Brief Treatment and Crisis Intervention Advance Access originally published online on July 6, 2006
Brief Treatment and Crisis Intervention 2006 6(3):255-267; doi:10.1093/brief-treatment/mhl006
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Original Article |
Gender Differences in Substance-Abuse Treatment Clients With Co-occurring Psychiatric and Substance-Use Disorders
From the Addiction Research Institute, University of Texas at Austin
Contact author: Laurel F. Mangrum, Research Scientist, University of Texas, Addiction Research Institute, 1717 West 6th Street, Suite 335, Austin, TX 78703. E-mail: lmangrum{at}mail.utexas.edu.
The study examined gender differences in a sample of 213 substance-abuse treatment clients with co-occurring severe and nonsevere psychiatric disorders. Results indicated that women had higher rates of posttraumatic stress disorder. Males displayed greater severity on psychiatric measures and received a greater array of ancillary services during treatment yet reported less social and psychological problem days at admission. Conversely, females presented relatively greater substance-use severity but reported higher levels of psychosocial distress and less problem days related to substance use. These findings suggest gender differences in problem recognition may exist, with males more readily admitting to problems related to substance use and females more open to acknowledging the effects of social and psychiatric problems. The current results have clinical implications for both the assessment process and the treatment programming.
KEY WORDS: co-occurring disorders, gender differences, substance-abuse treatment
The co-occurrence of psychiatric and substance-use disorders and the effects of comorbidity on the clinical presentation and outcomes of substance-abuse treatment clients are growing areas of study. Early research of this comorbidity focused on severely mentally ill (SMI) populations, identifying high prevalence rates and negative treatment outcome effects for clients with concomitant substance-use disorders (Drake, Bartels, Teague, Noordsy, & Clark, 1993). As a result of these findings, integrated treatment programs evolved to address the unique needs of this population (Drake, Mercer-McFadden, Muser, McHugo, & Bond, 1998; Muser, Noordsy, Drake, & Fox, 2003). To further understand and guide improvements in integrated treatment for SMI clients, studies have been conducted in an effort to identify client characteristics that may be associated with clinical features and outcomes. One area in this line of research has explored the role of gender as a potential factor affecting symptom presentation and treatment response.
A number of studies have examined gender differences in co-occurring psychiatric and substance-use disorder (COPSD) populations with severe mental illness. In an early study by Jerrell and Ridgely (1995) of 131 SMI clients entering one of three treatment modalities (24% female, 81% White), female clients had higher levels of psychiatric severity at admission but no other gender differences were found on demographics, psychiatric diagnoses, social functioning, substance-use severity, or treatment response. Comtois and Ries (1995) reported on gender comparisons in a sample of 338 SMI clients in a dual diagnosis integrated treatment program that was 36% female, 66% White, and 28% Black. No differences were found in demographics, legal status, substances of choice, psychiatric severity, treatment compliance, individual therapy received, or amount of case management services. More women had affective diagnoses and received a greater number of medication management services. Men were more likely to have a schizophrenia diagnosis, use polysubstances, and be under a payeeship and were rated by case managers as having greater substance-use severity and lower levels of social functioning compared to women. The authors noted, however, that the greater proportion of schizophrenic diagnoses in the male group may have confounded certain gender comparisons, particularly in the area of social functioning.
Brunette and Drake (1997) explored gender differences in a rural sample of 172 clients with schizophrenia that was predominantly male (78%) and White (96%). No differences were found on demographics, age of first substance use, substance-use severity, psychiatric diagnoses, psychiatric severity, or aggressive behavior. Women were found to have more children, higher levels of social contact, more medical problems, and greater incidence of victimization, whereas men reported more legal involvement. In a later study, Brunette and Drake (1998) attempted to replicate these findings in an urban sample of 108 homeless individuals with schizophrenia. This sample had a greater percentage of women (61%) and was primarily Black (91%). Similar to their previous findings, women were more likely to have children, to have increased social contacts, to have higher incidence of victimization, and to have had one or more days of illness in the past month. Women, however, did not report greater levels of chronic medical problems. Also, partially in line with previous findings, men had a greater history of incarceration but did not differ from women in number of criminal charges or convictions. No differences were found in substance-use severity, but men were more likely to have a marijuana-related diagnosis. In contrast to their earlier study results, women in this sample presented higher levels of psychiatric symptomatology. The authors speculated that a portion of the divergence in findings may be related to the effect of homelessness, citing literature suggesting higher levels of psychiatric severity in homeless women in general compared to men.
