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

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

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

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. 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

7. 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

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 (%)*
30.6
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

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
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. 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

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
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 <

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%
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 <

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
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) = ****
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 <

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 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

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
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%

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. * 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

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 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.

39. 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

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
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

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
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

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