Egyptian Journal of Psychiatry

ORIGINAL ARTICLE
Year
: 2019  |  Volume : 40  |  Issue : 2  |  Page : 64--73

Psychiatric and social profile of recovering substance-dependent women


Magd S Abol1, Rania Mamdouh2, Sherine El Mekawy1, Sally El Sheikh3,  
1 Addiction Unit, Psychiatry Department, School of Medicine, Cairo University, Cairo, Egypt
2 Addiction Unit, Psychiatry Department, School of Medicine, Cairo University, Cairo; Serenity Girls Center for Psychiatric and Addiction Management, Mokattam, Egypt
3 Kasr Al Maadi Center for Addiction, Maadi, korniche

Correspondence Address:
Rania Mamdouh
MSc Psychiatry, Mokattam, strret 19 from street 9, villa 587, PO box 11571
Egypt

Abstract

Objectives The objective of this article is to estimate the presence of psychiatric disorders among a group of recovering substance-dependents female patients and to assess the degree of social competence and support of the recovering substance-dependent women throughout the process of recovery. Patients and methods A total of 30 recovering substance-dependent women were selected as consecutive samples from private hospitals, private clinics, and private rehabilitation centers in Greater Cairo. Moreover, 30 controls were included who were nonsubstance-dependent volunteer women. All participants gave written consent and were subjected to the following interviews, assessments, and investigations: informed consent, Structured Clinical Interview for DSM axis I, Addiction Severity Index for cases, Social Support Questionnaire, Social Competence Scale, and urine sampling for cases. Results Most recovering substance-dependent women were single, mostly divorced, and unemployed. Benzodiazepines were the most common substance of abuse followed by opiates and alcohol. The period of sobriety was 6 months to 1 year in half of the cases. The addiction severity index revealed most cases had severe drug and alcohol use, severe psychiatric problems, and severe problems in their social relationships owing to drug dependence, and approximately half of the cases had severe medical and legal problems owing to drug dependence. Most of the recovering substance-dependent women showed low social competence and had limited to fair level of social support in their recovery. All recovering substance-dependent women had a psychiatric diagnosis. Major depressive disorder and posttraumatic stress disorder are the two most common psychiatric disorders found in recovering substance-dependent women. Conclusion There is a high prevalence of psychiatric disorders among recovering substance-dependent female patients. Their social competence is low, and they tend to have limited to fair social support throughout the process of recovery.



How to cite this article:
Abol MS, Mamdouh R, El Mekawy S, El Sheikh S. Psychiatric and social profile of recovering substance-dependent women.Egypt J Psychiatr 2019;40:64-73


How to cite this URL:
Abol MS, Mamdouh R, El Mekawy S, El Sheikh S. Psychiatric and social profile of recovering substance-dependent women. Egypt J Psychiatr [serial online] 2019 [cited 2019 Nov 19 ];40:64-73
Available from: http://new.ejpsy.eg.net/text.asp?2019/40/2/64/262551


Full Text



 Introduction



Substance dependence is as much a disorder of the brain as any other neurological or psychiatric illness. The worldwide effect of the production and consumption of illicit drugs is one of the gravest problems facing societies and governments today. It takes the form of disease, crime, corruption, political and social instability, and the erosion of many values that ordinary people take for granted as part of a dignified and secure life. Substance-dependence treatment needs a comprehensive, multidisciplinary approach including both pharmacological and psychosocial interventions (Commission of the European Communities, 2006). The World Drug Report of the United Nations Office on drug control and crime prevention in 2009 estimates the total number of people using illicit drugs at upward of 250 million people, equivalent to ∼4% of the global population aged 15–64 years. Of that number, as many as 38 million people are drug dependent [United Nations Office on Drug and Crime (UNDOC), {2009}]. The National Research on Addiction Program conducted in Egypt in 2009 revealed that the prevalence of substance misuse in Egypt was 9.6% of the population and 1.6% are substance dependents. The results also showed that 13.2% of men misused substance in comparison with 1% of women, which makes the approximate ratio 13 : 1 (National Research of Addiction, Egypt, 2009). A total of 15.8 (12.9%) million women aged 18 years or older have used illicit drugs in the past year (SAMHSA, 2004). Although the rates of substance abuse among adolescent girls remain somewhat lower than for their male counterparts, substance use remains a significant but under-researched problem among many young girls (Van Etten et al., 1999).

