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Vivian B. Brown, Ph.D. The Different Faces of Women and Co-Occurring Disorders CENTERS FOR INNOVATION IN HEALTH, MENTAL HEALTH AND SOCIAL SERVICES.

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Presentation on theme: "Vivian B. Brown, Ph.D. The Different Faces of Women and Co-Occurring Disorders CENTERS FOR INNOVATION IN HEALTH, MENTAL HEALTH AND SOCIAL SERVICES."— Presentation transcript:

1 Vivian B. Brown, Ph.D. The Different Faces of Women and Co-Occurring Disorders CENTERS FOR INNOVATION IN HEALTH, MENTAL HEALTH AND SOCIAL SERVICES

2 Mental Illness Substance Abuse Homelessness Trauma HIV/ AIDS Other Health Problems

3 Outreach Substance Abuse Substance Abuse Mental Health Safety & Trauma Safety & Trauma Health Children’s Services Children’s Services Parenting Vocational Training Vocational Training

4 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

5 SAMHSA’s Women with Co-Occurring Disorders and Violence Study

6 PROTOTYPES Allies New Directions for Families D.C. Trauma Collaboration Study Triad Women’s Project Portal Project Women Embracing Life & Living (W.E.L.L.) Franklin County Women’s Research Project Boston Consortium of Services for Families in Recovery The 9 National Program Sites

7 Program / SiteIntervention GroupComparison Group PROTOTYPES Los Angeles, CA 187215 Allies Stockton, CA 169266 Arapahoe House—New Directions for Families Metropolitan Denver, CO 57108 D.C. Trauma Collaboration Washington, D.C. 15097 Triad Women’s Project Avon Park, FL 179123 Boston Consortium of Services for Families in Recovery Boston, MA 181161 The W.E.L.L. Project Cambridge, MA 218110 Franklin County Women’s Research Project Greenfield, MA 105120 Portal Project New York, NY 169114 Total 14151314 Sample Sizes Across Program Sites by Condition (N=2,729)

8 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 (%)*30.617.527.33.26.034.26.75.325.418.1 Race** % White/Caucasian 41.356.352.113.481.537.478.485.37.150.3 Race** % African-American 22.916.618.279.413.227.86.13.166.827.2 Race** % Other Race 24.417.99.12.0 29.85.83.123.714.5 Race** %Multi-racial*** 11.47.64.84.01.02.68.24.92.15.6 Race** % None-specified 0.01.615.81.22.3 1.53.60.42.4 PROTOTYPES SCCAllies New Directions for Families DC Trauma Collaboration Study Triad Women’s ProjectBoston Consortium of Services The W.E.L.L. Project Franklin Co. Women’s Research Project Portal ProjectTotal * 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

9 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

10 Primary Outcomes & Measures OutcomesMeasures 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)

11 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

12 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

13 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

14 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

15 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

16 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 26.74 39.04 0.53 20.86 10.70 2.14 26.06 35.40 0.93 24.11 12.57 0.92 X 2 (N=402, df=1) = 2.36, ns Relationship Status (%) currently partnered previously partnered never partnered 29.41 32.09 38.50 27.40 31.60 40.90 X 2 (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%X 2 (N=401, df=1) = 9.64** NOTE: ns = not statistically significant, * p < 0.05, ** p < 0.01, *** p < 0.001, **** p < 0.0001

17 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%X 2 (N=402, df=4) = 41.85*** Serious physical illness or disability (% yes)40.32%34.41%X 2 (N=401, df=2) = 5.20, ns Mental heath case (% yes)61.50%63.72%X 2 (N=402, df=1) = 0.64, ns Childhood physical or sexual abuse (%) none low moderate high 28.88 32.62 24.06 14.44 28.37 34.41 20.46 16.74 X 2 (N=402, df=3) = 1.03, ns Any interpersonal abuse in the last 6 months (% yes)52.46%60.47%X 2 (N=393, df=2) = 2.56, ns History of homelessness (% ever)74.33%68.37%X 2 (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% X 2 (N=402, df=6) = 16.66* NOTE: ns = not statistically significant, * p < 0.05, ** p < 0.01, *** p < 0.001, **** p < 0.0001

