Gender Differences in Substance-Abuse Treatment Clients With Co-occurring Psychiatric and Substance-Use Disorders

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Treatment Clients With Co-occurring

Psychiatric and Substance-Use Disorders

Laurel F. Mangrum, PhD Richard T. Spence, PhD

Michelle D. Steinley-Bumgarner, MA

The study examined gender differences in a sample of 213 substance-abuse treatment clients with co-occurring severe and nonsevere psychiatric disorders. Results indicated that women had higher rates of posttraumatic stress disorder. Males displayed greater severity on psychiatric measures and received a greater array of ancillary services during treatment yet reported less social and psychological problem days at admission. Conversely, females presented relatively greater substance-use severity but reported higher levels of

psychosocial distress and less problem days related to substance use. These findings suggest gender differences in problem recognition may exist, with males more readily admitting to problems related to substance use and females more open to acknowledging the effects of social and psychiatric problems. The current results have clinical implications for both the assessment process and the treatment programming. [Brief Treatment and Crisis Intervention6:255–267 (2006)]

KEY WORDS: co-occurring disorders, gender differences, substance-abuse treatment.

The co-occurrence of psychiatric and substance-use disorders and the effects of comorbidity on the clinical presentation and outcomes of substance-abuse treatment clients are growing areas of study. Early research of this comorbid-ity focused on severely mentally ill (SMI) pop-ulations, identifying high prevalence rates and negative treatment outcome effects for cli-ents with concomitant substance-use disorders

(Drake, Bartels, Teague, Noordsy, & Clark, 1993). As a result of these findings, inte-grated treatment programs evolved to address the unique needs of this population (Drake, Mercer-McFadden, Muser, McHugo, & Bond, 1998; Muser, Noordsy, Drake, & Fox, 2003). To further understand and guide improve-ments in integrated treatment for SMI clients, studies have been conducted in an effort to identify client characteristics that may be asso-ciated with clinical features and outcomes. One area in this line of research has explored the role of gender as a potential factor affecting symptom presentation and treatment response. A number of studies have examined gender differences in co-occurring psychiatric and

From the Addiction Research Institute, University of Texas at Austin.

Contact author: Laurel F. Mangrum, Research Scientist, University of Texas, Addiction Research Institute, 1717 West 6th Street, Suite 335, Austin, TX 78703. E-mail:

lmangrum@mail.utexas.edu. doi:10.1093/brief-treatment/mhl006 Advance Access publication July 6, 2006

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substance-use disorder (COPSD) populations with severe mental illness. In an early study by Jerrell and Ridgely (1995) of 131 SMI clients entering one of three treatment modalities (24% female, 81% White), female clients had higher levels of psychiatric severity at admission but no other gender differences were found on demograph-ics, psychiatric diagnoses, social functioning, substance-use severity, or treatment response. Comtois and Ries (1995) reported on gender com-parisons in a sample of 338 SMI clients in a dual diagnosis integrated treatment program that was 36% female, 66% White, and 28% Black. No differences were found in demographics, legal status, substances of choice, psychiatric sever-ity, treatment compliance, individual therapy received, or amount of case management serv-ices. More women had affective diagnoses and received a greater number of medication man-agement services. Men were more likely to have a schizophrenia diagnosis, use polysubstances, and be under a payeeship and were rated by case managers as having greater substance-use sever-ity and lower levels of social functioning com-pared to women. The authors noted, however, that the greater proportion of schizophrenic di-agnoses in the male group may have confounded certain gender comparisons, particularly in the area of social functioning.