Research had shown that a woman’s family background has an important influence on substance misuse. The behavior of other family members can influence a woman’s own behavior; therefore, research has shown that having a family background of heavy drinking or drug misuse can increase the likelihood of a woman having problems with substance misuse herself [National Institute on Alcohol Abuse and Alcoholism (NIAAA), {1990}]. Women can become addicted quickly to certain drugs, such as (crack) cocaine. Therefore, by the time they seek help, their addiction may be difficult to treat. Women who use drugs often have other serious health problems, sexually transmitted diseases, and mental health problems, such as depression. Many women who use drugs have had troubled lives. Studies have found that at least 70% of women drug users have been sexually abused by the age of 16 years. Most of these women had at least one parent who abused alcohol or drugs. Often, women who use drugs have low self-esteem, little self-confidence, and feel powerless. They often feel lonely and are isolated from support networks [National Institute on Drug Abuse (NIDA), (2006)]. The prevalence of psychiatric disorders is at least doubled in the presence of substance dependence. The relation between psychiatric comorbidity and substance dependence might be related to that one of them causes the other or both substance dependence and psychiatric disorders occur at the same time (Hamdi et al., 2009). Moreover, comorbid psychiatric symptoms complicate treatment of drug dependence and are associated with higher rates of relapse following completion of substance use treatment programs (Regier et al., 1999). Substance-dependent women were significantly more likely than men to have experienced a major depressive episode, have dysthymia (Kessler et al., 1994), and present with behaviors consistent with borderline personality disorder [American Psychiatric Association (APA), {1994}]. Of all the anxiety disorders, posttraumatic stress disorder (PTSD) is viewed as a key obstacle to improving substance-dependence treatment outcome among women (Breslau et al., 1991, 1997a, 1997b; Kessler et al., 1995).

Women are often not well supported by partners, family, and others in their recovery efforts compared with men. Inadequate referral systems and lack of appropriate services present additional barriers for those women who do seek assistance (Wilsnack and Wilsnack, 2003).

Social support for abstinence has been found to be associated with positive treatment outcome among drug court participants. Different types of social support from family, friends, and significant others influence women’s treatment and recovery. Specifically, emotional, practical, informational, financial, and socializing supports were assessed using the Social Support Behaviors Scale (Rogers and McMillin, 1989).

 Patients and methods



Research design

This research is a case–control study. Each participant was subjected to psychometric tests to assess the severity of addiction status in cases, psychiatric health, social competence level, and the social support degree.

Patients

The study was carried out on 60 participants who were classified into cases and controls:Cases included 30 recovering substance-dependent women who were selected as consecutive samples from private hospitals, private clinics, and private rehabilitation centers in Greater Cairo during the period from November 2009 till April 2010.Controls included 30 nonsubstance-dependent volunteer women. They were selected by snow balling from relatives of both groups.

Inclusion criteria included being of Egyptian nationality, aged between 18 and 45 years old, accepting to participate in the research by a written consent, recovering psychoactive substance dependents for at least 6 months for case participants, and known to be free from psychiatric disorders and psychoactive substance dependency for controls.

Exclusion criteria included mental subnormality, organic brain syndromes, any history of intake during the last 6 months for case participants, and a history of known psychoactive substance dependency for controls.

Methods and procedures

All participants gave written consent and were subjected to the following interviews, assessments, and investigations: informed consent, Structured Clinical Interview for DSM (SCID) axis I, Addiction Severity Index (ASI) for cases, Social Support Questionnaire, Social Competence Scale, and urine sampling using Drug Screening Strips applied to cases for at least every month during the first 6 months of recovery and just before the research study. The clinical interview and psychological assessments were performed individually by the researcher.

Structured clinical Interview for DSM-IV axis I disorders (First et al., 1997)

SCID-I is a semistructured interview used to determine Diagnostic statistical manual IV (DSM-IV) axis I disorders (major mental disorders). There are many published studies in which the SCID was the diagnostic instrument used. Major parts of the SCID had been translated into other languages, including Danish, French, German, Greek, Hebrew, Italian, Portuguese, Spanish, Swedish, Turkish, Zulu, and Arabic.

