Methamphetamine use continues to rise on a global scale (1), and methamphetamine-involved overdoses claim lives in staggering numbers (2). This humanitarian crisis is further fueled by maternal, fetal, and child deaths related to methamphetamine exposure (3–6). Moreover, ample evidence implicates methamphetamine in lasting health and psychosocial problems that severely affect parents and their children (3–5). Women who use methamphetamine are burdened by mental disorders in the perinatal period (5), and parents who use methamphetamine are overstrained by their caregiving roles in often adverse living conditions (7). Infants can experience serious damage, such as microcephaly, due to intrauterine methamphetamine exposure (5, 8). Child development is compromised as a result of these factors, as evidenced by lower IQ scores as well as internalizing (e.g., depression) and externalizing symptoms (e.g., aggression) (5, 7, 8). Despite the urgency for prevention and intervention, the uptake of antenatal, pediatric, and mental health services is low and too late in this population (5, 9, 10). Moreover, pregnant women who use methamphetamine leave substance use treatment against professional advice even more often than pregnant women who use other illicit drugs or alcohol (11).

The stark contrast between care needs and utilization highlights the importance of developing programs that are easily accessible and appealing to those impacted by methamphetamine. Pregnancy and parenthood can create a strong motivation for abstinence (7), but treatment may not be accessed due to fear of stigma and punitive measures (5, 12, 13). Thus, transparency and the commitment to keeping families together are paramount. To reach women of childbearing age, expecting parents, and parents of minors, different avenues within the healthcare system, social services, and the community should be used. Linking these avenues also promises to help families achieve lasting health benefits as continuity of care is instrumental in sustaining abstinence (14, 15).

We are aware of only one study that at least partly addressed this care gap. This study compared methamphetamine-specific psychoeducation with a program also covering relationship and parenting skills tailored to South-African pregnant women (12). Both group interventions reduced methamphetamine use and risky sexual behavior, and 92% of participants completed the 4-session comprising interventions (12). Only 14% had been in substance use treatment before, indicating that access to care can be improved substantially (12).

Acknowledging the unmet needs of families affected by substance use disorders, the concept “Mama denk an mich” (MAMADAM, “Mommy think of me”) was developed to deliver coordinated care across disciplines and settings. After having demonstrated the feasibility of MAMADAM (9, 16), we here present its potential to improve the mental health of pregnant women and parents who use methamphetamine. The findings on outcome prediction provide critical information for patient assessment and program optimization. With this report, we hope to encourage the implementation and study of similar initiatives to promote the well-being of parents and children impacted by methamphetamine.

This is a real-life observational study of integrated care for expecting and new parents with methamphetamine-related psychiatric disorders, which was approved by the ethics committee at the Carl Gustav Carus Faculty of Medicine at the Technische Universität Dresden, Germany.

We studied 84 patients with methamphetamine-related mental disorders (1 × F15.0, 8 × F15.1, 74 × F15.2, 1 × F19.2; diagnosed according to the International Classification of Diseases, 10th revision). This sample comprised 27 expecting parents and 57 parents of minors (mean age of child ± SD, min-max: 19.02 ± 30.59, 1–144 months; newborns counted as 1 month). Sixteen patients (19.0%) dropped out before receiving a care plan, 27 (32.1%) completed part of the program, and 41 (48.8%) transitioned successfully to community care. Average program participation was over 6 months (mean ± SD, min-max: 202.49 ± 167.42, 0–793 days) and not statistically different between patients who partially and those who successfully completed treatment (n = 68, U = 655.00, z = 1.27, p = 0.203).

Table 1 displays demographics according to outcome, showing no statistical differences in sex, age, years of methamphetamine use, and prior addiction rehab. The proportion of pregnant women was significantly lower in the early than in the late dropout group, and all women who gave birth during treatment completed it successfully. Three-fourths of patients had psychiatric comorbidities. Groups were comparably affected except for attention-deficit hyperactivity disorder (ADHD). Although there was only a trend to an overall significant difference between groups, ADHD was significantly less common in patients successfully than in those partially completing the program.

When accounting for the order of outcomes (worst to best: early dropout, partial completion, successful completion), depression, substance use comorbidity, and prior addiction rehab emerged as significant predictors. Patients with substance use comorbidities were more likely to have a better outcome, whereas the opposite applied to patients with depressive disorders and patients with prior addiction rehab. Table 2 lists the unique (net) contribution of each significant predictor to variations in outcomes (controlled for the other significant predictors).

None of the outcome predictors or variables with considerable group differences were significantly related to one another (see Table 3). Yet, there was one trend-level significant association with 59.3% of expecting parents compared with 36.8% of parents having prior addiction rehab. Of note, expecting parents, patients with prior addiction rehab, and patients with ADHD featured a significantly longer use of methamphetamine. Regular methamphetamine use was also numerically longer for patients who dropped out compared with those who completed MAMADAM successfully.

