Vivian B. Brown, Ph.D.

The Different Faces of Women and Co-Occurring Disorders

CENTERS FOR INNOVATION IN HEALTH, MENTAL HEALTH

AND SOCIAL SERVICES

Mental

Illness

SubstanceAbuse

HomelessnessTrauma

HIV/AIDS

Other Health

Problems

Out

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Out

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Substa

nce

Abuse

Substa

nce

Abuse

Mental Health

Mental Health

Safety &

TraumaSafety &

Trauma

Health

Health

Children’sServices

Children’sServices

Parenting

ParentingVoca

tional

Trai

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g

Voca

tional

Trai

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Some Gender Disparities

• Women advance more rapidly from use to regular use to first treatment episode than do men

• When women enter treatment, in spite of fewer years of use and smaller quantities used, the substance use severity is generally equivalent to men

• At treatment entry, women average more medical, psychiatric, and adverse social consequences than men

• Higher rates in women than men in certain co-occurring mental health disorders: mood disorders, anxiety, eating disorders, PTSD

SAMHSA’s Women with Co-Occurring Disorders and

Violence Study

PROTOTYPES

Allies New Directions for Families D.C. Trauma

CollaborationStudy

Triad Women’s Project

Portal Project

Women Embracing Life & Living (W.E.L.L.)

Franklin CountyWomen’s ResearchProject

Boston Consortium ofServices for Families inRecovery

The 9 National Program Sites

Program / Site Intervention Group Comparison Group

PROTOTYPES

Los Angeles, CA187 215

Allies

Stockton, CA169 266

Arapahoe House—New Directions for Families

Metropolitan Denver, CO57 108

D.C. Trauma Collaboration

Washington, D.C.150 97

Triad Women’s Project

Avon Park, FL179 123

Boston Consortium of Services for Families in Recovery

Boston, MA181 161

The W.E.L.L. Project

Cambridge, MA218 110

Franklin County Women’s Research Project

Greenfield, MA105 120

Portal Project

New York, NY169 114

Total 1415 1314

Sample Sizes Across Program Sites by Condition (N=2,729)

Baseline Demographic Characteristics by Program Site: Hispanic Ethnicity

Variable

(n =402)(n =435) (n =165) (n =247) (n =302) (n =342) (n =328) (n =225) (n =283) (n=2729)

Hispanic Ethnicity (%)* 30.6 17.5 27.3 3.2 6.0 34.2 6.7 5.3 25.4 18.1

Race**

% White/Caucasian41.3 56.3 52.1 13.4 81.5 37.4 78.4 85.3 7.1 50.3

Race**

% African-American22.9 16.6 18.2 79.4 13.2 27.8 6.1 3.1 66.8 27.2

Race**

% Other Race24.4 17.9 9.1 2.0 2.0 29.8 5.8 3.1 23.7 14.5

Race**

%Multi-racial***11.4 7.6 4.8 4.0 1.0 2.6 8.2 4.9 2.1 5.6

Race**

% None-specified0.0 1.6 15.8 1.2 2.3 2.3 1.5 3.6 0.4 2.4

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* Hispanic ethnicity was measured independent of race; ** Not all percentages total to 100%, as excluded from the totals were subjects for whom data were missing; *** Category includes subjects who identified two or more races

Participants in the Study

• 2,729 women were enrolled in the study

• All are18 or older with histories of mental health and substance abuse services use and histories of physical or sexual abuse

• Average age (both groups) is about 26. Age ranges from 18 to 76

• 54% were Caucasian, 18% Hispanic/Latina, 29% African American

• 87% were mothers

• 50% had completed high school

Primary Outcomes & Measures

Outcomes Measures

Substance Abuse: Addiction Severity Index– Alcohol Composite (ASI-A)

– Drug Abuse Composite (ASI-D)

Mental Health: Brief Symptom Inventory– Global Severity Index (GSI)

Trauma: Post Traumatic Diagnostic Scale– Post Traumatic Symptom Scale (PSS)

The 6-Month Outcome Components

• Intent-to-treat design

• 2,006 women (1,023 in intervention condition, 983 in comparison condition) were interviewed 6 months after initial enrollment re: outcomes plus services received and other elements

• Four outcome measures: mental health symptoms, alcohol use, other drug use, and trauma-related symptoms

• Women in both intervention and comparison conditions had decreased symptoms in all four areas at 6 months

Differences between Intervention and Comparison Conditions

• On two of four measures (post-traumatic symptoms and drug use severity), women in the intervention programs showed significantly greater improvement than those in usual care

