Adults with Fetal Alcohol Spectrum Disorders Show Gender-Specific Mental Health and Substance Use Risks

Adults living with fetal alcohol spectrum disorders carry a substantially heavier burden of mental illness, suicidal behavior, and substance use than the general population, according to one of the largest clinical studies of its kind, published in the International Journal of Mental Health and Addiction. In a sample of 238 adults diagnosed with fetal alcohol spectrum disorders (FASD) at a specialized diagnostic service in Germany, roughly one in three women reported having attempted suicide at least once, and more than a third of participants met criteria for at least one comorbid mental health disorder. The findings, reported by Henrike Schecke of the LVR-University Hospital Essen and colleagues, offer some of the most detailed structured-interview data yet on the psychiatric realities of adults with FASD, and they expose a striking gap between the scale of need and the availability of appropriate care.

Fetal alcohol spectrum disorders are a group of lifelong neurodevelopmental conditions caused by alcohol exposure during pregnancy. The spectrum encompasses three subtypes: fetal alcohol syndrome (FAS), in which growth retardation and characteristic craniofacial features such as a narrow upper lip, a smoothed philtrum, and shortened palpebral fissures are fully present; partial fetal alcohol syndrome (pFAS), where these physical markers appear only incompletely; and alcohol-related neurodevelopmental disorder (ARND), in which the physical signs are absent but the neurocognitive damage remains. Across all subtypes, the core injury involves the brain. Affected individuals commonly experience impairments in executive function, intelligence, attention, learning, memory, impulse control, self-regulation, and social cognition. Global prevalence estimates vary widely, from 0.2 to 25 percent depending on region, with the highest rates in Europe and South Africa; in Germany, an estimated one to two people per 100 live with FASD. Despite being described in the scientific literature since the late 1960s, the condition is still widely under-recognized, particularly in adults, in whom the facial features tend to become less distinctive over time while psychiatric symptoms persist or even worsen.

The new study set out to address a persistent weakness in the existing literature: most previous estimates of psychiatric comorbidity in adults with FASD rest on very small or highly selective samples. A landmark 1998 study included only 25 participants and found that 92 percent met criteria for at least one DSM-IV Axis I disorder, with 48 percent also diagnosed with a personality disorder. A widely cited meta-analysis by Popova and colleagues reported a pooled prevalence of 54.5 percent for alcohol or drug use disorders among people with FASD, with alcohol use disorders four times and illicit drug-related disorders 21 times more common than in the general US population. A Swedish registry study of 79 adoptees from Eastern Europe found psychiatric hospitalization rates of 33 percent, compared with 5 percent in the general Swedish population. Yet these figures derive from convenience samples, orphan cohorts, or small clinical series, and almost none came from German-speaking countries. Larger, systematically assessed samples, and in particular gender-separated analyses, had been lacking.

The Essen team recruited 238 adults, 51.3 percent of them women and 48.7 percent men, who attended the hospital’s specialized FASD diagnostic service, established in 2018 in a German metropolitan area. The mean age was 28 years and the mean global IQ was 74, close to the range of mild intellectual disability. Among the diagnoses, 46.6 percent of participants had FAS, 38.7 percent had pFAS, and 14.7 percent had ARND. Because Germany has no evidence-based adult-specific diagnostic guideline, the researchers applied the German S3 guideline for children and adolescents together with a national expert consensus adapted for adults. Prenatal alcohol exposure, facial morphology, growth retardation, and multiple neurocognitive domains, including global intelligence, attention, memory, planning, and executive functioning, were measured with standardized assessments across two appointments of roughly two to three hours each.

Crucially, psychiatric comorbidity was not inferred from records or questionnaires. The researchers administered the DIPS Open Access, a structured clinical interview based on DSM-5 criteria that is comparable to the internationally used SCID-5 and has been repeatedly validated in German-speaking outpatient, inpatient, and research populations. This diagnostic rigor matters, because structured interviews substantially reduce the over- and under-reporting that can distort prevalence estimates in vulnerable populations with cognitive impairments. Categorical variables were compared between women and men using chi-square tests, or Fisher’s exact test where expected cell counts fell below five.