Brunette and Drake (1997) explored gender differences in a rural sample of 172 clients with schizophrenia that was predominantly male (78%) and White (96%). No differences were found on demographics, age of first substance use, substance-use severity, psychiatric diag-noses, psychiatric severity, or aggressive be-havior. Women were found to have more children, higher levels of social contact, more medical problems, and greater incidence of vic-timization, whereas men reported more legal in-volvement. In a later study, Brunette and Drake (1998) attempted to replicate these findings in an urban sample of 108 homeless individuals with schizophrenia. This sample had a greater

percentage of women (61%) and was primarily Black (91%). Similar to their previous findings, women were more likely to have children, to have increased social contacts, to have higher incidence of victimization, and to have had one or more days of illness in the past month. Women, however, did not report greater levels of chronic medical problems. Also, partially in line with previous findings, men had a greater history of incarceration but did not differ from women in number of criminal charges or convictions. No differences were found in substance-use severity, but men were more likely to have a marijuana-related diagnosis. In contrast to their earlier study results, women in this sample presented higher levels of psy-chiatric symptomatology. The authors specu-lated that a portion of the divergence in findings may be related to the effect of home-lessness, citing literature suggesting higher lev-els of psychiatric severity in homeless women in general compared to men.

Three more recent studies have examined gender differences in SMI clients with COPSD. DiNitto, Webb, and Rubin (2002) explored gen-der differences in a sample of 97 SMI clients entering inpatient substance-abuse treatment. The sample was relatively equal in gender dis-tribution (53% female) and racially/ethnically diverse (59% White, 28% Black, and 13% His-panic). The study compared gender charac-teristics on the ‘‘Addiction Severity Index’’ (McLellan et al., 1992) at admission and follow-ups at 30, 60, and 90 days. Due to inconsistent follow-up rates, the follow-up data were aggre-gated over these three points for analyses. At treatment entry, no differences were found in employment, medical problems, years of sub-stance use, subsub-stance-abuse treatment history, length of last voluntary abstinence, psychiatric diagnoses, or history of psychiatric treatment. Women were more likely to be divorced, to be on public assistance, to be living with a sub-stance abuser, and to have dependents. Women

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reported a greater history of overdose, had more relatives with substance-abuse problems, and were rated higher by interviewers as in need of drug treatment. Addiction Severity Index composite scores in the family/social and psy-chiatric domains were higher for women; in these areas, women reported more problem days, greater distress, and more family members with psychiatric problems. Women were also more likely than men to have a history of vic-timization, particularly in the area of sexual abuse. Men were more likely to have never mar-ried, to have worked a greater number of days in the past month, and to have an alcohol-only problem. Although there were no gender differ-ences on the legal composite, men were more likely to be on probation or parole, have a his-tory of incarceration, and be in treatment for le-gally motivated reasons. At follow-up, women continued to have higher psychiatric and fam-ily/social composite scores than men, but no dif-ferences in the other domains were found. In their summary, the authors suggested these results may indicate that women are more so-cially attuned to relationship and psychological issues, thus better able to recognize and report these types of problems relative to men.

Gearon, Nidecker, Bellack, and Bennett (2003) explored gender differences in a sample of 52 COPSD SMI clients receiving outpatient psychi-atric treatment and included comparisons on sources of substances and reasons for substance use. The sample was obtained from an inner-city mental health center and was 42% female and predominantly Black (70%). In this study, no differences were found in demographics, sub-stance-use severity, age of first substance use, psychiatric diagnoses, or psychiatric severity. Women were more likely to be dependent on heroin, have a history of physical victimization, engage in prostitution or sex trading for drugs, obtain money from immediate family members for drugs, buy drugs from friends, and use drugs to test personal control. Men were more likely to

be dependent on marijuana and demonstrated a trend toward greater comorbid alcoholism.