Three more recent studies have examined gender differences in SMI clients with COPSD. DiNitto, Webb, and Rubin (2002) explored gender differences in a sample of 97 SMI clients entering inpatient substance-abuse treatment. The sample was relatively equal in gender distribution (53% female) and racially/ethnically diverse (59% White, 28% Black, and 13% Hispanic). The study compared gender characteristics on the "Addiction Severity Index" (McLellan et al., 1992) at admission and follow-ups at 30, 60, and 90 days. Due to inconsistent follow-up rates, the follow-up data were aggregated over these three points for analyses. At treatment entry, no differences were found in employment, medical problems, years of substance use, substance-abuse treatment history, length of last voluntary abstinence, psychiatric diagnoses, or history of psychiatric treatment. Women were more likely to be divorced, to be on public assistance, to be living with a substance abuser, and to have dependents. Women reported a greater history of overdose, had more relatives with substance-abuse problems, and were rated higher by interviewers as in need of drug treatment. Addiction Severity Index composite scores in the family/social and psychiatric domains were higher for women; in these areas, women reported more problem days, greater distress, and more family members with psychiatric problems. Women were also more likely than men to have a history of victimization, particularly in the area of sexual abuse. Men were more likely to have never married, to have worked a greater number of days in the past month, and to have an alcohol-only problem. Although there were no gender differences on the legal composite, men were more likely to be on probation or parole, have a history of incarceration, and be in treatment for legally motivated reasons. At follow-up, women continued to have higher psychiatric and family/social composite scores than men, but no differences in the other domains were found. In their summary, the authors suggested these results may indicate that women are more socially attuned to relationship and psychological issues, thus better able to recognize and report these types of problems relative to men.
Gearon, Nidecker, Bellack, and Bennett (2003) explored gender differences in a sample of 52 COPSD SMI clients receiving outpatient psychiatric treatment and included comparisons on sources of substances and reasons for substance use. The sample was obtained from an inner-city mental health center and was 42% female and predominantly Black (70%). In this study, no differences were found in demographics, substance-use severity, age of first substance use, psychiatric diagnoses, or psychiatric severity. Women were more likely to be dependent on heroin, have a history of physical victimization, engage in prostitution or sex trading for drugs, obtain money from immediate family members for drugs, buy drugs from friends, and use drugs to test personal control. Men were more likely to be dependent on marijuana and demonstrated a trend toward greater comorbid alcoholism.
Grella (2003) examined the effect of gender in a sample of 400 SMI clients who were recruited from 11 adult residential drug treatment programs in Los Angeles County. The sample was relatively balanced in gender (53% female) and race/ethnicity (44% White, 35% Black, and 13% Hispanic). Gender groups were compared in a number of domains, including quality of life, self-efficacy, service needs, and treatment motivation and barriers, in addition to the more standard areas of analyses. Results indicated that women were more likely to be Black, to be married, to have children, and to engage in prostitution for income. Women also had higher rates of posttraumatic stress disorder, self-identified a wider array of service need types, and greater need for both family- and trauma-related services. Men were more likely to be White, to never be married, to be legally involved, and to engage in property crime for income. Men began using substances at an earlier age; had used more substance types; and had greater percentages of alcohol, marijuana, and opioid dependence disorders. No gender differences were found in age, education, employment, quality of life, self-efficacy, psychiatric severity, or mood and psychotic disorder diagnoses. Further, men and women were relatively equivalent on measures of treatment initiation, motivation, and barriers, as well as self-identified need for services in the areas of treatment recovery, health, employment, education, and medication. The author noted that although a number of gender differences were identified, the similarities between men and women were considerable.
