risk factor for suicide (References from intro).

The higher incidence of co-morbid cocaine, multiple drug dependencies and psychiatric diagnoses among SI women indicates a need for psychiatric evaluation and treatment, including medications. These findings are also consistent with, and extends to pregnant populations, studies showing that the co-occurrence of mood and substance use disorders puts patients at greater risk of suicide than does either a mood or substance use disorder alone (Aharonovich, Liu, Nunes, & Hasin, 2002; Dhossche, Meloukheia, & Chakravorty, 2000; Tondo, 1999).

The results showing greater rates of victimization in women with suicidal ideation support previous studies linking a history of physical and sexual abuse with suicidal ideation during pregnancy (Farber, Herbert, & Reviere, 1996) and expands these findings to a substance abusing pregnant population and to include emotional abuse. The results of this study showing greater rates of PTSD in women with SI also supports previously reported findings between suicidal ideation and PTSD among pregnant drug dependent women (Tuten, Jones, Tran, & Svikis, 2004; Moylan, Jones, Haug, Kissin, & Svikis, 2001).

Limitations

For complete interpretation of the results, some limitations should be noted. First, the results of this study are limited in their generalizability to other populations (non-treatment seeking, non-pregnant drug-using populations). Second, research suggests that the ASI may underestimate the prevalence of physical and sexual abuse (Langeland, Draijer, & van den Brink, 2003; Langeland, van den Brink, Draijer, & Hartgers, 2001). Third, by virtue of their selection to enroll into a comprehensive care drug treatment program, this sample may represent a more severe group of women. Fourth, the absence of DSM-Axis II data precludes comparison to other studies examining associations between Borderline Personality Disorder, substance use, and suicidal ideation (Welch, & Linehan, 2002; O’Boyle, & Brandon, 1998). Fifth, it is unclear what role the potential stress of pregnancy (unplanned vs. planned) plays in the report of suicidal ideation, which is something that should be examined more closely in future research. Finally, as with other studies that rely on self-report, response bias could lead to an underestimation of the true prevalence of suicidal ideation in this population; however, the fact that significant differences were found increase the confidence that these are important and robust findings.

CONCLUSIONS

Based on data collected as part of the National Comorbidity Survey (NCS), among non-drug using adults in the U.S., it is estimated that the lifetime prevalence of suicidal ideation is 13.5%. Of this group, it is estimated that 90% of unplanned suicide attempts and 60% of planned first attempts will occur within one year of suicidal ideation (Kessler, Borges, & Walters, 1999). Among substance abusers, current substance use puts individuals at even greater risk for unplanned suicide among those with suicidal ideation (Borges, Walters, Kessler, 2000). Given that the present sample reported suicidal ideation at a rate three-and-a-half times greater than in the general population of treatment-seeking, drug-dependent adults (Chatham, Knight, Joe, & Simpson, 1995), this provides a compelling marker for the scope of the problem.

The present findings support a strong association between suicidal ideation and impairment in psychosocial functioning in this population and suggest that drug treatment programs should identify women who may be at risk for suicidal ideation and/or attempts (Rossow, & Lauritzen, 1999; Magruder-Habib, Hubbard, & Ginzbury, 1992). Early identification of this highly impaired sub-group of treatment seeking substance dependent pregnant women may improve both the maternal and child outcomes. However, benefits will only be gained if more focused and intensive clinical attention is provided, such as services addressing psychiatric and lifestyle problems. Future research should examine whether suicidal ideation is an indication of poor treatment outcomes for pregnant, drug-dependent women. Furthermore, suicidal ideation should be assessed on a regular basis to determine whether the symptoms remit as treatment progresses and abstinence is maintained. Emphasis should be placed on ensuring that women reporting suicidal ideation are monitored and given appropriate psychiatric treatment referrals. Interventions designed to alleviate suicidal thoughts could also impact treatment retention and success.

Acknowledgments

This aticle was supported by NIDA Grants R01 DA12403 and 5 T32 DA07209. The authors thank Marquerite Laban and the staff of the Center for Addiction and Pregnancy for assistance in this research, and to Tim Mudric for statistical assistance.

Contributor Information

Marc L. Copersino, Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, and the Intramural Research Program, National Institute on Drug Abuse, National Institutes of Health, U.S. Department of Health and Human Services, 5500 Nathan Shock Drive, Baltimore, MD 21224.

Hendrée Jones, Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, and the Center for Addiction and Pregnancy, Johns Hopkins Bayview Medical Center, 4940 Eastern Avenue, D4 East 442, Baltimore, MD 21224..

Michelle Tuten, Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, and the Center for Addiction and Pregnancy, Johns Hopkins Bayview Medical Center, 4940 Eastern Avenue, D4 East 442, Baltimore, MD 21224..

Dace Svikis, Department of Psychology, Virginia Commonwealth University, 612 North Lombardy Street, P.O. Box 843033, Richmond, VA 23284..

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