Grella (2003) examined the effect of gender in a sample of 400 SMI clients who were recruited from 11 adult residential drug treatment pro-grams in Los Angeles County. The sample was relatively balanced in gender (53% female) and race/ethnicity (44% White, 35% Black, and 13% Hispanic). Gender groups were com-pared in a number of domains, including quality of life, self-efficacy, service needs, and treatment motivation and barriers, in addition to the more standard areas of analyses. Results indicated that women were more likely to be Black, to be married, to have children, and to engage in prostitution for income. Women also had higher rates of posttraumatic stress disor-der, self-identified a wider array of service need types, and greater need for both family- and trauma-related services. Men were more likely to be White, to never be married, to be legally involved, and to engage in property crime for income. Men began using substances at an ear-lier age; had used more substance types; and had greater percentages of alcohol, marijuana, and opioid dependence disorders. No gender differ-ences were found in age, education, employ-ment, quality of life, self-efficacy, psychiatric severity, or mood and psychotic disorder diag-noses. Further, men and women were rela-tively equivalent on measures of treatment initiation, motivation, and barriers, as well as self-identified need for services in the areas of treatment recovery, health, employment, edu-cation, and medication. The author noted that although a number of gender differences were identified, the similarities between men and women were considerable.

Results from these studies of gender differen-ces in COPSD clients with severe mental ill-nesses indicate a number of overall trends. Women appear to be more likely to have chil-dren, a greater history of victimization and asso-ciated traumatic stress, more medical problems

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and may be more able or willing to identify re-lationship and psychiatric problems. Findings in the areas of substance-use and psychiatric se-verity are inconsistent; differences that were found tended to suggest that men may present more severe substance-use symptoms and women greater psychiatric distress. These find-ings, however, are limited to studies of individ-uals with severe mental illnesses. Other lines of research suggest that the types of comorbidity in substance-abuse treatment clients may ex-tend beyond the severe mental illnesses to in-clude other psychiatric disorders of lesser severity. For example, community surveys, such as the Epidemiological Catchment Area study (Regier et al., 1993; Robins & Regier, 1991) and the National Comorbidity Survey (Kessler, Chui, Demler, & Walters, 2005; Kessler et al., 1997), have identified substantial comorbidity rates in the general population. Results of these epide-miological studies led Compton et al. (2000) to ex-amine patterns of comorbidity in a sample of 425 clients entering drug treatment and found a 73% overall prevalence rate of any non-substance-use disorder. The most common diagnoses in the sample were antisocial personality disorder (44%), phobic disorder (39%), major depressive disorder (24%), dysthymia (12%), and general-ized anxiety disorder (10%). The findings of Compton et al. suggest that non-SMI diagnoses are likely to be common in individuals seeking substance-abuse treatment.

Another factor that may influence comorbid-ity characteristics is the treatment setting from which a COPSD sample is drawn. The theoret-ical interaction between COPSD symptom se-verity and treatment setting is described in the quadrants of care model (National Association of State Mental Health Program Directors & National Association of State Alcohol and Drug Abuse Directors, 1999), which is a conceptual framework that considers the levels of both psychiatric and substance-abuse severity in de-termining the most likely locus of care for the

COPSD client. In this model, COPSD clients with more severe levels of substance abuse and less severe mental illness are more likely to be seen in substance-abuse treatment sys-tems; conversely, clients with greater psychiat-ric severity and less severe substance use are more likely to present in mental health systems. A number of studies support this pattern, indi-cating that schizophrenia and other psychotic disorders are more common among COPSD clients in programs that are primarily mental health treatment providers relative to tradi-tional substance-abuse treatment programs (Havassy, Alvidrez, & Owen, 2004; Hien, Zimberg, Weisman, First, & Ackerman, 1997; Mangrum & Spence, 2005; Primm et al., 2000). Given this heterogeneity in the COPSD pop-ulation, more studies are needed for explor-ing client characteristics across a broader spectrum of psychiatric disorders. The current study focuses on gender differences in a sam-ple of COPSD clients entering substance-abuse treatment that includes both severe and nonse-vere mental illnesses. The aim of the study is to determine if gender distinctions in this sample, containing a wider array of psychiatric disor-ders, are similar to those found in previous studies of SMI populations.