Results from these studies of gender differences in COPSD clients with severe mental illnesses indicate a number of overall trends. Women appear to be more likely to have children, a greater history of victimization and associated traumatic stress, more medical problems and may be more able or willing to identify relationship and psychiatric problems. Findings in the areas of substance-use and psychiatric severity are inconsistent; differences that were found tended to suggest that men may present more severe substance-use symptoms and women greater psychiatric distress. These findings, however, are limited to studies of individuals with severe mental illnesses. Other lines of research suggest that the types of comorbidity in substance-abuse treatment clients may extend beyond the severe mental illnesses to include other psychiatric disorders of lesser severity. For example, community surveys, such as the Epidemiological Catchment Area study (Regier et al., 1993; Robins & Regier, 1991) and the National Comorbidity Survey (Kessler, Chui, Demler, & Walters, 2005; Kessler et al., 1997), have identified substantial comorbidity rates in the general population. Results of these epidemiological studies led Compton et al. (2000) to examine patterns of comorbidity in a sample of 425 clients entering drug treatment and found a 73% overall prevalence rate of any non-substance-use disorder. The most common diagnoses in the sample were antisocial personality disorder (44%), phobic disorder (39%), major depressive disorder (24%), dysthymia (12%), and generalized anxiety disorder (10%). The findings of Compton et al. suggest that non-SMI diagnoses are likely to be common in individuals seeking substance-abuse treatment.
Another factor that may influence comorbidity characteristics is the treatment setting from which a COPSD sample is drawn. The theoretical interaction between COPSD symptom severity and treatment setting is described in the quadrants of care model (National Association of State Mental Health Program Directors & National Association of State Alcohol and Drug Abuse Directors, 1999), which is a conceptual framework that considers the levels of both psychiatric and substance-abuse severity in determining the most likely locus of care for the COPSD client. In this model, COPSD clients with more severe levels of substance abuse and less severe mental illness are more likely to be seen in substance-abuse treatment systems; conversely, clients with greater psychiatric severity and less severe substance use are more likely to present in mental health systems. A number of studies support this pattern, indicating that schizophrenia and other psychotic disorders are more common among COPSD clients in programs that are primarily mental health treatment providers relative to traditional substance-abuse treatment programs (Havassy, Alvidrez, & Owen, 2004; Hien, Zimberg, Weisman, First, & Ackerman, 1997; Mangrum & Spence, 2005; Primm et al., 2000). Given this heterogeneity in the COPSD population, more studies are needed for exploring client characteristics across a broader spectrum of psychiatric disorders. The current study focuses on gender differences in a sample of COPSD clients entering substance-abuse treatment that includes both severe and nonsevere mental illnesses. The aim of the study is to determine if gender distinctions in this sample, containing a wider array of psychiatric disorders, are similar to those found in previous studies of SMI populations.
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Methods |
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Subjects
The sample was drawn from six state-funded substance-abuse treatment programs participating in the Texas Co-occurring State Incentive Grant (COSIG) project. The program locations included two urban, two rural, and two border areas. The Texas COSIG project consists of two components designed to promote system change and to enhance specialized clinical skills of substance-abuse treatment providers in serving COPSD clients. The first component of the project includes focused education at the clinician level on treatment issues relevant to COPSD and training on the use of diagnostic and assessment instruments to enhance identification of psychiatric comorbidity and to monitor progress of clients. The second component consists of a voucher system that provides additional funding for the procurement of ancillary services in an effort to address the multifaceted needs of COPSD clients and to support the treatment and recovery process. The types of adjunct services provided by the voucher system include childcare, housing support, transportation, food assistance, education support, employment assistance, clothing, medical care, prescriptions, and peer mentoring.
The sample consisted of 213 adult clients entering substance-abuse treatment who subsequently qualified for the COSIG voucher program based on the presence of a comorbid non-substance-use disorder determined through diagnostic interview. The sample was recruited from participating COSIG programs between March 2005 and January 2006. Clients were provided a cover letter explaining the nature of the project and their right to decline participation in research and evaluation activities using client data. The total sample was 60% male, 53% Hispanic, 41% White, and 7% Black.
Measures
Both project-specific and state administrative client data were collected for analysis from the following sources.
Mini International Neuropsychiatric Interview.
