Vivian B. Brown, Ph.D.

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

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

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

8. Baseline Demographic Characteristics by Program Site: Hispanic Ethnicity Triad Women’s Project New Directions for Families DC Trauma Collaboration Study Boston Consortium of Services Franklin Co. Women’s Research Project The W.E.L.L. Project PROTOTYPES SCC 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 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. 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 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) 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 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)

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 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

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

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