Journal of Research in Peace, Gender and Development (ISSN: 2251-0036) Vol. 2(3) pp. 56-59, March 2012
Available online@ http://www.interesjournals.org/JRPGD
Copyright ©2012 International Research Journals
Review
Psychotropic drug abuse and the unwanted pregnancy
state
Dr. S. E. Oriaifo1
Department of Pharmacology and Therapeutics College of Medicine A.A.U. Ekpoma
E-mail: stephenoriaifo@yahoo.com
Accept 23 March, 2012
The study was undertaken to determine the psychosomatic symptoms in unwanted pregnancy patients
and the pattern of psychotropic drug abuse. It was designed as a single-centre, randomized,
prospective study in which pregnant women between 16 and 35 years participated in the clinical and
structured interviews. Clinical interviews were used to diagnose the unwanted pregnancy state in 540
patients compared to a similar group of control patients; and to know the pattern of their selfmedication with psychotropic drugs. Structured interviews were used to score the Hamilton`s ratings
and Geriatric Depression Scales deployed to screen for anxiety and depression respectively. The mean
Hamilton Anxiety Rating Scale (HARS) and Geriatric Depression Scale (GDS) scores were significantly
greater in test patients with presentation of unwanted pregnancy at first trimester compared to
controls (P < 0.05). At the first trimester, 84% (163 patients) of the patients with positive HARS scores
had self-medication with diazepam and 25% abused cannabis. The patients that screened positively for
depression also self-medicated with diazepam and alcohol. The results are suggestive of an
association between the unwanted pregnancy state, psychosomatic symptoms and self-medication.
Keywords: Unwanted pregnancy, depression, anxiety, drug abuse.
INTRODUCTION
Psychosomatic disorders and unwanted pregnancy
Unwanted pregnancy may be defined as a pregnancy
that is not desired by one or both biologic parents and
may therefore be carried to term with resentment and or
anger (Pohlman, 1968). In Nigeria, the incidence has
been determined by investigators to lie between 26% and
28% of all pregnancies (Sedgh et al., 2006; Oye-Adeniran
et al., 2004). Although the unwanted pregnancy state is
known to be associated with psychosomatic disorders
and drug abuse, the subject has not been well
researched, at least, in developing countries (Gipson et
al, 2008).
The causes of unwanted pregnancy include unwanted
sexual intercourse especially in teenagers, rape, low
socio-economic status (Geelhoed et al., 2002), low
educational status and violence. Women who experience
physical violence from their husbands are significantly
less likely to adopt contraception and more likely to
experience unwanted pregnancy (Stephenson et al.,
2008).
There are substantial phenomenological differences
between a `chosen` and an unwanted pregnancy
(Lundquist, 2008). For example, unwanted pregnancies
pose negative health consequences which include
depression and anxiety (Goicolea and Sebastian, 2010;
Klima, 1998). The conscious and unconscious anger and
upset leads to more psychosomatic problems (Pohlman,
1968).
Pregnancy-Induced Alterations in Pharmacokinetics
and Pharmacodynamics
Pregnancy
causes
major
pharmacokinetic
and
pharmacodynamic changes in the body (Little, 1999).
These include delayed gastric emptying, decreased
gastrointestinal motility, increased volume of distribution,
decreased drug binding capacity, decreased albumin
levels and enhanced hepatic metabolism with induced
Oriaifo 57
liver metabolic pathways (Stowe and Nemeroff, 1998).
There is also greater renal clearance and glomerular
filtration rate increases. Plasma volume increases by 3040%. The foetus has lower plasma protein binding, lower
hepatic functioning, relatively increased cardiac output
and greater permeability in the blood-brain-barrier in
comparison with adults. These changes all point to the
importance during pregnancy of cautious prescribing, the
need for lower doses of medication and monotherapy,
and regular follow-up for any possible side-effects, in
order to protect both mother and foetus (Kohen, 2004).
