[Skip to Content]
Sign In
Individual Sign In
Create an Account
Institutional Sign In
OpenAthens Shibboleth
[Skip to Content Landing]
Figure.  Adjusted Odds Ratios (aORs) for Cannabis Use During Pregnancy by Mental Health Characteristics for 196 022 Pregnancies
Adjusted Odds Ratios (aORs) for Cannabis Use During Pregnancy by Mental Health Characteristics for 196 022 Pregnancies

International Classification of Diseases, Ninth Revision, Clinical Modification and International Statistical Classification of Diseases, Tenth Revision, Clinical Modification diagnosis codes were used to identify depressive disorders, anxiety disorders, and trauma diagnoses during pregnancy (ie, from last menstrual period through date of live birth). Self-reported depression symptom categories are based on the Patient Health Questionnaire–9,5 which has been administered during standard prenatal care visits starting in 2012 (score <5, none; score 5-9, mild depression; score 10-14, moderate depression; score ≥15, moderately severe to severe depression); 17 145 pregnancies (8.8%) did not have data on Patient Health Questionnaire–9 depression symptoms and were not included in analyses where depression symptoms were the variable of interest. Three self-reported questions were used to identify intimate partner violence; 16 030 pregnancies (8.2%) did not have data on self-reported intimate partner violence and were not included in analyses where intimate partner violence was the variable of interest.

Table.  Characteristics of 196 022 Pregnancies at Kaiser Permanente Northern California, 2012 to 2017, Overall and by Prenatal Cannabis Use
Characteristics of 196 022 Pregnancies at Kaiser Permanente Northern California, 2012 to 2017, Overall and by Prenatal Cannabis Use
1.
Agrawal  A, Rogers  CE, Lessov-Schlaggar  CN, Carter  EB, Lenze  SN, Grucza  RA.  Alcohol, cigarette, and cannabis use between 2002 and 2016 in pregnant women from a nationally representative sample.  JAMA Pediatr. 2019;173(1):95-96. doi:10.1001/jamapediatrics.2018.3096PubMedGoogle ScholarCrossref
2.
Young-Wolff  KC, Tucker  LY, Alexeeff  S,  et al.  Trends in self-reported and biochemically tested marijuana use among pregnant females in California from 2009-2016.  JAMA. 2017;318(24):2490-2491. doi:10.1001/jama.2017.17225PubMedGoogle ScholarCrossref
3.
Latuskie  KA, Andrews  NCZ, Motz  M,  et al.  Reasons for substance use continuation and discontinuation during pregnancy: a qualitative study.  Women Birth. 2019;32(1):e57-e64. doi:10.1016/j.wombi.2018.04.001PubMedGoogle ScholarCrossref
4.
Chang  JC, Tarr  JA, Holland  CL,  et al.  Beliefs and attitudes regarding prenatal marijuana use: perspectives of pregnant women who report use.  Drug Alcohol Depend. 2019;196:14-20. doi:10.1016/j.drugalcdep.2018.11.028PubMedGoogle ScholarCrossref
5.
Kroenke  K, Spitzer  RL, Williams  JB.  The PHQ-9: validity of a brief depression severity measure.  J Gen Intern Med. 2001;16(9):606-613. doi:10.1046/j.1525-1497.2001.016009606.xPubMedGoogle ScholarCrossref
6.
Committee on Obstetric Practice.  Committee Opinion No. 722: marijuana use during pregnancy and lactation.  Obstet Gynecol. 2017;130(4):e205-e209. doi:10.1097/AOG.0000000000002354PubMedGoogle ScholarCrossref
Limit 200 characters
Limit 25 characters
Conflicts of Interest Disclosure

Identify all potential conflicts of interest that might be relevant to your comment.

Conflicts of interest comprise financial interests, activities, and relationships within the past 3 years including but not limited to employment, affiliation, grants or funding, consultancies, honoraria or payment, speaker's bureaus, stock ownership or options, expert testimony, royalties, donation of medical equipment, or patents planned, pending, or issued.

Err on the side of full disclosure.

If you have no conflicts of interest, check "No potential conflicts of interest" in the box below. The information will be posted with your response.

Not all submitted comments are published. Please see our commenting policy for details.