Methods

Subjects

The sample was drawn from six state-funded substance-abuse treatment programs partici-pating in the Texas Co-occurring State Incen-tive Grant (COSIG) project. The program locations included two urban, two rural, and two border areas. The Texas COSIG project con-sists of two components designed to promote system change and to enhance specialized clinical skills of substance-abuse treatment providers in serving COPSD clients. The first component of the project includes focused

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education at the clinician level on treatment issues relevant to COPSD and training on the use of diagnostic and assessment instruments to enhance identification of psychiatric comor-bidity and to monitor progress of clients. The second component consists of a voucher system that provides additional funding for the pro-curement of ancillary services in an effort to ad-dress the multifaceted needs of COPSD clients and to support the treatment and recovery pro-cess. The types of adjunct services provided by the voucher system include childcare, housing support, transportation, food assistance, educa-tion support, employment assistance, clothing, medical care, prescriptions, and peer mentoring. The sample consisted of 213 adult clients entering substance-abuse treatment who sub-sequently qualified for the COSIG voucher pro-gram based on the presence of a comorbid non-substance-use disorder determined through diagnostic interview. The sample was recruited from participating COSIG programs between March 2005 and January 2006. Clients were provided a cover letter explaining the nature of the project and their right to decline partic-ipation in research and evaluation activities using client data. The total sample was 60% male, 53% Hispanic, 41% White, and 7% Black.

Measures

Both project-specific and state administrative client data were collected for analysis from the following sources.

Mini International Neuropsychiatric Inter-view. The Mini International Neuropsychiat-ric Interview (MINI) (Sheehan et al., 1998) is a structured diagnostic interview that assesses for the most frequently diagnosed Diagnostic and Statistical Manual for Mental Disorders— Fourth Edition (DSM-IV) and International Classification of Diseases—Tenth Revision (ICD-10) disorders. The MINI was designed to provide a brief and easy to administer

inter-view while retaining the sensitivity and speci-ficity of more extensive diagnostic interviews that often require administration by licensed professionals. With training, the MINI can be administered by individuals without extensive education or training in psychiatry or psychol-ogy. The MINI has been validated against a number of standard diagnostic interviews, such as the Structured Clinical Interview for DSM-III-R and the Composite International Diagnostic Interview (Lecrubier et al., 1997; Sheehan et al., 1997, 1998). The MINI consists of separate modules that assess a specific disorder and may be used independently of each other. In this study, the MINI modules administered were major depressive disorder, dysthymia, manic and hypomanic episode, panic disorder, obsessive-compulsive disorder, posttraumatic stress disorder, alcohol dependence and abuse, substance dependence and abuse, psychotic dis-order and mood disdis-order with psychotic features, and generalized anxiety disorder.

Brief Symptom Inventory. The Brief Symp-tom Inventory (BSI) (Derogatis, 1993) is a client self-report inventory that measures psycholog-ical symptom severity on nine primary dimen-sions (somatization, obsessive compulsive, interpersonal sensitivity, depression, anxiety, hostility, phobic anxiety, paranoid ideation, and psychoticism) and three global severity in-dices (Global Severity Index, Positive Symptom Distress Index, and Positive Symptom Total).

Brief Derogatis Psychiatric Rating Scale.

The Brief Derogatis Psychiatric Rating Scale (BDPRS) (Derogatis, 1978) is a brief psychiatric rat-ing scale that allows a clinician to rate a client’s symptom severity on nine primary dimensions and one global rating. The BDPRS is a companion instrumenttotheBSIandprovidesclinicianratings on the same nine primary symptom dimensions.

Behavioral Health Integrated Provider Sys-tem. Behavioral Health Integrated Provider

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System (BHIPS) is the mandatory data collection and outcomes-monitoring system for state-funded substance-abuse treatment providers in the state of Texas. Programs are required to report client data at admission, discharge, and 60-day follow-up. Types of data collected through the BHIPS system include client demographics, drug- and alcohol-use patterns, use disorder diagnoses, substance-abuse treatment characteristics, and client-reported levels of functioning in a variety of areas such as employment, living situation, medical concerns, and psychological health. Data regarding ancillary services received through the COSIG voucher system were also available from BHIPS.