The Mini International Neuropsychiatric Interview (MINI) (Sheehan et al., 1998) is a structured diagnostic interview that assesses for the most frequently diagnosed Diagnostic and Statistical Manual for Mental Disorders—Fourth Edition (DSM-IV) and International Classification of Diseases—Tenth Revision (ICD-10) disorders. The MINI was designed to provide a brief and easy to administer interview while retaining the sensitivity and specificity of more extensive diagnostic interviews that often require administration by licensed professionals. With training, the MINI can be administered by individuals without extensive education or training in psychiatry or psychology. The MINI has been validated against a number of standard diagnostic interviews, such as the Structured Clinical Interview for DSM-III-R and the Composite International Diagnostic Interview (Lecrubier et al., 1997; Sheehan et al., 1997, 1998). The MINI consists of separate modules that assess a specific disorder and may be used independently of each other. In this study, the MINI modules administered were major depressive disorder, dysthymia, manic and hypomanic episode, panic disorder, obsessive-compulsive disorder, posttraumatic stress disorder, alcohol dependence and abuse, substance dependence and abuse, psychotic disorder and mood disorder with psychotic features, and generalized anxiety disorder.
Brief Symptom Inventory.
The Brief Symptom Inventory (BSI) (Derogatis, 1993) is a client self-report inventory that measures psychological symptom severity on nine primary dimensions (somatization, obsessive compulsive, interpersonal sensitivity, depression, anxiety, hostility, phobic anxiety, paranoid ideation, and psychoticism) and three global severity indices (Global Severity Index, Positive Symptom Distress Index, and Positive Symptom Total).
Brief Derogatis Psychiatric Rating Scale.
The Brief Derogatis Psychiatric Rating Scale (BDPRS) (Derogatis, 1978) is a brief psychiatric rating scale that allows a clinician to rate a client's symptom severity on nine primary dimensions and one global rating. The BDPRS is a companion instrument to the BSI and provides clinician ratings on the same nine primary symptom dimensions.
Behavioral Health Integrated Provider System.
Behavioral Health Integrated Provider System (BHIPS) is the mandatory data collection and outcomes-monitoring system for state-funded substance-abuse treatment providers in the state of Texas. Programs are required to report client data at admission, discharge, and 60-day follow-up. Types of data collected through the BHIPS system include client demographics, drug- and alcohol-use patterns, substance-use disorder diagnoses, substance-abuse treatment characteristics, and client-reported levels of functioning in a variety of areas such as employment, living situation, medical concerns, and psychological health. Data regarding ancillary services received through the COSIG voucher system were also available from BHIPS.
Training
All staff of the six COSIG programs were provided an 8-h training conducted by the State of Texas personnel concerning fundamental issues in treating clients with COPSD. Clinical staff of the programs were given an additional 4-h training by the first author on the administration and scoring of diagnostic and assessment instruments, including the MINI, BSI, and BDPRS. Clinicians' use and scoring of these measures were monitored by the authors, and additional booster trainings were provided as needed at the programs to enhance quality of administration. Across all programs, a total of 25 counselors administered the measures with the following degrees/certifications—Licensed Chemical Dependency Counselor: 40%, Licensed Chemical Dependency Counselor Intern: 20%, Licensed Master or Clinical Social Worker/Licensed Professional Counselor: 12%, Bachelor's Degree: 12%, Psychology Intern: 8%, MD: 4%, and PhD: 4%.
Analyses
Men and women were compared on demographic variables, psychiatric diagnoses, substance-use characteristics, psychiatric severity, ancillary services, and treatment characteristics. Continuous variables were analyzed using t test analyses, and categorical variables were assessed using 
2 analyses. Cases with missing data were omitted from the analyses of that variable. At the time of the study, discharge data were available for 81% of the sample (females: 84%, males: 79%), with the remainder of the clients still receiving treatment services. Although BHIPS collects 60-day follow-up information, insufficient follow-up data were available for the current analyses.
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Results |
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Demographic and social characteristics of the gender groups are reported in Table 1. Comparisons in this domain revealed that women were younger, were more likely to have children, were more often living in group quarters or an institutional setting, and had higher levels of legal involvement. Men were older and had greater homelessness rates. No differences were found in race/ethnicity, marital status, or employment status. Although women had higher rates of legal involvement, no differences were found in the incidence of client-reported driving while intoxicated, public intoxication, or other substance-related arrests during the year prior to admission.