• On mental health status, differences almost reach significance

• Effect sizes are small, but present

Morrissey, J.P. et al. (2005) Journal of Substance Abuse Treatment

6-Month Data on All Sites

• On drug use problem severity (ASI-D), 49% of the

intervention women and 36% of the comparison

women reported no drug use or drug-related

problems at 6 months

• On alcohol use problem severity (ASI-A), 52% of

intervention and 40% of comparison women

reported no use or related problems at 6 months

Differences between Intervention and Comparison Conditions

• The 12-month effect sizes for mental health and post traumatic symptoms show statistically significant improvements for women in the intervention condition relative to those in the comparison condition

• The two substance use severity outcomes show no additional improvement over the corresponding values at 6 months

Morrissey, J.P. et al. (2005) Psychiatric Services

• Baseline and 12 months assessments completed by 136 Intervention and 177 Comparison group women (78% of Sample)

• Measures:– Addiction Severity Index (ASI)

– Brief Symptom Inventory

– Posttraumatic Symptom Scale (PSS)

– Life Stressor Checklist – revised

– Coping Skills Scale

Local Outcome Study Los Angeles Site – PROTOTYPES

Baseline Demographic and Clinical Characteristics of Study Population by Condition

Intervention (N = 187)

Comparison(N = 215)

Statistical Test

Age (years) mean (SD) range

33.15 (8.45)18 to 59

33.26 (8.89)18 to 61

F(1,400) = 0.01, ns

Education (years) Mean (SD) 11.60 (2.13) 11.61 (2.24) F(1,397) = 0.00, ns

Race/ethnicity (%) Hispanic White Asian/Pac. Islander Black American Indian Biracial

26.7439.040.5320.8610.702.14

26.0635.400.9324.1112.570.92

X2 (N=402, df=1) = 2.36, ns

Relationship Status (%) currently partnered previously partnered never partnered

29.4132.0938.50

27.4031.6040.90

X2 (N=402, df=1) = 0.29, ns

Number of Children mean (SD) 2.37 (1.87) 2.60 (2.22) F(1,400) = 1.30, ns

Confinement in jail (% ever) 91.44% 80.47% X2 (N=401, df=1) = 9.64**

NOTE: ns = not statistically significant, * p < 0.05, ** p < 0.01, *** p < 0.001, **** p < 0.0001

Baseline Demographic and Clinical Characteristics of Study Population by Condition (continued)

Intervention (N = 187)

Comparison(N = 215)

Statistical Test

Required to be in treatment (% yes) 64.61% 38.14% X2 (N=402, df=4) = 41.85***

Serious physical illness or disability (% yes) 40.32% 34.41% X2 (N=401, df=2) = 5.20, ns

Mental heath case (% yes) 61.50% 63.72% X2 (N=402, df=1) = 0.64, ns

Childhood physical or sexual abuse (%) none low moderate high

28.8832.6224.0614.44

28.3734.4120.4616.74

X2 (N=402, df=3) = 1.03, ns

Any interpersonal abuse in the last 6 months (% yes) 52.46% 60.47% X2 (N=393, df=2) = 2.56, ns

History of homelessness (% ever) 74.33% 68.37% X2 (N=402, df=1) = 1.73, ns

Most troublesome drug (%) Heroin Cocaine/crack Methamphetamine Alcohol Alcohol and drugs Poly drug Hallucinogens/marijuana/other

3.3%21.7%38.6%7.5%

12.08%7.6%9.3%

3.7%22.8%32.6%9.8%18.1^10.7%2.3%

X2 (N=402, df=6) = 16.66*

NOTE: ns = not statistically significant, * p < 0.05, ** p < 0.01, *** p < 0.001, **** p < 0.0001

Results: Treatment Retention

• Women in the Intervention Group were less likely to drop out than Comparison Group

Results: Treatment Outcomes

• On the PSS, there was greater improvement for Intervention than Comparison Groups

• Use of coping skills increased from baseline to 12 months for the Intervention Group, but slightly decreased for the Comparison Group

Results: Effects of Treatment Completion on Outcome

• Women who completed treatment showed more improvement on most outcomes than women who did not complete

Mean Scores at Baseline and at 12 Months, and Results of Repeated Measures Analyses of Variance on Treatment Outcomes

Intervention Comparison Statistical Test

ASI alcohol Baseline M (SD) 12-month M (SD)

N = 1360.18 (0.29)0.06 (0.17)

N = 1770.27 (0.35)0.13 (0.23)

IC:Time:X:

F(1,311) = 10.01**F(1,311) = 55.96****F(1,311) = 0.53, ns

ASI drug Baseline M (SD) 12-month M (SD)

N = 1350.19 (0.15)0.04 (0.07)

N = 1760.25 (0.14)0.08 (0.11)

IC:Time:X:

F(1,309) = 18.13****F(1,309) = 330.29****F(1,309) = 1.23, ns

GSI Baseline M (SD) 12-month M (SD)

N = 1361.07 (0.68)0.80 (0.72)

N = 1771.09 (0.69)0.86 (0.77)

IC:Time:X:

F(1,311) = 0.25, nsF(1,311) = 35.48****F(1,311) = 0.34, ns

PSS Baseline M (SD) 12-month M (SD)

N = 13620.43 (10.22)13.78 (11.10)

N = 17719.05 (11.84)15.11 (12.91)

IC:Time:X:

F(1,311) = 0.00, nsF(1,311) = 60.91****F(1,311) = 3.99*

Coping Skills Baseline M (SD) 12-month M (SD)

N = 13452.61 (17.83)56.32 (20.15)

N = 17354.26 (17.51)52.96 (20.09)

IC:Time:X:

F(1,305) = 0.23, nsF(1,305) = 0.96, nsF(1,305) = 4.12*

NOTES: On ASI, GSI, and PSS, higher scores indicate higher symptoms. On coping skills, higher scores indicate greater skills. IC = main effects for intervention versus comparison condition, Time = main effects for time (baseline versus 12 months), X = interaction between condition and time. ns = not statistically significant, * p < 0.05, ** p < 0.01, *** p < 0.001, **** p < 0.0001.

Cumulative Dropout During First 12 Weeks

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Post Traumatic Symptom Scale at Baseline and 12 Months

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Interaction Between Group, Treatment Completion & Coping Skills

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PROTOTYPES Community Assessment Service Center for Service Planning

Area 3 (SPA 3 CASC)

• SPA 3 covers the San Gabriel and Pomona Valleys, 720 square miles, with an estimated population of 1.9 million

• Population ranks higher than 13 states and the District of Columbia

Measures

• Each person assessed using a form of the Addiction Severity Index (McLellan et al.)– ASI Adult

– ASI Lite• Subset of ASI Adult, not used for initial assessment

– BSAP (Behavioral Severity Assessment Program)• ASI Adult + additional mental health indicators

• Used to link individuals to services– Ideally matched to severity of the person’s needs

About These Data

• SPA 3 CASC has 3 locations– El Monte (primary location), Pasadena, Pomona

• N = 12,550– 4,517 females (36%), 8,033 males (64%)

– Gender distribution varies by referral source• More females from CalWORKs, more males from

Prop 36

– Assessed September 14, 2000 – June 30, 2005

Percent from Referral Source by Race/Ethnicity: Females (n=4,517)

CalWORKsn = 1,602

Prop 36n = 1,093

General Reliefn = 1,488

Communityn = 334

White 14.3% 39.6% 28.0% 26.3%

Black 13.3% 14.2% 16.9% 13.8%

American Indian

0.6% 1.6% 2.1% 1.8%

Asian/Pacific Islander

1.9% 1.8% 1.3% 2.4%

Hispanic 69.4% 42.2% 51.4% 47.6%

Unknown 0.6% 0.6% 0.4% 1.2%

Percent Experienced Depression: Past 30 Days and Lifetime [R]

0%

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80%

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Male 30 Days 56.5% 10.4% 18.4% 22.6%

Male Lifetime 79.3% 31.9% 47.3% 49.6%

Female 30 Days 78.3% 20.4% 28.0% 39.5%

Female Lifetime 91.0% 52.0% 65.0% 62.9%

CalWORKs Prop 36 General Relief Community

Percent Experienced Serious Anxiety: Past 30 Days and Lifetime [R]

0%

20%

40%

60%

80%

100%

Male 30 Days 64.1% 10.7% 17.2% 23.4%

Male Lifetime 62.1% 23.5% 37.9% 46.8%

Female 30 Days 77.8% 21.0% 27.0% 38.3%

Female Lifetime 85.0% 39.2% 54.9% 50.0%

CalWORKs Prop 36 General Relief Community

Psychiatric Diagnosis

• Subset of clients further assessed for DSM-IV diagnoses

– N = 2,215, assessed with BSAP (478 males, 1,737 females)

– Overall 72.3% of those assessed had any Axis I or Axis II diagnosis (not including substance abuse or dependence)

• 89.7% including substance abuse or dependence

– 67.5% had an Axis I psychiatric (non-AOD) diagnosis

– 23.4% had an Axis I substance abuse or dependence diagnosis

– 8.8% had a diagnosis Axis II personality disorder

– Within each Axis, only one diagnosis could be coded

• May undercount prevalence of multiple diagnoses

Percent Assessed with Any DSM-IV Axis I or Axis II Diagnosis* [G,R,GxR]

0%

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Males 53.6% 7.1% 42.6% 24.2%

Females 82.6% 23.1% 53.5% 88.6%

CalWORKs Prop 36 General Relief Community

* Not including Axis I Substance Abuse or Dependence Diagnoses

Percent of Clients Assessed with a Primary Axis I Disorder (n = 2,215)