Addiction severity index (Mc Lellan et al., 1992)

The ASI is a semistructured interview designed to provide a multidimensional assessment of problems presented by patients with substance use disorders to guide initial treatment planning and to allow monitoring of patient’s progress over time. It is designed for use in inpatient and outpatient alcohol and drug abuse treatment settings. It gathers information on seven functional areas often affected by medical status, employment and support, drug use, alcohol use, legal state, family and social status, and psychiatric status. Each section includes questions about the frequency, duration, and severity of problems over the patient’s lifetime and in the past 30 days.

Social competence questionnaire (Sarason and Sarason, 1985)

The questionnaire was designed to measure the level of the social competence in a sample of teenagers and adults. It was translated into Arabic by Abd El-Kerim (1990). The results of the questionnaire had proved to be an indicator of the psychological well-being of an individual by measuring how competent he/she is in the society

Social support inventory (Timmerman et al., 2000)

The items are scored on a five-point scale: 1=much too little support, 2=too little support, 3=enough support, 4=too much social support, and 5=much too much support. Three global categories can be interpreted as follows: 1=much dissatisfaction with support, 2=dissatisfaction with support, and 3=satisfaction with support. The inventory consists of six subscales: everyday emotional support (four items), social support by problems (eight items), informative support (four items), instrumental support (seven items), social companionship scale (five items), and the final subscale, esteem support (six items), and another eight items that are not part of a subscale. A total measure of social support can be obtained by summation of all 42 items.

The scale was translated into Arabic and prepared, validated, and standardized by the research hospital psychologist and research team.

Statistical analysis

Contingency table

A contingency table is a way of summarizing the relationship between variables, each of which can take only a small number of values. It is a table of frequencies classified to the values of the variables in question.

A contingency table is used to summarize category data. It may be enhanced by including the percentages that fall into each category.

χ2 test of association

The χ2 test of association allows the comparison of two attributes in a sample of data to determine if there is any relationship between them.

The idea behind this test is to compare the observed frequencies with the frequencies that would be expected if the null hypothesis of no association/statistical independence was true. By assuming the variables are independent, we can also predict an expected frequency for each cell in the contingency table.

If the value of the test statistic for the χ2 test of association is too large, it indicates a poor agreement between the observed and expected frequencies, and the null hypothesis of independence/no association is rejected when value less than 0.05 was used.

 Results



[Table 1] shows that the age of 80% (n=24) of the cases ranged between 20 to 35 years, whereas the age of 16.7% (n=5) of the controls ranged from more than 30–35 years. Half of the cases (50%, n=15) were divorced compared with 3.3% (n=1) of the controls. Most cases (63.3%, n=19) and half of the controls (50%, n=15) were highly educated, but the difference was not statistical significant. Almost half of the cases (53.3%, n=16) were not working, whereas 73.3% (n=22) of controls were working.{Table 1}

[Table 2] shows that 50.0% (n=15) of cases started taking drugs at the age ranging from 15 to 20 years, and 53.3% (n=16) of cases used cannabis as their drug of onset. A large proportion of cases were dependent on substances for a period ranging between 10 and 15 years, representing 46.7% (n=14) of the cases, and 50% (n=15) of the cases had been sober from 6 months to 1 year compared with 6.7% (n=2) who had been sober for more than 5 years.{Table 2}

All cases (100%, n=30) received the same type of treatment in the form of hospitalization and going through twelve-step facilitation.

