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