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In the area of primary substance-use diagnoses, men were more often diagnosed with alcohol disorders, whereas women more frequently received cocaine diagnoses (see Table 2). On non-substance-use diagnoses, women were more likely to be diagnosed with posttraumatic stress disorder. No gender differences were found among the other disorder types or in the total number of non-substance-use diagnoses. Approximately 75% of both men and women received two or more non-substance-use diagnoses, with the most common being a combination of an affective and an anxiety disorder.
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Substance-abuse treatment and substance-use history characteristics are reported in Table 3. No gender differences were found in previous detox or nondetox substance-abuse treatment or incidence of past year emergency room visits. A greater proportion of women had attended Alcoholics Anonymous over the past month, and of those attending Alcoholics Anonymous, women had attended a higher number of meetings compared to men. Men reported more years of primary substance use but did not significantly differ from women in age of first use or in history of intravenous drug use. Analyses indicated that men were more likely to use alcohol as their primary substance, whereas women more often used cocaine, crack, and opiates and were more likely to engage in polysubstance use. Women also had higher rates of daily use over the past 6 months but did not differ from men in average days of use during the month prior to admission.
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Table 4 displays client-reported problem days in the month prior to admission, BSI scores, and BDPRS ratings that were significantly different between men and women. Women reported a greater number of problem days related to medical, employment, family, social, and psychological problems, whereas men reported more problem days related to drug or alcohol use. On psychiatric severity measures, men displayed greater levels of symptomatology on both self-report and clinician ratings. Males had higher mean scores on the phobic anxiety, paranoid ideation, psychoticism, and positive symptom total scales of the BSI and were also rated more severely by clinicians on the paranoid ideation and psychoticism scales of the BDPRS. No gender differences were found on the remaining scales of the BSI or BDPRS.
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As previously described, discharge data were available for 81% of the sample. Comparisons on treatment service types indicated that men were more likely to receive detox services than women (47% vs. 28%;
2(5) = 31.86, p < .0001). Comparisons of ancillary services received during treatment are reported in Table 5. Analyses revealed that, in general, men received more types of voucher services. Among the ancillary service categories, greater proportions of men received food assistance, housing support, transportation, and peer mentoring, whereas more women received medical services and prescriptions. In this sample, no clients received education support or employment services. Further, only one client had received services in the childcare and clothing categories, precluding gender analyses on these variables. No gender differences were found in length of stay, treatment completion, abstinence rates, or Alcoholics Anonymous attendance during the month prior to discharge.
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Conclusions |
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The current study explored gender differences in a sample of COPSD clients that included both severe and nonsevere mental illnesses in an effort to expand on previous gender research using SMI populations. The present analyses revealed that women were more likely to have children and be living in a group or institutional setting and had higher rates of legal involvement. By contrast, males in this sample were older and had higher rates of homelessness. In the area of substance use, men were more likely to use alcohol as a primary substance, had more years of primary substance use, and reported more problem days related to substance use relative to women. Women more often used powder cocaine, crack, and opiates as primary substances and reported more problem days related to medical, employment, family, social, and psychological issues at treatment entry. Although women had been using their primary substance for a shorter period of time than men, they displayed evidence of greater substance-use severity; higher proportions of women reported engaging in polysubstance use and daily use of primary substances over the past 6 months. Further, there were no differences between men and women in age of first substance-use or substance-abuse treatment history, suggesting that women entered treatment more quickly than men after initiating substance use. Comparisons among diagnostic categories revealed that women had higher rates of posttraumatic stress disorder, but no gender differences were found in the rates of other disorders. On psychiatric measures, men displayed greater levels of psychiatric severity on standardized self-report and clinician ratings in the areas of phobic anxiety, paranoia, and psychoticism. At discharge, analyses of ancillary service use indicated that men received more types of services and were more likely to receive housing, food assistance, transportation, and peer mentoring, whereas women more frequently obtained medical care and prescription services. No gender differences were found in length of stay, treatment completion, or abstinence rates at termination of treatment.