• 45.6% Mood Disorders

• 7.6% Adjustment Disorders

• 0.7% Psychotic Disorders

• 9.9% Anxiety Disorders

• 2.4% Occupational Problem

• < 1% Eating Disorders, Attention Deficit Disorders, Abuse or Neglect

• 5.8% Other diagnostic categories

• 23.4% Substance Abuse or Dependence

• 2.3% Diagnosis Deferred on Axis I

Percent of CASC Clients Referred to Any Treatment [R,GxR]

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Males 84.6% 85.2% 73.1% 93.0%

Females 81.1% 81.6% 78.6% 88.7%

CalWORKs Prop 36 General Relief Community

Percent of CASC Clients Enrolled in Treatment (of those referred) [R,GxR]

0%

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40%

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Males 72.7% 73.0% 56.3% 90.8%

Females 67.0% 70.9% 72.8% 82.5%

CalWORKs Prop 36 General Relief Community

PROTOTYPES WomensLink CMHS Project

• Eligibility: women living with HIV/AIDS and at least 1 Mental Health Diagnosis. The mental health diagnosis could not be solely a substance use disorder (SAMHSA/CMHS)

• Screening:

– Step 1 – PRIME-MD Patient Health Questionnaire (Spitzer, Kroenke, & Williams, 1999)

– Step 2 – MINI (Sheehan, Lecrubier, Sheehan, Amorim, et al, 1998)

• Enrollment: September 30, 2001 – August 30, 2006; a total of 277 women were screened: 62.8% African American, 18.1% Latina, 15.5% White, 2.2% Native American; of those screened, 84 women were diagnosed with a DSM-IV Axis I or Axis II mental health diagnosis and accepted enrollment in program; of those women enrolled, 69% were African American, 20.2% Latina, 6% White, and 3.6% Native American

Summary of Axis I Diagnoses

Diagnosis Category Percentage

Mood Disorders 75%

Depressive Disorders 69.0%

Bipolar Disorder 7.2%

Anxiety Disorders 9.5%

Schizophrenia and Other Psychotic Disorders 7.2%

Overall, 81.0% had a single Axis I diagnosis and 19.0% had two or more Axis I diagnoses.

Substance Use

Note: 36.9% reported participating in substance abuse treatment in past year

Drug/Alcohol Use % Use Last 30 Days % Use Ever

Any Alcohol 20.2% 82.1%

Any Illegal Drug 20.2% 59.5%

Cocaine/Crack 6.0% 52.4%

Heroin 0% 15.5%

Methamphetamines 1.2% 10.7%

Barbiturates/Sedatives 1.2% 17.9%

Hallucinogens 0% 16.7%

Marijuana/Hashish 13.1% 57.1%

Services Provided

• Individual counseling/psychotherapy

• Group counseling

• Psychiatric care with bilingual, bicultural women psychiatrist

• Peer support services

• Case management

• Transportation

• Child care

• Linkages to medical/HIV services

• Linkages to housing, food, other benefits

Retention & Outcomes

• Retention: Mean time in program was 1,349 days (standard error = 58 days), which translates to an average of over 3 years with the program

• Outcomes:– Significant reductions in psychological distress

– Significant improvements in health-related quality of care (e.g., cognitive functioning and emotional well-being)

– Significant improvements in measures of HIV-related health, such as CD4 counts and viral load

– The majority of women who were living in shelters at intake were successfully transitioned into stable housing at follow-up

PROTOTYPES Pregnant and Postpartum Women (PPW) Program (CSAT)

• October 1, 2006 –

• Enrollment began January 2007 for all 8 grantees

• As of March 31, 2007, PROTOTYPES Women’s Center has enrolled 20 women– 45% Latina

– 35% African American

– 30% White

• 8 pregnant and 12 postpartum women (with 10 children enrolled at this time)

Substance Use

• 17% reported injection drug use in the past 12 months

• 28% of the women had been diagnosed at some time with a mental illness

Type of Drug Ever Used Used in Last Year Used Last 30 Days

Heroin 22% 11% 6%

Alcohol 94% 44% 22%

Barbiturates 6% 6% 6%

Methamphetamines 83% 72% 50%

Cocaine (Powder) 11% 0% 0%

Cocaine (Crack) 28% 22% 11%

Marijuana/Hashish 44% 39% 11%

PCP/Angel Dust 6% 0% 0%

Other Hallucinogens 22% 0% 0%

Librium/Valium 6% 6% 0%

Other Opiates 11% 11% 11%

Inhalants 6% 0% 0%

Postpartum Depression

• Our project is also looking at postpartum depression as an issue for intervention

• Utilizing the Postpartum Depression Scale (PDSS)* (Beck & Gable, 2002)

• N = 15 screened

• 53% screen positive for major postpartum depression

• 27% scored in a range indicating significant symptoms of postpartum depression

* The PDSS Short Form is strongly correlated with EPDS (r=0.76, p<0.0001); SCID Depression (r=0.67, p<0.0001)