The results paint a picture of considerable psychological suffering. Overall, 31 percent of men and 41 percent of women met criteria for at least one comorbid mental health disorder, compared with a 12-month prevalence of 27 percent in the general German population. Anxiety disorders were the most common, affecting 13.8 percent of men and 13.1 percent of women, followed by major depression at 7.8 percent in men and 9.8 percent in women. Post-traumatic stress disorder was diagnosed in 4.1 percent of women, higher than the 2.3 percent reported for the general German population. Notably, the expected gender gap in overall psychiatric morbidity largely disappeared in this sample: women and men with FASD were affected at similar rates, a pattern that diverges from the well-replicated general-population finding that women experience more depression and anxiety while men show more substance problems.

The suicidality data are the study’s most alarming finding. Lifetime suicide attempts were reported by 32.8 percent of women and 17.2 percent of men, rates that dwarf general-population lifetime estimates of between 0.4 and 5.1 percent in Germany and the United States. The figures are consistent with earlier smaller studies and with data showing that completed suicide is a leading cause of death in FAS, with one large Canadian study reporting that 15 percent of people with FAS died by suicide. The researchers point to an accumulation of risk factors: the cognitive and daily-life impairments that come with FASD, financial hardship, low social support, heightened impulsivity, and frequent histories of trauma. The higher rate among women mirrors patterns seen in general psychiatric research, potentially reflecting greater exposure to victimization and traumatization. The authors argue that caregivers and professionals working with people with FASD should routinely assess suicidality and establish easy-to-use emergency strategies for individuals at acute risk.

Substance use presented a more nuanced picture. Thirty-day alcohol use was reported by 49.1 percent of men and 36.1 percent of women, actually below the rates in the general German population, where 74.8 percent of men and 66 percent of women had drunk alcohol in the preceding 30 days. More strikingly, 9.5 percent of men and 13.1 percent of women in the FASD sample had never consumed alcohol in their lives, a higher proportion of lifetime abstinence than in the general population. Cannabis told a different story: 30.2 percent of men and 17.2 percent of women reported use in the past 12 months, well above the general-population figures of 10.7 percent for men and 6.8 percent for women, and above even the young adult age groups. The researchers speculate that some individuals may use cannabis to self-medicate symptoms shared with ADHD, such as impulsivity and hyperactivity, or to regulate sleep problems, which are common in FASD. This self-treatment could be particularly harmful, since both acute and chronic cannabis use impair learning, memory, and attention, the very functions already compromised by prenatal alcohol exposure, potentially accelerating functional decline.

Formal substance use disorders, however, were far rarer in this sample than the literature had suggested: alcohol use disorders were diagnosed in 2.6 percent of men and 0.8 percent of women, and cannabis use disorders in 1.7 percent of men and 0.8 percent of women, against earlier reports ranging from 9 percent to over 50 percent. The authors caution that the small absolute numbers limit firm conclusions, and that selection effects may cut in both directions. People with severe comorbid illness or low social support may never reach a specialized diagnostic center at all, given that such services are scarce in Germany, involve long waiting times, and often require travel and caregiver accompaniment. The true psychiatric burden among all adults with FASD could therefore be even higher than measured, and the absence of a quantified ADHD comorbidity assessment, deliberately omitted to spare patients a five-appointment diagnostic procedure, leaves open the possibility of confounding, since roughly half of children with FASD also meet criteria for ADHD, which itself elevates risks of psychiatric illness, substance use, and suicidal behavior.

For the researchers, the message is clear. Adults with FASD are not simply living with a neurodevelopmental condition; they are carrying a compounded burden of anxiety, depression, trauma, and suicidal risk that current care systems are ill-equipped to address. Greater awareness of FASD within mainstream psychiatric services could turn comorbid presentations into diagnostic opportunities, while treatment planning must account for the learning, memory, and attention deficits that can undermine standard therapeutic approaches. The study’s authors call for specialized treatment that targets not only FASD-specific symptoms but also the comorbid conditions that, untreated, may shorten lives. With prevention programs such as the German health-insurance-approved “Stress-Stop” intervention already available, the infrastructure for better care exists in embryo; what is needed now, the researchers argue, is the clinical and political will to scale it.