Psychotropic drugs and pregnancy
The American Pediatric Academy`s Committee On Drugs
is of the principle that no medication should be prescribed
for a pregnant or lactating woman unless it is necessary
for her health or that of her child. And that when practical
and consistent with the essentiality of controlling the
woman`s symptoms, a woman should be withdrawn from
psychotropic medication prior to conception. Traditionally,
psychotropic medications were
withheld during
pregnancy because of fear of teratogenic and other
effects. Evidence is emerging that the tricyclic
antidepressants and selective serotonin reuptake
inhibitors appear to be free of teratogenic effects (Ward
and Zamorski, 2002). Medications can potentially affect
the foetus by causing structural teratogenesis (birth
defects), behavioural teratogenesis and perinatal
syndromes. For example, the benzodiazepines are
increasingly being associated with oro-facial birth defects
when given in the first trimester and with perinatal
syndromes when given proximate to delivery (Ward and
Zamorski, 2002; Kohen, 2004). The guidelines for
psychotropic drug use in pregnancy recommends that
non-pharmacologic therapies should be tried first. It also
recommends that the selective serotonin reuptake
inhibitors be the agents of first choice in the treatment of
depressive and anxiety disorders and that collaboration
and consultation with mental health professionals should
be an important aspect of treatment planning (Ward and
Zamorski, 2002).
Aim of the study
The objective of the study was to investigate the extent of
psychosomatic symptoms in unwanted pregnancy
patients and the extent to which the symptoms fuel drug
abuse.
METHODS
This randomized, prospective, single-centre study was
carried out between 2000 and 2012 at Oseghale Oriaifo
Medical Centre, Ekpoma that has Ishan Senatorial
District as its catchment area. 540 patients aged 16-35
years with unwanted pregnancies, to whom the purpose
of study was explained and from whom consent was
obtained, were counseled throughout their pregnancy
duration which was to term. Clinical interviews were used
to determine the unwanted pregnancy state and the
pattern of psychotropic drug use. There was a control
group of 600 patients of same age bracket with wanted
pregnancies.
Screening for anxiety and depression: Structured faceto-face interviews were used to screen for anxiety and
depression using the 14-itemed Hamilton Anxiety Rating
Scale (HARS) (Hamilton, 1959) and the 30-itemed
Geriatric Depression Scale (GDS) (Mancuso et al, 2000)
respectively. Both are valid, easily-administered tests
suitable even for not-so-well educated groups. The
screening tests were administered at the first, second
and third trimesters of pregnancy
The table 1 shows that 600 patients enrolled as test
patients with unwanted pregnancies and 600 patients
enrolled as control patients with wanted pregnancies but
540 patients with the unwanted pregnancy state agreed
to continue with counseling
No. on self-medication: 194 patient (36%) of the 540
patients were on self-medication. 163 (84%) out of the
194 patients were on self-medication with diazepam. 49
patients (25%) were on self-medication with cannabis
and 23 patients (12%) were using alcohol. In the second
and third trimesters, no patient was on self-medication
due to the success of the counseling. Out of the control
patients with wanted pregnancies, none was on selfmedication
Average HARS Score: With the HARS scores, 16-20
represents mild anxiety, 20-25 represents moderate
anxiety and 25-30 represents severe anxiety. From the
Table, the average HARS score for the test patients at
the first trimester was 24.0 ± 8.0 SD and this reduced to
15.0 ± 9.0 SD at the third trimester.
Average GDS Score: With the GDS scores, 0-9
represents no depression, 10-20 represents mild
depression and 21-30 represents severe depression. In
this study, the average GDS score at the first trimester for
the test group was 12.0 ± 6.0 SD and decreased to 9.0 ±
7.0 SD at the third trimester.
Positive screening for anxiety: 194 patients (36%) of
the test group had positive screening for anxiety at the
first trimester, with HARS scores ranging from 22-28 but
at the third trimester, only 11 patients (2%) had positive
screening for anxiety.
Positive screening for depression: 21 patients (4%) of
the test group had positive screening for depression, with
GDS scores in the range 11-13. At the second and third
trimesters, no patient had positive screening for
depression.
It is of interest that the average HARS scores for the
control patients with wanted pregnancies increased from
58 J. Res. Peace Gend. Dev.
Table 1. Anxiety and Depression rating Scores in normal pregnancies and in the unwanted pregnancy state. Average HARS scores and GDS scores were significantly different at first
trimester between test and control groups (P < 0.01). HARS scores less than 16 reveal no anxiety and GDS scores less than 9 reveal no depression.