Training

All staff of the six COSIG programs were pro-vided an 8-h training conducted by the State of Texas personnel concerning fundamental issues in treating clients with COPSD. Clinical staff of the programs were given an additional 4-h training by the first author on the administra-tion and scoring of diagnostic and assessment instruments, including the MINI, BSI, and BDPRS. Clinicians’ use and scoring of these measures were monitored by the authors, and additional booster trainings were provided as needed at the programs to enhance quality of administration. Across all programs, a total of 25 counselors administered the measures with the following degrees/certifications—Licensed Chemical Dependency Counselor: 40%, Li-censed Chemical Dependency Counselor Intern: 20%, Licensed Master or Clinical Social Worker/Licensed Professional Counselor: 12%, Bachelor’s Degree: 12%, Psychology Intern: 8%, MD: 4%, and PhD: 4%.

Analyses

Men and women were compared on de-mographic variables, psychiatric diagnoses,

substance-use characteristics, psychiatric se-verity, ancillary services, and treatment charac-teristics. Continuous variables were analyzed usingttest analyses, and categorical variables were assessed using v2

analyses. Cases with missing data were omitted from the analyses of that variable. At the time of the study, dis-charge data were available for 81% of the sample (females: 84%, males: 79%), with the remainder of the clients still receiving treat-ment services. Although BHIPS collects 60-day follow-up information, insufficient follow-up data were available for the current analyses.

Results

Demographic and social characteristics of the gender groups are reported in Table 1. Compar-isons in this domain revealed that women were younger, were more likely to have children, were more often living in group quarters or an institutional setting, and had higher levels of legal involvement. Men were older and had greater homelessness rates. No differences were found in race/ethnicity, marital status, or employment status. Although women had higher rates of legal involvement, no differ-ences were found in the incidence of client-reported driving while intoxicated, public intoxication, or other substance-related arrests during the year prior to admission.

In the area of primary substance-use diagno-ses, men were more often diagnosed with alco-hol disorders, whereas women more frequently received cocaine diagnoses (see Table 2). On non-substance-use diagnoses, women were more likely to be diagnosed with posttraumatic stress disorder. No gender differences were found among the other disorder types or in the total number of non-substance-use diagno-ses. Approximately 75% of both men and women received two or more non-substance-use diagnoses, with the most common being

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a combination of an affective and an anxiety disorder.

Substance-abuse treatment and substance-use history characteristics are reported in Table 3. No gender differences were found in previous detox or nondetox substance-abuse treatment or incidence of past year emergency room visits. A greater proportion of women had attended Alcoholics Anonymous over the past month, and of those attending Alcoholics Anonymous, women had attended a higher number of meetings compared to men. Men reported more years of primary substance use but did not significantly differ from women

in age of first use or in history of intravenous drug use. Analyses indicated that men were more likely to use alcohol as their primary substance, whereas women more often used cocaine, crack, and opiates and were more likely to engage in polysubstance use. Women also had higher rates of daily use over the past 6 months but did not differ from men in aver-age days of use during the month prior to admission.

Table 4 displays client-reported problem days in the month prior to admission, BSI scores, and BDPRS ratings that were signifi-cantly different between men and women. TABLE 1.Demographic and Social Characteristics of Gender Groups

Gender

Variable Female (n= 86) Male (n= 127) df x2/tvalue p

Mean age 33.5 40.6 209 4.87 .0001 Race/ethnicity Black 1% 7% Hispanic 49% 55% White 49% 36% Others 1% 2% 3 6.35 ns Marital status Married/cohabitating 20% 24% Divorced 41% 40% Never married 39% 36% 2 0.47 ns Has children 38% 24% 1 5.35 .02 Years of education 12.2 11.9 209 0.96 ns Employment Employed 13% 13% Unemployed 81% 82%