The present study produced results that were both similar to and divergent from those in the existing literature examining COPSD samples with severe mental illness. Consistent with previous findings, the current analyses revealed that women were more likely to have children, had greater rates of posttraumatic stress disorder, displayed higher medical problems, and reported more psychosocial problems compared to men. However, contrary to past results, women in this sample were more likely to be legally involved relative to men and reported comparable rates of alcohol and other substance-related arrests during the past year. Further, the results of this study did not support trends noted in other studies in which men tended to display greater severity in substance use and women in psychiatric symptoms; in fact, the opposite pattern was found. Interestingly, males displayed greater severity on psychiatric measures and received a greater array of ancillary services yet reported less social and psychological problem days at admission to treatment compared to women. Conversely, females presented relatively greater substance-use severity but reported higher levels of psychosocial distress and less problem days related to substance use. These findings suggest that a differential pattern of awareness may exist regarding the effects of psychiatric and substance-use severity on life functioning, with males more readily admitting to problems related to substance use and females more open to acknowledging the effects of social and psychiatric problems. This potential influence of socialization on problem recognition was also posed by DiNitto et al. (2002) as an explanation for gender differences in client-reported psychosocial problems and family history found in their study. The possible presence of differential gender effects on client reporting has significant clinical implications for the assessment process and highlights the importance of using a variety of measures and informant sources to corroborate the client's problem presentation. Relying solely on client-reported problem days may be insufficient in identifying the full extent of symptomatology and associated psychosocial problem areas. In addition, gender differences in problem awareness may also indicate the need for treatment programming and interventions tailored toward increasing recognition of the broader and interactive effects of substance use and psychiatric problems on social functioning.
One of the most consistent findings in the gender literature has been the high prevalence of posttraumatic stress disorder and victimization in female clients. These findings suggest that routine screening for posttraumatic symptoms would be a clinically useful and important component when conducting admission assessments for substance-abuse treatment. Clients who suffer from this disorder may benefit from specialized groups to process trauma issues and to provide assistance in recognizing the potential use of substances to allay anxiety and distress related to victimization.
The current study expands on extant literature regarding gender differences in clients with COPSDs. Strengths of this study include the use of standardized psychiatric measures, multiple methods of client assessment, and sampling from six different programs from diverse areas of the state. The findings, however, are exploratory and have a number of limitations. Although the diagnostic data analyzed in this study were collected through structured interview, the interviewers were not all clinicians certified to make clinical diagnoses. Further, because the MINI is being implemented naturalistically in the COSIG project, interrater reliability data were not collected. Thus, these data can be considered diagnostic impressions, rather than official diagnoses. The MINI interview, however, can be a useful tool in substance-abuse treatment programs that often lack personnel trained in mental health; the interview can be used to screen for potential disorders and provide diagnostic impressions that can be further assessed through referral to mental health professionals. Another limitation concerns the use of administrative data that are obtained independently from a research project, precluding supervision of the data-reporting process. The state of Texas does verify samples of BHIPS information throughout the year during auditing visits, providing some level of data validation. Finally, the study contained numerous comparisons that increase the possibility of capitalizing on chance findings. This study was exploratory, however, and provides baseline information regarding gender characteristics in substance-abuse treatment clients with both severe and nonsevere psychiatric disorders. Future studies are needed for exploring gender features in this client population to replicate and expand on these findings.
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Acknowledgments |
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The authors would like to acknowledge the partnership and support of the staff at the Texas Department of State Health Services–Division for Mental Health and Substance Abuse Services in implementing this project and for assisting in retrieval of archival data for the present analysis. We would also like to acknowledge the staff of the following treatment programs who are participating in the COSIG project for providing client data and to recognize their continuing efforts to improve services for clients with COPSD: The Association for the Advancement of Mexican Americans (Edinburg), Fort Bend Regional Council on Substance Abuse (Stafford), Hill Country Community Mental Health and Mental Retardation Center (Kerrville), Homeward Bound, Inc. (El Paso), Lubbock Regional Mental Health and Mental Retardation Center (Lubbock), and Montrose Counseling Center (Houston). Portions of this manuscript were presented at the 2006 Research Society on Alcoholism Conference, Baltimore, MD. Conflict of Interest: None declared.
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References |
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