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Gender-Specific Treatment for Mental Health & Substance Use
DisordersChristine E. Grella, Ph.D.
UCLA Integrated Substance Abuse ProgramsDavid Geffen School of Medicine at UCLA
Presented at:
Workshop on Women’s Mental Health across the Life Course through a Sex-Gender Lens
March 7, 2018
Gender and Behavioral Disorders
Mental Health
Substance Use
Environmental Risk
Biological Risk
Etiology
Epidemiology
Treatment Access & Utilization
System-level Risk
Morbidity
Mortality
Population-level Risk
Global Burden of Disease
Sex Differences in Prevalence of Substance Use Disorders (SUD) and
Mental Disorders
Lifetime Prevalence of Psychiatric Disorders by Sex in NESARC
42.0
13.8 15.211.7
5.5
19.5
7.1
23.520.3
1.9
0
10
20
30
40
50
Any Alcohol Any Drug Any Mood Any Anxiety AntisocialPersonality
MenWomen
%
Source: Grant et al., 2004
Lifetime Prevalence of Drug Use Disorders in U.S. Population by Gender in NESARC
7.1
5.4
1.8
1.5
0.9
0.6
13.8
11.8
3.9
2.5
2.0
1.6
0 5 10 15
Any drug use disorder
Marijuana
Cocaine
Amphetamines
Opioids
Sedatives
Percent
MaleFemale
Includes both abuse and dependence based on DSM-IV criteria;Conway et al. (2006)
2:1 ratio
Growing Differentiation in Type of SUD by Gender Among Adolescents and Young
Adults With Any Use in NSDUH
0
10
20
30
40
50
Alcohol Marijuana Cocaine PrescriptionMeds
Male Female
Ages 12 - 17 Ages 18 - 25
0
10
20
30
40
50
Alcohol Marijuana Cocaine PrescriptionMeds
Male Female
*
Source: Cotto et al., 2010; * p < 0.01
Faster Progression from First Use to Disorder for Girls Relative to Boys with SUD by Age 16
0
1
2
3
4
5
6
7
8
9
Alcohol Nicotine Marijuana Any illicit drug
Male
Female
*
* *
Source: Costello et al. (1999). JCCP, 28, 298-311.
# Y
ears
Sin
ce F
irst
Use
Comorbid Psychopathology is More Prognostic of SUD among
Females
Gender and Comorbidity Comorbidity of SUD and mental disorders is well
established Magnitude of comorbidity tends to be greater for
females, particularly at lower levels of severity of substance use
Differences in temporal ordering of onset: ► Women: depression alcohol disorder► Men: alcohol disorder depression
Stronger association between internalizing & externalizing symptoms with severity of alcohol dep (e.g., symptoms, consumption) among women (Dawson et al., 2010)
Comorbidity of Substance Use and Mental Disorders Among Opioid Users in NESARC
Women opioid users are twice as likely as men to have mood or anxiety disorders
But women are less likely to have antisocial personality disorder or alcohol dependence.
ORs: women = 1, men = 0; * p < .05, ** p < .01; *** p < .001Mood disorders: major depression, dysthymia, manic disorder and hypomanic; Anxiety disorders: panic, social, specific, generalized anxiety disorderSource: Grella et al. (2009)
0.0
1.0
2.0
3.0
4.0
Mood** Anxiety*** ASP* Alc Dep**
2.1 2.0
0.6 0.6Odd
s Ra
tio
Comorbid Types among Juvenile Detainees: Cook County, IL
Source: Abram et al. (2003). AGP, 60, 1097-1108.
Females Males
Comorbid Types among Juvenile Detainees: Cook County, IL
Source: Abram et al. (2003). AGP, 60, 1097-1108.
Females Males • A recent 5-year follow-up showed that prevalence of most psychiatric disorders decreased over time, but there was continuing higher prevalence of affective disorders among females and substance use disorders among males.
• Substance use and disruptive disorders were most persistent over time – particularly among males
Abram et al. (2015). JAMA Psychiatry
Gender Differences in Chronic Health Problems in a Cohort of Opiate Users
38
36
23
45
7
22
9
19
11
45
41
2
58
22
0 20 40 60 80
Headaches/Migraines**
Circulatory Problems**
Heart Disease***
Asthma**
Arthritis*
Hypertension
Neurological Disorders*
Percent
MalesFemales
Average age at follow-up interview: 58.8 for males, 54.9 for females; p < .05, **p < .01, ***p < .001;Grella, C.E., & Lovinger, K. (2012). Addictive Behaviors, 37(3), 306-212.