This study evaluated the real-world adherence to integrated care by pregnant women and parents with methamphetamine-related mental disorders. Despite being challenged by their roles and psychiatric comorbidities, nearly half of our patients completed treatment successfully, and only one pregnant woman dropped out before receiving a care plan. These data support the notion that pregnancy and parenthood can be motivators for abstinence (7, 8, 19). We are not aware of any study that evaluated a comparable concept for this population, but methamphetamine use is generally associated with high dropout rates (8, 19). Less than one-fourth of patients with methamphetamine as their primary drug completed 180 days of outpatient drug treatment, a duration previously identified as necessary for treatment success (20). Moreover, pregnant women using methamphetamine left substance use treatment against professional advice even more often than those using other illicit drugs or alcohol (11).

Three-fourths of our patients had at least one other mental disorder, which reflects the high psychiatric morbidity reported in association with methamphetamine use (8, 19). Patients with depressive disorders were almost 5 times more likely to have less treatment success than patients without such a diagnosis. This aligns with an outpatient treatment study for methamphetamine dependence in which higher baseline depression predicted methamphetamine use before discharge and poorer treatment attendance (21). Although not predicted by baseline depression scores, methamphetamine use 3 years post-treatment was associated with major depression at follow-up (21). Together, these findings emphasize the need for routine assessment and treatment of depression. Exercise and psychological interventions can reduce depressive symptoms, but methamphetamine-induced cognitive deficits complicate the latter (8, 19). Medications including antidepressants have largely failed and their potential for drug interaction effects has been highlighted (8, 19). Yet, recent research suggests that glutamatergic modulators with antidepressant and pro-cognitive properties may prove effective in treating methamphetamine use disorder and comorbid depression (22).

ADHD was diagnosed in almost one-third of patients who dropped out of an established care plan. This proportion was about 4 times as high as in the successful outcome group. Moreover, ADHD was associated with more years of regular methamphetamine use, which was also numerically longer for patients who dropped out. Routine assessment for ADHD seems therefore imperative, not least because some patients report using methamphetamine to treat ADHD symptoms (8). The risk of misuse and drug interactions warrants close monitoring of pharmacotherapy, with long-acting formulations recommended if stimulant medication is prescribed (19).

A diagnosis of substance use comorbidity predicted a better outcome, which indicates that the benefits of MAMADAM extend to other drugs. Experiencing a substance use comorbidity might increase readiness for change and treatment. Patients with prior addiction rehab were, in comparison, more likely to have a worse outcome. Similarly, previous drug treatment predicted treatment attrition in pregnant women using methamphetamine weekly or more (11). Prior treatment could indicate greater disease severity or longer disease duration, as patients with prior addiction rehab featured more years of regular methamphetamine use. Of note, more years of regular methamphetamine use predicted poor outcome in a study of the methamphetamine-specific group psychotherapy that we provide in MAMADAM (18). The data collectively highlight that patients with previous drug treatment require close monitoring and greater support. Recognizing the value of their treatment experiences may be a way to better meet their needs and expectations, which should improve retention in care and health outcomes.

Integrated care is a promising strategy for pregnant women and parents with methamphetamine-related mental disorders. Pregnancy and parenthood provide opportunities to motivate change and engage a population that hardly accesses treatment despite the high psychiatric morbidity. Comorbid ADHD and depression warrant close monitoring as they jeopardize treatment engagement and success. Given the little information on the management of these conditions in the context of methamphetamine use, research is imperative to provide evidence-based interventions. Moreover, integrated care concepts should be disseminated to counter the increasing methamphetamine crisis that affects parents and children across the globe.

The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.

The studies involving human participants were reviewed and approved by the Ethics Committee at the Carl Gustav Carus Faculty of Medicine at the Technische Universität Dresden, Germany. Written informed consent for participation was not required for this study in accordance with the national legislation and the institutional requirements.

UZ, MP, MS, and SH contributed to the development of the care concept. MS, SH, TK, UZ, and MP were members of the care team. MP, UZ, CS, and MK designed the study. MP and JP obtained funding. MK, CS, MS, MP, and TK collected the data. JP analyzed and interpreted the data and wrote the manuscript. All authors contributed to manuscript revision, as well as read and approved the final version.

This work was supported by the German Research Foundation [TRR 265 (23)]. The article processing charge was paid from the Publication Fund of the Technische Universität Dresden. The funders were not involved in the conceptualization of the study, the collection, analysis, interpretation of data, the preparation of the manuscript, or the decision to submit it for publication.

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

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