18 Results: Treatment Retention Women in the Intervention Group were less likely to drop out than Comparison Group

19 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

20 Results: Effects of Treatment Completion on Outcome Women who completed treatment showed more improvement on most outcomes than women who did not complete

21 Mean Scores at Baseline and at 12 Months, and Results of Repeated Measures Analyses of Variance on Treatment Outcomes InterventionComparisonStatistical Test ASI alcohol Baseline M (SD) 12-month M (SD) N = 136 0.18 (0.29) 0.06 (0.17) N = 177 0.27 (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 = 135 0.19 (0.15) 0.04 (0.07) N = 176 0.25 (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 = 136 1.07 (0.68) 0.80 (0.72) N = 177 1.09 (0.69) 0.86 (0.77) IC: Time: X: F(1,311) = 0.25, ns F(1,311) = 35.48**** F(1,311) = 0.34, ns PSS Baseline M (SD) 12-month M (SD) N = 136 20.43 (10.22) 13.78 (11.10) N = 177 19.05 (11.84) 15.11 (12.91) IC: Time: X: F(1,311) = 0.00, ns F(1,311) = 60.91**** F(1,311) = 3.99* Coping Skills Baseline M (SD) 12-month M (SD) N = 134 52.61 (17.83) 56.32 (20.15) N = 173 54.26 (17.51) 52.96 (20.09) IC: Time: X: F(1,305) = 0.23, ns F(1,305) = 0.96, ns F(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.

22 Cumulative Dropout During First 12 Weeks

23 Coping Skills Scores at Baseline and 12 Months

24 Post Traumatic Symptom Scale at Baseline and 12 Months

25 Interaction Between Group, Treatment Completion & Coping Skills

26 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

27 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

28 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

29 Percent from Referral Source by Race/Ethnicity: Females (n=4,517) CalWORKs n = 1,602 Prop 36 n = 1,093 General Relief n = 1,488 Community n = 334 White14.3%39.6%28.0%26.3% Black13.3%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% Hispanic69.4%42.2%51.4%47.6% Unknown0.6% 0.4%1.2%

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

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

32 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

33 Percent Assessed with Any DSM-IV Axis I or Axis II Diagnosis* [G,R,GxR] * Not including Axis I Substance Abuse or Dependence Diagnoses

34 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

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

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

37 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

38 Summary of Axis I Diagnoses Diagnosis CategoryPercentage Mood Disorders75% Depressive Disorders69.0% Bipolar Disorder7.2% Anxiety Disorders9.5% Schizophrenia and Other Psychotic Disorders7.2% Overall, 81.0% had a single Axis I diagnosis and 19.0% had two or more Axis I diagnoses.

39 Substance Use Note: 36.9% reported participating in substance abuse treatment in past year Drug/Alcohol Use% Use Last 30 Days% Use Ever Any Alcohol20.2%82.1% Any Illegal Drug20.2%59.5% Cocaine/Crack6.0%52.4% Heroin0%15.5% Methamphetamines1.2%10.7% Barbiturates/Sedatives1.2%17.9% Hallucinogens0%16.7% Marijuana/Hashish13.1%57.1%

40 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

41 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

42 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)

43 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 DrugEver UsedUsed in Last YearUsed Last 30 Days Heroin22%11%6% Alcohol94%44%22% Barbiturates6% Methamphetamines83%72%50% Cocaine (Powder)11%0% Cocaine (Crack)28%22%11% Marijuana/Hashish44%39%11% PCP/Angel Dust6%0% Other Hallucinogens22%0% Librium/Valium6% 0% Other Opiates11% Inhalants6%0%

44 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 = 28 screened since March 2007 60.7% screen positive for major postpartum depression 17.9% 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)

45 Postpartum Depression continued 46.4% had elevated scores on the PDSS measure of Sleeping/Eating Disturbances 50.0% had elevated scores on the measure of Anxiety/Insecurity 46.4% had elevated scores on the measure of Emotional Lability 39.3% had elevated scores on the measure of Mental Confusion Of the 28 women assessed, 24 identified enough symptoms of postpartum depression that a long form of the PDSS was administered

46 Postpartum Depression continued 35.7% had elevated scores on the measure of Loss of Self 35.7% had elevated scores on the measure of Guilt/Shame 67.9% had elevated scores on the measure of Suicidal Thoughts


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