[Table 3] shows that benzodiazepines were the most commonly used substance (32.7%), followed by opiates (29.5%) and alcohol (8.1%).{Table 3}

[Table 4] shows that 40% (n=12) of cases had severe medical deterioration and 53.3% (n=16) had mild occupational deterioration. Most cases (90%, n=27) showed severe drug and alcohol use, more than half of the cases (53.3%, n=16) had severe problems in their social relationships owing to substance dependence, 66.7% (n=20) of the cases had severe psychiatric problems owing to substance dependence, almost half of cases (56.7%, n=17) had mild family history of alcohol and drug use and 30% (n=9) of the cases had severe legal problems owing to substance dependence.{Table 4}

[Table 5] shows a statistical significant difference between cases and controls regarding social competence. Overall, 70% (n=21) of cases had low social competence compared with no controls (n=0), and only 30% (n=9) of cases had high social competence compared with controls, where all participants (100%) had high social competence.{Table 5}

[Table 6] shows a statistically significant difference between cases and controls regarding social support. Overall, 43.4% (n=13) of cases had limited level of social support compared with none of the controls (0%), who all showed high level of social support.{Table 6}

[Table 7] shows that 16.7% (n=5) of cases had bipolar I disorder, 33.3% (n=10) had major depressive disorder, and 30% (n=9) had PTSD compared with none of the controls (0%) who had these disorders. The table also showed that 100% of cases had psychiatric disorders in their recovery process compared with none of the controls (0%).{Table 7}

 Discussion



The aim of this study is to estimate the presence of psychiatric disorders among recovering substance-dependent women, as well as to assess the degree of social competence and social support.

Most controls (60%, n=18) were married compared with only seven (23.3%) cases, and also 50% (n=15) of recovering substance-dependent women were divorced. The finding of this study was consistent with the study done by Snell and Morton (1991) who stated that the effect of drug abuse was enormous for women during addiction, treatment and also through recovery. Under the influence of drugs, women lose their spouses, their children, and their lives.

A huge body of literature supports the findings that women may not be well supported by their family, peers, and partner compared with men or nonsubstance-dependent women, and they face many barriers to enter treatment (Astley et al., 2000).

Differences in rates of occupation between cases and controls were statistically significant in the direction denoting that recovering females are the least working compared with controls.

This finding was consistent with Wickizer (2000) who compared between the work status, job skills, and job readiness between recovering substance-dependent women and nondependent women. The study found that the percentage of women who worked after treatment program was only 10% compared with nonsubstance-dependent women, which was 42%.Overall, 50.0% of the recovering substance-dependent women started taking drugs at the age ranging from 15 to 20 years. This is consistent with the Situation Analysis Report of Drug Abuse in Egypt, which found that the age of initiating drug use in Egypt is usually from 15 to 20 years old [The World Health Organization/East Mediterranean Regional Office, Cairo (WHO/EMRO), (2005)].

The findings are also consistent with the study of Abdel-Wahab (2003), in which it gathered information on drugs of onset of abuse and those used at the terminal destinations of drug addiction in Egypt and reported that cannabis and narcotics are mostly the drugs of onset used in Egypt. It is also consistent with the results of a study done by the Ministry of Health and Population that confirmed an increase of cannabis abuse in Egypt and stated that the onset of drug abuse had decreased from the age of 25 years to the age of 15 years (CAPMS-Egypt, 2006).

Overall, 46.7% (n=17) of the cases were dependent on drugs for a period ranging from more than 10 to 15 years. The duration of abuse for all the participants ranged from 1 to 30 years, whereas the mean duration was 9.5±6.6 years (Hafeiz, 1995).

Moreover, 50% (n=15) of cases had been sober from 6 months to 1 year, assuming the social and psychological barriers recovering women face in our society to complete recovery and stay sober. Of the cases, 100% (n=30) had been hospitalized, followed by 100% (n=30) who had taken the 12-step program and 60% (n=18) who had been through rehabilitation.

This is consistent with Vaillant (1998) and American Society of Addiction Medicine (ASAM, 2003) who support that the modes of treatment mostly used by substance-dependent patients are hospital detoxification, followed by short stay in hospital and relapse prevention programs, and the last treatment option used by patients was inspirational group membership and therapeutic communities (Vaillant, 1998; Graham and Mayo-Smith, 2003).