Test Patients
N=
No. On Self Medication
No. On Diazepam
No. On Cannabis
No. On Alcohol
Average HARS Score
Average GDS Score
No. with positive Screening for
anxiety (HARS Range)
No. with positive Screening for
depression (GDS Range)
540
First Trimester
194
163
49
23
24.0 + 8.0 SD
12.0 + 6.0 SD
194
(22 – 28)
21
(11 – 13)
14.0 ± 9.0 SD at the first trimester to 15.0 ± 7.0
SD at the third trimester and the average GDS
scores decreased from 8.5 ± 5.0 SD at the first
trimester to 7.5 ± 7.0 SD at the third trimester.
DISCUSSION
Inspite of the consensus that pregnancy should be
undertaken only with clear intent (Brown and
Eisenberg, 1995), the problem of the unwanted
pregnancy state is still of immense proportion in
Nigeria though the mind-set can be significantly
influenced and changed with proper counseling as
this series indicate. Counseling was able to
change 540 cases of unwanted pregnancies from
being unwanted to `wanted` over a 10-year
period.
Present results suggest that the unwanted
pregnancy state is associated with greater
psychosomatic symptoms compared to control
Second Trimester
0
Third Trimester
0
19.0 + 5.0 SD
9.0 + 9.0 SD
22
(20 -22)
0
15.0 + 9.0 SD
9.0 + 7.0 SD
11
(17 – 20)
0
Control Patients
600
First Trimester
0
Second Trimester
0
Third Trimester
0
14. 0 + 9.0 SD
8.5 + 5.0 SD
0
14.5 + 8.0 SD
8.0 + 7.0 SD
0
15.0+ 7.0 SD
7.5 + 7.0 SD
0
0
0
0
patients and this is in consonance with previous
observations
that
found
increase
of
psychosomatic symptoms in the unwanted
pregnancy state (Pohlman, 1968; Klima, 1998;
Gipson et al., 2008).
With counseling, the depressive symptoms
abated completely at the second and third
trimesters. Also the anxiety symptoms significantly
reduced from 36% at first trimester to 2% at third
trimester. This may be important because nonpharmacologic methods of treatment are
advocated in pregnancy (Ward and Zamorski,
2002).
The study also suggests a significant risk of
self-medication in the unwanted pregnancy state.
This may not appear surprising since previous
studies have found psychosomatic symptoms to
be a cause of psychotropic drug abuse (Lawrence
et al, 2004; Weiss et al, 1992; Brady, 2001;
Kendler et al, 1996) and anxiety disorders and
substance use disorders commonly co-occur
(Brady, 2001).
Diazepam is probably self-medicated because
it can cause sedation; it is cheap, easily available
and may have antidepressant effects (Tiller et al.,
1996). Cannabis is also probably self-medicated
because it has been reported to possess moodelevating properties (El-Alfy et al., 2010) and a
similarity between the chronobiologic effects of
alcohol and antidepressants has been reported. In
clinical practice, the selective serotonin re-uptake
inhibitors (SSRIs) antidepressants are currently
preferred to the benzodiazepines and the tricyclic
antidepressants (TCAs) for treatment of
psychosomatic symptoms because of the
undesirable effects of the benzodiazepines (Ward
and Zamorski, 2002) and the TCAs (Simon et al,
2002). Diazepam rapidly crosses the placental
barrier because of its marked lipid solubility
(Hauser, 1985) and its metabolite, N-demethyldiazepam is pharmacologically active with a long
half-life. Its use in the first trimester is associated
Oriaifo 59
with 0.6% increase of oral clefts and congenital
malformations of the central nervous system and urinary
tract (Altshuler et al., 1996) while Wisner and Perel in
1988 demonstrated that the benzodiazepines can
produce withdrawal symptoms, respiratory depression
and muscular hypotonia in infants.
Alcohol exposure during gestation can lead to
structural teratogenesis, behavioural teratogenesis and
perinatal syndromes exhibited by growth deficiency,
dysmorphic facial features and central nervous system
dysfunction termed fetal-alcohol syndrome or the lesser
known alcohol-related neurodevelopmental defect (Famy
et al., 1998). Alcohol exposure during gestation has been
called the most common known cause of mental
retardation. Ethanol increases the absorption of cannabis
(Luka and Orozco, 2001) and there is evidence for an
embryotoxic role of marihuana in rabbits (Rosenkrantz et
al., 1986).
CONCLUSION
Present evidence points to an association between the
unwanted pregnancy state, psychosomatic symptoms
and psychotropic drug abuse which often-at- times lead
to self-medication with the potentially foeto-toxic agents
diazepam, cannabis and alcohol.
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