Global Burden of Disease: Disability-Adjusted Life Years (DALYs) for all Mental Disorders and SUD
by Age and Sex
Whiteford et al. (2013). Global burden of disease attributable to mental and substance use disorders: findings from the Global Burden of Disease Study 2010, The Lancet, 382, 1575-1586.
Boys < age 10 had greater proportion of burden than girls of equivalent age, accounted for by childhood behavioral disorders
Over age 10, girls & women had greater burden from mental disorders than boys, whereas men have greater burden than women for SUD across all ages
Depression & anxiety disorders are most prevalent
Disparities in SUD Treatment Access and Utilization
Women with SUD Have Lower Rates of Help-seeking and Tend to Enter Treatment at
Higher Levels of Severity
0%
20%
40%
60%
80%
100%
Total Men Women
28 30.5 24
72 69.5 76Did not seek helpSought help
Source: NESARC baseline sample with past-year alcohol or other drug dependence; N = 1,262; p < .001Grella & Stein, 2013
Reasons for Not Seeking Help for Alcohol Problems by Gender in NESARC
67
10
19
26
16
70
16
18
31
21
0 20 40 60 80
Minmize problem
Fear
Structural barriers
Stigma
Financial
Percent
WomenMen
Source: Otiniano Verissimo & Grella, 2017; p< .05 for indicated variables
Reasons for Not Seeking Help for Drug Problems by Gender in NESARC
71
15
25
37
23
61
21
23
41
25
0 20 40 60 80
Minmize problem
Fear
Structural barriers
Stigma
Financial
Percent
WomenMen
Source: Otiniano Verissimo & Grella, 2017 p< .05 for indicated variables
Reasons for Not Seeking Help Among Women with Alcohol Problems
by Race/Ethnicity
33
18 1519
25
15
2822
28
16 16 16
0
20
40
60
80
Stigma Fear oftreatment
Structuralbarriers
Treatmentpessimism
Perc
ent
WhiteAfrican AmericanLatino
Source: NESARC Wave I sample; interactions of gender x ethnicity significant at p < .05 controlling for socio-demographics; Otiniano & Grella, 2017
Reasons for Not Seeking Help Among Women with Drug Problems
by Race/Ethnicity
43
23 21
40
24 26
36
14
28
0
20
40
60
80
Stigma Fear oftreatment
Structuralbarriers
Perc
ent
WhiteAfrican AmericanLatino
Source: NESARC Wave I sample; interactions of gender x ethnicity significant at p < .05 controlling for socio-demographic and severity; Grella & Otiniano, manuscript in preparation
Gender-Specific SUD Treatment Programs and
Services
SUD Treatment Facilities that Provide Special Services or Programs for
Women and Types of Services Provided
65%
35%
Source: SAMHSA, National Survey of Substance Abuse Treatment Services (N-SSATS), 2012
Women-only SUD Programs Typically provide more services that women need
related to mental health, domestic violence & trauma exposure, child welfare & parenting.
Women in these programs tend to have more severe problems than those in mixed-gender programs.
Yet, relative to mixed-gender programs, women-only residential programs are associated with:► longer treatment retention► better outcomes regarding drug use, criminal
behavior, incarceration, & family reunification
Summary of Main Points1. Sex differences are evident in neurobiology of
psychoactive substance use and addiction, epidemiology, & disease progression.
2. Males have higher rates of alcohol and drug use, but sex differences in types of substances used beginning in adolescence and increasing over time.
3. Patterns of male and female drug use at population-level are converging over time, perhaps due to lessened gender role differentiation.
4. Females display more comorbidity of SUD and MH disorders, beginning in adolescence.
5. Comorbid psychopathology, especially behavioral disorders, are more prognostic of alcohol and drug dependence among females.
Summary of Main Points6. Women have greater exposures to trauma (both as
children and adults), which heightens risk for SUD, MH disorders, & associated health problems.
7. Overall burden of disease related to MH & SUD is greater among women due to higher prevalence and persistence of mental health disorders (depression & anxiety) and comorbidity of these disorders with physical health problems
8. With regard to treatment, women:► have lower rates of treatment for SUD, but higher use of
mental health services ► report different barriers to accessing SUD treatment related
to stigma, fear, & financial problems, which also vary by race/ethnicity
► show more favorable outcomes in women-only programs which typically provide more services to meet their needs