Pregnant, Substance-Using Women
Treatment Improvement Protocol (TIP) Series 2

Mental Health Assessment ¹⁹

• Distinguish between drug-induced psychiatric symptoms and a major mental disorder. Symptoms such as anxiety, agitation, and paranoia can be manifestations of a state of drug intoxication or of the withdrawal syndrome itself and at times require no medications. Ongoing psychosocial support may help minimize many of these symptoms. On the other hand, confirmed mental illness may necessitate the continuation of medications, such as antidepressants or antipsychotics, which have been previously effective in treating the underlying disorder. It is mandatory that a diagnosis of mental illness be ruled out before such medication is stopped. It must be remembered that evidence is inconclusive regarding the safe use of any psychotropic medication in pregnant women. A thorough assessment of the risks versus the benefits must be made prior to administering these medications.

• Establish any previous history of psychiatric illness before developing the medical withdrawal treatment plan. Efforts should be made to contact previous therapists, treating agencies, and mental health facilities for this crucial information.
• Establish communication early in treatment with mental health personnel involved in the patient's care. These individuals often can provide important history, help build an alliance with the patient, support discharge planning, and provide assistance in the event of an acute management crisis.
• Individualize medical withdrawal plans for each patient. Carefully review standard guidelines and amend them if there are significant psychiatric problems to be treated.
• Set up arrangements to involve mental health personnel, where appropriate, in establishing diagnoses and in developing the treatment plan.
• Continue prescribed medications and provide appropriate followup for patients who enter alcohol and other drug treatment programs with well-documented, diagnosed psychiatric illnesses that require psychopharmacologic medication.
• Continue any prescribed medications, such as methadone and chlordiazepoxide, except as advised by the patient's health and mental health care providers. Patients should be supported in this decision by treatment programs. Some support groups may inappropriately encourage women to abandon all medications.
• Do not avoid seeking therapy for the patient because of the complex combination of pregnancy, addiction, and psychiatric problems. Careful planning and staff coordination are usually effective in treatment.
• Use well-validated psychiatric assessment scales in the diagnosis and followup of individual patients (see Appendix B).
• Consider issues of codependency, adult children of alcoholics/other addictions, and deep trauma from childhood in the evaluation of patients.

Guidelines for Medical Withdrawal

Orders for medication should be individualized to minimize the types and doses prescribed. Psychotropic drugs may need to be prescribed throughout medical withdrawal. The use of psychotropic drugs must be considered on a case-by-case basis, taking into consideration their effects on the mother and fetus, particularly with respect to interactions with methadone and possible congenital abnormalities. Behavioral management techniques should be developed to minimize the need for these medications. Providing adequate staff, structure, limits, and support are important treatment methods.

Other Issues

Agitation and oppositional or impulsive behavior can be manifestations of cognitive impairments, such as attention deficit disorder, limited intelligence, mild retardation, or psychotic illness. Patients with these behaviors can appear to have difficulty comprehending or complying with treatment expectations. Awareness of these deficits can help staff manage these problems and adapt treatment methods to minimize or avoid unnecessary confrontations.