Limit 140 characters
Limit 3600 characters or approximately 600 words
    2 Comments for this article
    EXPAND ALL
    PTSD
    Maggie Konze |
    Cannabis is extremely helpful for PTSD symptoms. It is one of the qualifying conditions for the medical therapeutic cannabis program in NH.
    CONFLICT OF INTEREST: None Reported
    RE: Association of depression, anxiety, and trauma with cannabis use during pregnancy
    Tomoyuki Kawada, Professor | Nippon Medical School
    I have read the article by Young-Wolff et al. (1) with great interest. The authors conducted a cross-sectional study to examine the association of mental disorder and trauma history with prenatal cannabis use. Adjusted odds ratios (ORs) (95% confidence intervals [CIs]) of pregnant women with anxiety, depression, and anxiety plus depression for cannabis use were 1.90 (1.76-2.04), 2.25 (2.11-2.41), and 2.65 (2.46-2.86), respectively. In addition, adjusted ORs (95% CIs) of pregnant women with mild, moderate, and moderately severe to severe depression symptoms for cannabis use were 1.60 (1.53-1.67), 2.09 (1.96-2.23), and 2.55 (2.35-2.77), respectively. Furthermore, adjusted ORs (95% CIs) of pregnant women with a trauma diagnosis and self-reported intimate partner violence for cannabis use were 2.82 (2.59-3.06) and 1.94 (1.74-2.15), respectively. I have two concerns about their study.

    First, the authors mentioned a study limitation concerning causal association in the first paragraph of "Discussion". Cannabis has some psychiatric risk by long-term use, and the lowering effect on anxiety and depression should be handled with caution. Kosiba et al. conducted a meta-analysis of the association of patient-reported symptoms of pain, anxiety, and depression with medical cannabis use (2). In this paper, they cited some reviews regarding the effect of prolonged cannabis use on subsequent symptoms of pain, anxiety, and depression. Twomey reported that cannabis use was significantly associated with increased odds of anxiety, although some adjustment attenuated the risk of anxiety (3). Mammen et al. reported that past-6-month cannabis use was associated with greater mental health symptoms of anxiety and mood disorders, and lower treatment response (4). Kosiba et al. concluded that the short and long-term effects of medical cannabis in relation to pain, anxiety, and depression should be specified (2). I agree with their recommendation.

    Second, the authors mentioned the health risk of prenatal cannabis use to the fetus. There are several papers regarding the risk (5,6), although many confounders exist on the association. Quantitative risk assessment is needed by considering methodological problems.


    References

    1. Young-Wolff KC, Sarovar V, Tucker LY, et al. Association of depression, anxiety, and trauma with cannabis use during pregnancy. JAMA Netw Open 2020;3(2):e1921333. doi:10.1001/jamanetworkopen.2019.21333

    2. Kosiba JD, Maisto SA, Ditre JW. Patient-reported use of medical cannabis for pain, anxiety, and depression symptoms: Systematic review and meta-analysis. Soc Sci Med 2019;233:181-192. doi:10.1016/j.socscimed.2019.06.005

    3. Twomey CD. Association of cannabis use with the development of elevated anxiety symptoms in the general population: a meta-analysis. J Epidemiol Community Health 2017;71(8):811-816. doi:10.1136/jech-2016-208145

    4. Mammen G, Rueda S, Roerecke M, Bonato S, Lev-Ran S, Rehm J. Association of cannabis with long-term clinical symptoms in anxiety and mood disorders: A systematic review of prospective studies. J Clin Psychiatry 2018;79(4):17r11839. doi:10.4088/JCP.17r11839

    5. Schreiber S, Pick CG. Cannabis use during pregnancy: Are we at the verge of defining a "fetal cannabis spectrum disorder"?. Med Hypotheses 2019;124:53–55. doi:10.1016/j.mehy.2019.02.017

    6. Jaques SC, Kingsbury A, Henshcke P, et al. Cannabis, the pregnant woman and her child: weeding out the myths. J Perinatol 2014;34(6):417–424. doi:10.1038/jp.2013.180
    CONFLICT OF INTEREST: None Reported
    READ MORE
    Research Letter
    Substance Use and Addiction
    February 19, 2020

    Association of Depression, Anxiety, and Trauma With Cannabis Use During Pregnancy

    Author Affiliations
    • 1Division of Research, Kaiser Permanente Northern California, Oakland
    • 2Weill Institute for Neurosciences, Department of Psychiatry, University of California, San Francisco
    • 3Regional Offices, Kaiser Permanente Northern California, Oakland
    • 4Department of Psychiatry, Kaiser Permanente San Jose, San Jose, California
    JAMA Netw Open. 2020;3(2):e1921333. doi:10.1001/jamanetworkopen.2019.21333
    Introduction

    Prenatal cannabis use is increasing,1,2 and several qualitative studies3,4 indicate that pregnant women self-report using cannabis to manage stress and mood. However, few epidemiological studies have examined whether pregnant women with mental health disorders and trauma are at increased risk of using cannabis during pregnancy. Data from the Kaiser Permanente Northern California (KPNC) large integrated health care system, which provides universal screening for prenatal cannabis use by self-report and urine toxicology testing, were used in this cross-sectional study to examine the association of depression, anxiety, and trauma diagnoses and symptoms with prenatal cannabis use.