Not in labor force 6% 5% 2 0.13 ns

Living situation With family 54% 63% Group quarters 12% 5% Living alone 6% 7% Institutional setting 16% 1% Homeless 12% 24% 4 24.61 .0001 Legal

Any legal involvement 33% 18% 1 5.7 .02

DWI past year 6% 7% 1 0.12 ns

Public intoxication past year 4% 2% 1 0.84 ns

Other substance-related arrests 11% 5% 1 2.58 ns

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Women reported a greater number of problem days related to medical, employment, family, social, and psychological problems, whereas men reported more problem days related to drug or alcohol use. On psychiatric severity measures, men displayed greater levels of symptomatology on both self-report and clini-cian ratings. Males had higher mean scores on the phobic anxiety, paranoid ideation, psycho-ticism, and positive symptom total scales of the BSI and were also rated more severely by clinicians on the paranoid ideation and psy-choticism scales of the BDPRS. No gender dif-ferences were found on the remaining scales of the BSI or BDPRS.

As previously described, discharge data were available for 81% of the sample. Comparisons on treatment service types indicated that men were more likely to receive detox services than women (47% vs. 28%; v2(5) ¼ 31.86, p , .0001). Comparisons of ancillary services re-ceived during treatment are reported in Table 5.

Analyses revealed that, in general, men re-ceived more types of voucher services. Among the ancillary service categories, greater propor-tions of men received food assistance, housing support, transportation, and peer mentoring, whereas more women received medical services and prescriptions. In this sample, no clients received education support or employment services. Further, only one client had received services in the childcare and clothing catego-ries, precluding gender analyses on these var-iables. No gender differences were found in length of stay, treatment completion, absti-nence rates, or Alcoholics Anonymous atten-dance during the month prior to discharge.

Conclusions

The current study explored gender differences in a sample of COPSD clients that included both severe and nonsevere mental illnesses in TABLE 2.Diagnostic Characteristics of Gender Groups

Gender

Variable Female (n= 86) Male (n= 127) df x2/tvalue p

Primary substance-use diagnoses

Alcohol 21% 45% Cocaine 33% 20% Opioid 25% 24% Polysubstance 7% 3% Others 14% 9% 4 14.78 .005 Non-substance-use diagnoses Depression 41% 50% 1 1.93 ns Bipolar 42% 35% 1 1.14 ns Dysthymia 14% 9% 1 1.49 ns Hypomania 2% 5% 1 1.29 ns Panic disorder 33% 24% 1 2.07 ns Obsessive compulsive 31% 28% 1 0.37 ns Posttraumatic stress 40% 23% 1 6.86 .009 Generalized anxiety 42% 46% 1 0.30 ns Psychotic 2% 5% 1 1.29 ns Note.ns¼nonsignificant.

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an effort to expand on previous gender research using SMI populations. The present analyses revealed that women were more likely to have children and be living in a group or institu-tional setting and had higher rates of legal in-volvement. By contrast, males in this sample were older and had higher rates of homeless-ness. In the area of substance use, men were more likely to use alcohol as a primary sub-stance, had more years of primary substance use, and reported more problem days related to substance use relative to women. Women

more often used powder cocaine, crack, and opiates as primary substances and reported more problem days related to medical, employ-ment, family, social, and psychological issues at treatment entry. Although women had been us-ing their primary substance for a shorter period of time than men, they displayed evidence of greater substance-use severity; higher propor-tions of women reported engaging in polysub-stance use and daily use of primary subpolysub-stances over the past 6 months. Further, there were no differences between men and women in age of TABLE 3.Substance-Abuse Treatment and Substance-Use History of Gender Groups