Benzodiazepines were the most commonly used substance by cases (32.7%), followed by opiates (29.5%) and alcohol (8.1%), which was consistent with the studies done by Amodei et al. (1996) and Jorm et al. (2000) that stated that women were more likely than men to be prescribed benzodiazepines and sleeping pills for nonmedical reasons such as coping with grief or stress. They were prescribed these drugs when adjusting to natural reproductive processes such as menses, pregnancy, childbirth, and menopause, which may cause pain and discomfort and interfere with life events. Because of the multiple roles carried out by many women in labor and domestic work they perform, it was found consistent with the studies done by Amodei et al. (1996) and Jorm et al. (2000), which stated that women were more likely than men to be prescribed benzodiazepines and sleeping pills for nonmedical reasons such as coping with grief or stress. The findings of the study correspond to the study done by Abdel-Gawad (2002), which noted that most of heroin users would use opioid analgesics such as tramadol as a replacement drug in case heroin is not available, or they may use tramadol as an analgesic during their trials for self-abstinence (self-medication) from heroin.

Regarding the ASI, all candidates were physically deteriorated owing to substance dependence from mild to severe form. The finding is consistent with the studies which indicate that major health consequences of opioid use include higher risk of premature death and, when opioids are injected, increased risk of blood borne infections such as HIV and hepatitis B and C [The World Health Organization (WHO), United Nations Office on Drugs and Crime (UNDOC), UNAIDS, 2004b].

Individuals with opioid dependence who often inject drugs of unknown potency and quality − in conjunction with other substances − frequently experience overdose with high risk of death. Longitudinal studies suggest that ∼2–3% of them die each year. The mortality rate for dependent heroin users is between 6 and 20 times greater than that expected for those in the general population of the same age and sex [The World Health Organization (WHO), United Nations Office on Drugs and Crime (UNDOC), UNAIDS, 2004c].

Substance dependence in this study was accompanied by occupational deterioration ranging from moderate to mild degrees in all cases. The study finding is consistent with studies that indicate that substance dependence results in significant costs to society through unemployment, homelessness, family disruption, loss of economic productivity, social instability, and criminal activities [The World Health Organization (WHO), United Nations Office on Drugs and Crime (UNDOC), UNAIDS, 2004b].

Most cases (90%, n=27) had severe use of drugs and alcohol, and no participant had mild use of drugs and alcohol. This finding is consistent with data from WHO which states that all psychoactive substances can be harmful to health, depending on how they are taken, in what amounts and how frequently [The World Health Organization (WHO), 2005c].

All patients in this study were facing social problems owing to substance dependence ranging from moderate (46.7%, n=14) to severe (53.3%, n=16) degree. One of the main social consequences to substance dependence is the stigma and stereotypes against users and abusers. It is the main barrier to treatment and care of people with substance dependence and related problems [The World Health Organization (WHO), 2005c]. Studies in the countries of the east Mediterranean region have shown that persons with drug dependence have the highest stigma among a list of two dozen health conditions. This stigma prevents the affected persons from getting care. An example is the recent study from Greater Cairo, where only 12% of those dependent on drugs had received treatment at any time [United Nations Office on Drugs and Crime (UNDOC), {2004}].

All cases in the study had psychiatric problems owing to drug dependence. Overall, 66.7% (n=20) had severe psychiatric problems owing to substance dependence. This is consistent with many studies which found that drug intake especially opiates is associated with a broad range of psychiatric manifestations ranging from intensely dysphoric withdrawal symptoms, depression, impulse control symptoms, intense anxiety, psychotic symptoms especially paranoid delusions and hallucinations, suicidal and self-injurious behavior. These psychiatric disorders occur in addition to tolerance, withdrawal and intoxication symptoms of the different types of drugs [The World Health Organization (WHO), Geneva, 2004c]. The psychiatric manifestations co-occurring with substance dependence were profoundly studied and were interpreted as the long-term consequences of neurobiological adaptations and the opioid system regulation to prolonged drug use. These phenomenon are a consequence of sustained-opioid receptor stimulation by opiate drugs inducing neurochemical adaptations in opioid receptor-bearing neurons. The results extend well beyond reward circuits to other brain areas, notably, those involved in learning and stress response. Important regions are the amygdala, hippocampus, and cerebral cortex, which are all connected to nucleus accumbens (Kieffer and Evans, 2002).

Substance dependence in this study is accompanied by family history of substance use ranging from mild to severe degrees.

