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

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

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

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

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

Sample Sizes Across Program Sites by Condition (N=2,729) Intervention Group Comparison Group PROTOTYPES Los Angeles, CA 187 215 Allies Stockton, CA 169 266 Arapahoe House—New Directions for Families Metropolitan Denver, CO 57 108 D.C. Trauma Collaboration Washington, D.C. 150 97 Triad Women’s Project Avon Park, FL 179 123 Boston Consortium of Services for Families in Recovery Boston, MA 181 161 The W.E.L.L. Project Cambridge, MA 218 110 Franklin County Women’s Research Project Greenfield, MA 105 120 Portal Project New York, NY 114 Total 1415 1314

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/Caucasian 41.3 56.3 52.1 13.4 81.5 37.4 78.4 85.3 7.1 50.3 % African-American 22.9 16.6 18.2 79.4 13.2 27.8 6.1 3.1 66.8 27.2 % Other Race 24.4 17.9 9.1 2.0 29.8 5.8 23.7 14.5 %Multi-racial*** 11.4 7.6 4.8 4.0 1.0 2.6 8.2 4.9 2.1 5.6 % None-specified 0.0 1.6 15.8 1.2 2.3 1.5 3.6 0.4 2.4 New Directions for Families Triad Women’s Project Collaboration Study DC Trauma Boston Consortium of Services PROTOTYPES SCC The W.E.L.L. Project Franklin Co. Women’s Research Project Portal Project Allies Total * 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 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

Local Outcome Study Los Angeles Site – PROTOTYPES 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

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 X2 (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 X2 (N=402, df=1) = 0.29, ns Number of Children 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 28.88 32.62 24.06 14.44 28.37 34.41 20.46 16.74 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 = 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 N = 135 0.19 (0.15) 0.04 (0.07) N = 176 0.25 (0.14) 0.08 (0.11) F(1,309) = 18.13**** F(1,309) = 330.29**** F(1,309) = 1.23, ns GSI 1.07 (0.68) 0.80 (0.72) 1.09 (0.69) 0.86 (0.77) F(1,311) = 0.25, ns F(1,311) = 35.48**** F(1,311) = 0.34, ns PSS 20.43 (10.22) 13.78 (11.10) 19.05 (11.84) 15.11 (12.91) F(1,311) = 0.00, ns F(1,311) = 60.91**** F(1,311) = 3.99* Coping Skills N = 134 52.61 (17.83) 56.32 (20.15) N = 173 54.26 (17.51) 52.96 (20.09) 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.

Cumulative Dropout During First 12 Weeks

Coping Skills Scores at Baseline and 12 Months

Post Traumatic Symptom Scale at Baseline and 12 Months

Interaction Between Group, Treatment Completion & Coping Skills

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 N = 12,550 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) CalWORKs n = 1,602 Prop 36 n = 1,093 General Relief n = 1,488 Community n = 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% 1.3% 2.4% Hispanic 69.4% 42.2% 51.4% 47.6% Unknown 0.4% 1.2%

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

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

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

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

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

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

Substance Use Drug/Alcohol Use % Use Last 30 Days % Use Ever Any Alcohol 20.2% 82.1% Any Illegal Drug 59.5% Cocaine/Crack 6.0% 52.4% Heroin 0% 15.5% Methamphetamines 1.2% 10.7% Barbiturates/Sedatives 17.9% Hallucinogens 16.7% Marijuana/Hashish 13.1% 57.1% Note: 36.9% reported participating in substance abuse treatment in past year

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 Type of Drug Ever Used Used in Last Year Used Last 30 Days Heroin 22% 11% 6% Alcohol 94% 44% Barbiturates Methamphetamines 83% 72% 50% Cocaine (Powder) 0% Cocaine (Crack) 28% Marijuana/Hashish 39% PCP/Angel Dust Other Hallucinogens Librium/Valium Other Opiates Inhalants 17% reported injection drug use in the past 12 months 28% of the women had been diagnosed at some time with a mental illness

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)

Postpartum Depression continued Of the 28 women assessed, 24 identified enough symptoms of postpartum depression that a long form of the PDSS was administered 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

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