Gender

Variable Female (n= 86) Male (n= 127) df x2/tvalue p

Substance-abuse treatment

Previous detox 61% 69% 1 1.45 ns

Number of previous detox 1.8 1.7 207 0.33 ns

Previous nondetox 76% 78% 1 0.06 ns

Number of previous nondetox 1.8 1.8 207 0.26 ns

Attended AA over the past 30 days 49% 31% 1 6.59 .02

Number of AA meetings attended 11.6 7.5 78 2.12 .04

Emergency room visit past year 39% 35% 1 0.36 ns

Substance-use history

Age of first use of primary 21 19.5 206 1.25 ns

Years of use of primary 12.7 21.1 206 5.41 .0001

History of IV drug use 58% 56% 1 0.11 ns

Primary substance Alcohol 21% 47% Cocaine 19% 10% Crack 18% 10% Opiates 32% 26% Marijuana 3% 4% Others 7% 3% 5 16.63 .01 Polysubstance use 51% 37% 1 4.2 .05

Frequency of use of primary

No use 5% 2%

Less than monthly 1% 3%

One to three times per month 1% 6%

One to two times per week 1% 8%

Three to six times per week 18% 29%

Daily 74% 52% 5 16.58 .01

Average days of use of primary

Past 30 days 14.1 15.7 209 1.11 ns

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first substance-use or substance-abuse treat-ment history, suggesting that women entered treatment more quickly than men after initiat-ing substance use. Comparisons among diag-nostic categories revealed that women had higher rates of posttraumatic stress disorder, but no gender differences were found in the rates of other disorders. On psychiatric meas-ures, men displayed greater levels of psychiat-ric severity on standardized self-report and clinician ratings in the areas of phobic anxiety, paranoia, and psychoticism. At discharge, anal-yses of ancillary service use indicated that men

received more types of services and were more likely to receive housing, food assistance, trans-portation, and peer mentoring, whereas women more frequently obtained medical care and pre-scription services. No gender differences were found in length of stay, treatment completion, or abstinence rates at termination of treatment. The present study produced results that were both similar to and divergent from those in the existing literature examining COPSD samples with severe mental illness. Consistent with pre-vious findings, the current analyses revealed that women were more likely to have children,

TABLE 5.Ancillary Services Received Through COSIG Voucher by Gender Groups Gender

Variable Female (n= 86) Male (n= 127) df x2/tvalue p

Housing 66% 86% 1 11.39 .001 Food assistance 44% 76% 1 22.89 .0001 Transportation 46% 76% 1 19.93 .0001 Medical care 31% 10% 1 15.05 .0001 Prescriptions 16% 5% 1 8.04 .005 Peer mentoring 37% 70% 1 22.58 .0001

Total service types received 2.4 3.2 211 4.55 .0001

TABLE 4.Problem Days and Psychiatric Severity at Admission of Gender Groups Gender

Variable Female (n= 86) Male (n= 127) df x2/tvalue p

Problem days during past 30 days

Medical 4.7 1.8 207 2.50 .02 Employment 8.2 3.0 207 3.53 .001 Family 6.9 2.3 207 3.44 .001 Social 5.3 2.3 207 2.38 .02 Psychological 5.6 2.2 207 2.94 .01 Drug/alcohol 19.0 25.3 207 3.75 .001 BSI Phobic anxiety 55.1 58.9 211 2.17 .03 Paranoid ideation 56.9 60.1 211 2.74 .01 Psychoticism 56.3 59.4 211 2.30 .02