    Methods

    Pregnant women with live births at KPNC who completed a self-reported questionnaire on prenatal substance use and a urine toxicology test at their first prenatal visit (at approximately 8 weeks’ gestation) during standard prenatal care from 2012 to 2017 were included. Confirmatory tests were performed for positive toxicology tests. Of 219 071 pregnancies, 1042 (0.5%) without the date of the last menstrual period, 21 115 (9.6%) without a toxicology test, and 892 (0.4%) with no answer to the question about self-reported cannabis use were excluded.

    The KPNC institutional review board approved this study and waived the need for informed consent. This study follows the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) reporting guideline.

    Depressive and anxiety disorders and trauma diagnoses during pregnancy were ascertained from the electronic health record. International Classification of Diseases, Ninth Revision, Clinical Modification and International Statistical Classification of Diseases, Tenth Revision, Clinical Modification diagnosis codes used to identify depressive disorders, anxiety disorders, and trauma diagnoses during pregnancy (ie, from last menstrual period through date of live birth) are provided in the eAppendix in the Supplement. Self-reported depression symptoms (based on the Patient Health Questionnaire–95; score <5, none; score 5-9, mild depression; score 10-14, moderate depression; score ≥15, moderately severe to severe depression) and intimate partner violence were assessed via universal screening at the first prenatal visit. The 3 self-reported questions used to identify intimate partner violence at the first prenatal visit are shown in the eAppendix in the Supplement.

    We compared demographic and mental health characteristics of pregnant women with and without any prenatal cannabis use (by self-report and/or a positive toxicology test). P values were calculated using separate generalized estimating equation models to account for some women having more than 1 pregnancy during the study period. Next, the adjusted odds ratios (aORs) and 95% CIs of any prenatal cannabis use by mental health diagnoses or symptoms were estimated using generalized estimating equation models to account for women with multiple pregnancies during the study, adjusting for year, median neighborhood annual household income, age, and self-reported race/ethnicity. Two-sided P < .05 was considered statistically significant. Data analysis was performed using SAS statistical software version 9.4 (SAS Institute) from June 2019 to October 2019.

    Results

    Of the 196 022 pregnancies, 69 925 (35.7%) were white, 29 486 (15.0%) were aged less than 25 years (mean [SD] age, 30.3 [5.4] years), and the median (interquartile range) neighborhood annual household income was $70 859 ($51 893-$93 036); 11 681 pregnancies (6.0%) screened positive for prenatal cannabis (Table). The prevalence of mental health conditions ranged from 1.9% (intimate partner violence) to 11.0% (depression symptoms of at least moderate severity). Women who used cannabis, compared with those who did not use cannabis, were younger (age <25 years, 4904 [42.0%] vs 24 582 [13.3%]), had lower annual household incomes (income <$51 893, 4697 [40.3%] vs 44 251 [24.0%]), were more likely to be African American (2296 [19.7%] vs 8185 [4.4%]) or Hispanic (3652 [31.3%] vs 51 052 [27.7%]), and were less likely to be Asian (333 [2.9%] vs 34 001 [18.4%]) (Table). Women who used cannabis were also more likely than those who did not use cannabis to have an anxiety disorder (969 [8.3%] vs 8728 [4.7%]), depressive disorder (1235 [10.6%] vs 7892 [4.3%]), anxiety disorder and depressive disorder (975 [8.4%] vs 5682 [3.1%]), depression symptoms (mild, 3419 [32.2%] vs 41 279 [24.5%]; moderate, 1415 [13.3%] vs 11 744 [7.0%]; and moderately severe to severe, 875 [8.3%] vs 5608 [3.3%]), trauma diagnosis (966 [8.3%] vs 3719 [2.0%]), and self-reported intimate partner violence (473 [4.4%] vs 3016 [1.8%]) (Table).

    Compared with women without depressive or anxiety disorders, those with anxiety disorders (aOR, 1.90; 95% CI, 1.76-2.04), depressive disorders (aOR, 2.25; 95% CI, 2.11-2.41), or both (aOR, 2.65; 95% CI, 2.46-2.86) had greater odds of cannabis use (Figure). Similarly, compared with women without depression symptoms, those with mild (aOR, 1.60; 95% CI, 1.53-1.67), moderate (aOR, 2.09; 95% CI, 1.96-2.23), and moderately severe to severe symptoms (aOR, 2.55; 95% CI, 2.35-2.77) had increased odds of cannabis use. Women with (vs without) a trauma diagnosis (aOR, 2.82; 95% CI, 2.59-3.06) and with (vs without) self-reported intimate partner violence (aOR, 1.94; 95% CI, 1.74-2.15) also had greater odds of cannabis use.

