Gender Differences in Treatment Needs, Services, Utilization, and Outcomes

1
Gender Differences in Treatment Needs, Services,
Utilization, and Outcomes

• Karol Kaltenbach, PhD
• Department of Pediatrics
• Jefferson Medical College
• Thomas Jefferson University

2
APA Disclosure Statement

• This is to acknowledge I have no relationship
  with any manufacturer of a product or service I
  intend to discuss.

3
Overview

• History of specialized services for women
• Assessing comprehensive needs of women
• Complexity of needs and treatment outcomes

4
History of Specialized Services for Women

• NIDA 1974
• Research demonstration projects for womens
  treatment
• Womens special needs and the delineation of
  gender specific treatment strategies were
  identified over 20 years ago
• Beschner, Reed, Mondanaro (Eds) 1981
• Treatment services for drug dependent women

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History of Specialized Services for Women

• Federal grant programs, e.g. NIDA Perinatal 20
  and CSAT pregnant and post-partum demonstration
  grants, provided support for development and
  enhancement of womens treatment services in the
  late 80s 90s

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Specialized Treatment Services for Women

• Programs in US
• Residential 41 women-only
• 23 pregnant/postpartum women
• (SAMHSA National Survey of Substance Abuse
  Treatment Services (N-SSATS) 2001)
• Of women who need treatment only 20 receive
  treatment
• (SAMHSA, OAS 2002)

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Services Models for Womens Treatment

• Finnegan, Hagan, Kaltenbach (1991)
• Scientific foundation of clinical practice
  Opiate use in pregnant women
• Jansson, Svikis, et al (1996)
• Pregnancy and addiction A comprehensive care
  model
• Kaltenbach Comfort (1996)
• Comprehensive treatment for pregnant substance
  abusing women
• Finkelstein, Kennedy, Thomas, Kearns (1997)
  Gender specific substance abuse treatment

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Woman Centered Treatment Model

• Comprehensive treatment approach that addresses
• Addiction
• Medical/Psychiatric
• Psychosocial
• Parenting
• Educational/Vocational
• issues of both women and their children

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Specialized Programs

• Women-only programs more likely to provide
• Pregnancy, pediatric and childrens services
• Client advocacy/case management
• Classes on social skills, practical skills,
  parenting, anger management
• Assistance with housing and transportation
• Peer support groups and social outings
• (Grella et al., 1999)

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Effectiveness of Specialized Treatment Services

• Residential
• Women in women-only programs had
• More time in treatment
• More likely to complete treatment
• (Grella, 1999)

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Effectiveness of Specialized Treatment Services

• Women in gender-specialized programs
• Use more services throughout treatment than
  women in traditional coed program
• Have higher rates of abstinence
• More likely to see themselves as doing
  
• well in treatment
• (Nelson-Zupko, 1997)

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Effectiveness of Woman Centered Treatment

• Treatment for Pregnant Women
• Increased Gestational Age, Birth-weight, Apgar
  Scores
• Less likely to require NICU services
• Those admitted to NICU had shorter stays
• Average net savings for women in treatment of
  4,644 per moth/infant pair
• (Svikis, et.al., 1997)

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Assessing Comprehensive Treatment Needs of Women

• Instruments
• Most assessment tools are based primarily on
  males
• Addiction Severity Index
• Most widely used standard data collection
  instrument
• Initially developed and tested solely on males
• Acceptable levels of reliability and validity
  with
• a number of populations
• Limited in assessing critical areas for women

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Assessing Comprehensive Needs of Women

• ASI limited in assessing
• Medical issues related to pregnancy
• Care-giving responsibilities
• Child and partner relationships
• Victimization

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Assessing Comprehensive Needs of Women

• Psychosocial History (PSH)
• Instrument that retains the fundamental structure
  of the ASI but expanded to include
• Family history and relationships
• Relationships with partner
• Responsibilities for children
• Pregnancy history
• History of violence and victimization
• Family legal issues
• Housing arrangements

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Complexity of Needs

• Personal and Family Characteristics
• Residential Outpatient
• Age 27.9
  29.6
• Education 11.8
  10.8
• Employment 77 94
• Job training 48
  38
• (Comfort Kaltenbach, Journal of Psychoactive
  Drugs, 1999)

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Personal and Family Characteristics

• Residential Outpatient
• Currently Receiving
• Public Assistance 84 81
• Relationship status
• Married 6
  17
• Not Married 84
  53
• Long-term
• relationship 10
  30

18
Personal and Family Characteristics

• Residential Outpatient
• Housing History
• Homeless in past 3 yr. 68
  21
• Current Living arrangements
• Family/Friends 51
  43
• Father of Baby 10
  29
• Shelter
  26 7
• No Stable Housing 6
  7
• Other
  6 14

19
Personal and Family Characteristics

• Substance Use by Partner
• No use 31 33
• Drug and/or alcohol use 42 42
• Recovery 27 25
• D/A Treatment
• Ever 41 40
• Currently 15 25