Positive symptom total 58.1 63.9 211 3.98 .001

BDPRS

Paranoid ideation 1.5 2.1 207 3.23 .002

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had greater rates of posttraumatic stress disor-der, displayed higher medical problems, and reported more psychosocial problems com-pared to men. However, contrary to past results, women in this sample were more likely to be legally involved relative to men and reported comparable rates of alcohol and other substance-related arrests during the past year. Further, the results of this study did not sup-port trends noted in other studies in which men tended to display greater severity in sub-stance use and women in psychiatric symp-toms; in fact, the opposite pattern was found. Interestingly, males displayed greater severity on psychiatric measures and received a greater array of ancillary services yet reported less social and psychological problem days at ad-mission to treatment compared to women. Con-versely, females presented relatively greater substance-use severity but reported higher levels of psychosocial distress and less problem days related to substance use. These findings suggest that a differential pattern of awareness may exist regarding the effects of psychiatric and substance-use severity on life functioning, with males more readily admitting to problems related to substance use and females more open to acknowledging the effects of social and psy-chiatric problems. This potential influence of socialization on problem recognition was also posed by DiNitto et al. (2002) as an explanation for gender differences in client-reported psy-chosocial problems and family history found in their study. The possible presence of differ-ential gender effects on client reporting has significant clinical implications for the assess-ment process and highlights the importance of using a variety of measures and informant sources to corroborate the client’s problem pre-sentation. Relying solely on client-reported problem days may be insufficient in identifying the full extent of symptomatology and associ-ated psychosocial problem areas. In addition, gender differences in problem awareness may

also indicate the need for treatment program-ming and interventions tailored toward increas-ing recognition of the broader and interactive effects of substance use and psychiatric prob-lems on social functioning.

One of the most consistent findings in the gender literature has been the high prevalence of posttraumatic stress disorder and victimiza-tion in female clients. These findings suggest that routine screening for posttraumatic symp-toms would be a clinically useful and important component when conducting admission assess-ments for substance-abuse treatment. Clients who suffer from this disorder may benefit from specialized groups to process trauma issues and to provide assistance in recognizing the poten-tial use of substances to allay anxiety and distress related to victimization.

The current study expands on extant litera-ture regarding gender differences in clients with COPSDs. Strengths of this study include the use of standardized psychiatric measures, multiple methods of client assessment, and sam-pling from six different programs from diverse areas of the state. The findings, however, are exploratory and have a number of limitations. Although the diagnostic data analyzed in this study were collected through structured inter-view, the interviewers were not all clinicians certified to make clinical diagnoses. Further, because the MINI is being implemented natu-ralistically in the COSIG project, interrater re-liability data were not collected. Thus, these data can be considered diagnostic impressions, rather than official diagnoses. The MINI interview, however, can be a useful tool in substance-abuse treatment programs that often lack personnel trained in mental health; the in-terview can be used to screen for potential dis-orders and provide diagnostic impressions that can be further assessed through referral to mental health professionals. Another limitation concerns the use of administrative data that are obtained independently from a research

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project, precluding supervision of the data-reporting process. The state of Texas does ver-ify samples of BHIPS information throughout the year during auditing visits, providing some level of data validation. Finally, the study con-tained numerous comparisons that increase the possibility of capitalizing on chance findings. This study was exploratory, however, and pro-vides baseline information regarding gender characteristics in substance-abuse treatment clients with both severe and nonsevere psychi-atric disorders. Future studies are needed for exploring gender features in this client popula-tion to replicate and expand on these findings.

Acknowledgments

The authors would like to acknowledge the partnership and support of the staff at the Texas Department of State Health Services–Division for Mental Health and Substance Abuse Services in implementing this project and for assisting in retrieval of archival data for the present analysis. We would also like to acknowledge the staff of the following treatment programs who are participating in the COSIG project for providing client data and to recognize their continuing efforts to improve services for clients with COPSD: The Association for the Advancement of Mexican Americans

(Edinburg), Fort Bend Regional Council on Substance Abuse (Stafford), Hill Country

Community Mental Health and Mental Retardation Center (Kerrville), Homeward Bound, Inc. (El Paso), Lubbock Regional Mental Health and Mental Retardation Center (Lubbock), and Montrose Counseling Center (Houston). Portions of this manuscript were presented at the 2006 Research Society on Alcoholism Conference, Baltimore, MD.

Conflict of Interest:None declared.

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