    Discussion

    Depression, anxiety, and trauma diagnoses and symptoms were associated with higher odds of cannabis use among pregnant women in California. These results support previous qualitative findings that pregnant women self-report using cannabis to manage mood and stress3,4 and suggest a dose-response association, with higher odds of cannabis use associated with co-occurring depressive and anxiety disorders and greater depression severity. However, research is needed to determine the direction of these associations, because cannabis use might also cause or worsen mental health problems during pregnancy.

    This study has several limitations. It takes place in 1 large health care system in California, and the findings may not generalize to all pregnant women. Cannabis screening at KPNC is limited to pregnant women at approximately 8 weeks’ gestation. Cannabis use may have occurred before women realized they were pregnant, and these findings do not reflect continued use throughout pregnancy. Furthermore, we are unable to determine whether our findings would differ among nonpregnant women treated at KPNC. Finally, urine toxicology tests may infrequently detect prepregnancy cannabis use.

    The health risks of prenatal cannabis use to the fetus are complex and may vary with administration mode and frequency of use; however, no amount of cannabis use during pregnancy has been shown to be safe.6 Pregnant women should be screened for cannabis use, asked about their reasons for use, educated about potential risks, and advised to quit. Furthermore, early screening for prenatal depression, anxiety, and trauma, and linkage to appropriate interventions might mitigate the risk of prenatal cannabis use.

    Back to top
    Article Information

    Accepted for Publication: December 14, 2019.

    Published: February 19, 2020. doi:10.1001/jamanetworkopen.2019.21333

    Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2020 Young-Wolff KC et al. JAMA Network Open.

    Corresponding Author: Kelly C. Young-Wolff, PhD, MPH, Division of Research, Kaiser Permanente Northern California, 2000 Broadway, Oakland, CA 94612 (kelly.c.young-wolff@kp.org).

    Author Contributions: Dr Young-Wolff had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

    Concept and design: Young-Wolff, Sarovar, Goler, Avalos.

    Acquisition, analysis, or interpretation of data: Sarovar, Tucker, Goler, Alexeeff, Ridout, Avalos.

    Drafting of the manuscript: Young-Wolff, Sarovar, Ridout.

    Critical revision of the manuscript for important intellectual content: All authors.

    Statistical analysis: Young-Wolff, Sarovar, Alexeeff.

    Obtained funding: Young-Wolff.

    Administrative, technical, or material support: Young-Wolff, Sarovar, Tucker.

    Supervision: Young-Wolff.

    Conflict of Interest Disclosures: None reported.

    Funding/Support: This study was supported by National Institutes of Health National Institute on Drug Abuse K01 Awards DA043604 and R01 DA047405 and National Institutes of Health National Institute of Mental Health K01 Award MH103444.

    Role of the Funder/Sponsor: The funders had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

    References
    1.
    Agrawal  A, Rogers  CE, Lessov-Schlaggar  CN, Carter  EB, Lenze  SN, Grucza  RA.  Alcohol, cigarette, and cannabis use between 2002 and 2016 in pregnant women from a nationally representative sample.  JAMA Pediatr. 2019;173(1):95-96. doi:10.1001/jamapediatrics.2018.3096PubMedGoogle ScholarCrossref
    2.
    Young-Wolff  KC, Tucker  LY, Alexeeff  S,  et al.  Trends in self-reported and biochemically tested marijuana use among pregnant females in California from 2009-2016.  JAMA. 2017;318(24):2490-2491. doi:10.1001/jama.2017.17225PubMedGoogle ScholarCrossref
    3.
    Latuskie  KA, Andrews  NCZ, Motz  M,  et al.  Reasons for substance use continuation and discontinuation during pregnancy: a qualitative study.  Women Birth. 2019;32(1):e57-e64. doi:10.1016/j.wombi.2018.04.001PubMedGoogle ScholarCrossref
    4.
    Chang  JC, Tarr  JA, Holland  CL,  et al.  Beliefs and attitudes regarding prenatal marijuana use: perspectives of pregnant women who report use.  Drug Alcohol Depend. 2019;196:14-20. doi:10.1016/j.drugalcdep.2018.11.028PubMedGoogle ScholarCrossref
    5.
    Kroenke  K, Spitzer  RL, Williams  JB.  The PHQ-9: validity of a brief depression severity measure.  J Gen Intern Med. 2001;16(9):606-613. doi:10.1046/j.1525-1497.2001.016009606.xPubMedGoogle ScholarCrossref
    6.
    Committee on Obstetric Practice.  Committee Opinion No. 722: marijuana use during pregnancy and lactation.  Obstet Gynecol. 2017;130(4):e205-e209. doi:10.1097/AOG.0000000000002354PubMedGoogle ScholarCrossref
    ×