20
Personal and Family Characteristics

• Substance Use by Family
• RT OP
• No Yes No Yes
• Biological mother 53 37 37 53
• Biological father 27 67
  28 72
• Female caregiver 89 11
  67 33
• Male caregiver 100
  20 80
• Maternal grandmother 58 42
  72 21
• Maternal grandfather 43 50
  45 55

21
Personal Characteristics

• Victimization
• Residential Outpatient
• One/more types of victimization 73
  89
• Domestic violence 45
  65
• Rape
  43 54
• Childhood abuse/neglect 32 39

22
Personal Characteristics

• Legal Status
• Residential Outpatient
• Family legal problems 45 31
• Requested order of protection 22 23
• Ever arrested 32 23
• Ever incarcerated 23 13

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Treatment Outcomes

• What are the factors that result in successful
  outcomes?
• Literature reflects a variety of conceptual
  frameworks that are gender neutral
• Patient-treatment matching
• Motivation to change
• Treatment process
• Retention in treatment

24
Treatment Outcomes

• We know relatively little of the relationship
  between womens characteristics/needs and
  treatment outcome.

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Treatment Outcomes

• Retrospective study of 133 pregnant women
  enrolled in comprehensive gender specific
  outpatient treatment to identify factors that
  predict retention, abstinence, and service
  utilization
• (Comfort Kaltenbach, Substance Abuse, 2000)

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Treatment Outcomes

• Measures
• PSH
• Factor analyses procedures reduced set of
  predictors to 27 variables organized into five
  factors
• Personal Stability
• Opiate Dependence
• Psychiatric and Medical problems
• Multiple family problems
• High-risk lifestyle

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Treatment Outcomes

• Summary of Findings
• Retention predicted by
• Personal Stability
• Opiate Dependence
• Fewer Psychiatric and Medical Problems
• Multiple Family Problems
• (multiple R2.153, plt.0001)

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Treatment Outcomes

• Summary of Findings
• Abstinence predicted by
• Lower scores on High-Risk Lifestyle (trend)
• (multiple R2.035, p.059)

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Treatment Outcomes

• Summary of Findings
• Utilization of Required Services
• Lower scores on Multiple Family Problems
• (multiple R2.069, p.021)
• Utilization of Specialized Services
• Psychiatric and Medical Services (trend)
• (multiple R2.045, p.061)

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Treatment Outcomes

• Prospective Longitudinal Study
• Women (95) enrolled for a minimum of 3 months
  with 12 month follow-up data
• Outpatient (60)
• Residential (35)
• (Comfort Kaltenbach, Addictive Behaviors, 2003)

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Treatment Outcomes

• Treatment Outcome Variables
• Treatment duration
• Intensity of service utilization
• Engagement in treatment
• Satisfaction with treatment services
• Substance use during treatment

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Treatment Outcomes

• Summary
• Outpatient
• The most noteworthy predictors for women in
  outpatient treatment were differing combinations
  of
• Social support
• Life stressors
• Levels of past substance abuse
• Chronic medical conditions

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Treatment Outcomes

• Summary
• Residential
• The most significant predictors for women in
  residential treatment reflected lower levels of
  personal risk factors
• Partner abuse
• Prostitution
• Homelessness
• Depression

34
Treatment Outcomes

• More responsibilities
• Care-giving responsibilities
• Less financial assistance from family

35
Treatment Outcomes

• Conclusion
• No simple predictors of womens substance abuse
  treatment outcomes
• Assessment areas of particular value
• Social support Chronic medical problems
• Daily stressors Childbirth history
• Life satisfaction Childcare responsibilities
• Partner abuse Engagement in treatment
• Psychiatric history

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Predictors of Program Completion for Women in
Residential Treatment

• Five domains of patient characteristics to
  predict completion of treatment
• Socio-demographics
• Substance use
• Legal involvement
• Psychological functioning
• Social relations
• (Knight et.al. Am J Drug Alcohol Abuse, 2001)

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Predictors of Program Completion for Women in
Residential Treatment

• Predictors of treatment completion
• Education
• Recent arrests
• Peer deviance
• (Knight et. al. 2001)

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Predictors of Program Completion for Women in
Residential Treatment

• Noteworthy trends
• Women who were not married
• Women who had two or more children
• Women who had an open child welfare case
• Women who had psychological problems
• Appeared to be at greater risk for non-completion
• (Knight et. al. 2001)

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Treatment for Women

• In summary, limited research on gender specific
  treatment
• Biopsychosocial characteristics of women
• Treatment utilization and retention
• Psychiatric co-morbidity

40
Treatment for Women

• Need for continued research
• Development of assessments that reflect the
  complex issues of pregnant and parenting drug
  dependent women
• Systematic investigations of barriers to
  treatment
• Pharmacological treatment and pregnancy
• Treatment outcomes for mother and child