This finding is consistent with a huge body of literature that asserts that one family member’s substance abuse is often influenced by substance using behaviors of others in the family, and these complex interrelationships can profoundly affect their lives [Substance Abuse and Mental Health Services Administration (SAMHSA), {1999}]. Dependence on other drugs also shows a familial pattern. The increased risk is partly owing to environmental factors (parental modeling, neglect, and early child abuse), but genetic factors are also important. Numerous studies of laboratory animals have revealed genetically transmitted differences in the reinforcing effects of alcohol and various drugs such as cocaine and opioids and show that genetic factors powerfully influence sensitivity to toxic effects. The evidence for genetic factors in human vulnerability to alcoholism and other drug dependence is derived most convincingly from twin and adoption studies, but family studies are also revealing (Kaplan and Sadock, 2003).

Substance dependence caused many legal problems to the cases from mild to severe degrees. This is consistent with the study done by the Australian Institute of Criminology, which stated that female detainees were more likely than male ones to attribute their crime to illicit drug use, and many women had become regular users of illicit drugs before their first arrest; this occurred on average at the age of 21 years. The use of illicit drugs was associated, particularly in female detainees, with property offending. Alcohol use is more likely to be associated with violent crime than with other crimes and regular and dependent alcohol use increased women’s likelihood of being involved in violent offending, although not to the same extent as it did in men (Australian Institute of Criminology, 2009). It was demonstrated that female drug addicts commit relatively fewer violent crimes compared with male addicts and were more likely to engage in drug-related crimes, such as property crimes and prostitution (Chen, 2009). This finding is consistent with many studies estimation that in some countries around three-quarters of people in prison have alcohol or other drug-related problems, and more than one-third may be opioid dependent. Approximately one-third will have been imprisoned for drug-related offenses. Some level or continued drug use often occurs in prison and is usually associated with high risk of HIV transmission owing to sharing/reusing injecting equipment and drug solution. On release, prisoners with opioid dependence are at high risk of relapse and overdose. The costs of law enforcement, court time and imprisonment together contribute substantially to the social costs associated with opioid dependence. In general, studies indicate that pure justice interventions, without associated opioid dependence treatment, have very limited effect on drug using behavior and reoffending among individuals with drug dependence [The World Health Organization (WHO), United Nations Office on Drugs and Crime (UNDOC), UNAIDS, 2004d].

Most cases (70%, n=21) had low social competence compared with controls (n=0), who had high level of social competence. The finding of our study is consistent with many studies that state that substance abuse clearly impairs one’s ability to work and to cope in the society, but little data are available to indicate threshold levels that would clearly impair job performance. Most states have adopted clinical standards as a means of identifying those who should receive treatment before work training (Becker and Duffy, 2002).

It is also consistent with the study done by Rapheal and Bryant (2004) which states that women are widely disadvantaged by economic and social factors. Women in the paid workforce consistently earn 20% less than men. Women’s work in the home and childrearing remains unpaid and unprotected by the social safety net. Numerous concerns about systemic economic and social discrimination experienced by women have been stated. Poverty, wage disparities, and social program reductions as well as lack of childcare, lack of social housing, and ongoing violence against women are some of the factors that continue to negatively affect women (Rapheal and Bryant, 2004).

It is also consistent with the study done by United Nations Office on Drugs and Crime (UNDOC, 2004) which states that women using drugs face much social, personal, and cultural stigmatization. For female drug users, the guilt and shame associated with drug use is often also added to the stigma. Additionally, in comparison with men, women seeking treatment seem to be younger, with fewer resources, have dependent children and often live with a drug-using partner. They are more likely to have experienced trauma and have higher rates of concurrent psychiatric problems. All of these factors make it even more difficult for women to access and stay in treatment and difficult as well to cope in society [United Nations Office on Drugs and Crime (UNDOC), {2004}].

Overall, 43.4% of cases had limited level of social support compared with none of participant (n=0) of control group, who all had high level of social support. The finding of this study is consistent with the study done by Podkopacz et al. (2006) which stated that social support for abstinence has been found to be associated with positive treatment outcome among drug court participants, after assessing how different types of social support from family, friends, and significant others influenced client progress through a Minnesota Drug Court. Specifically, emotional, practical, informational, financial, and socializing supports were assessed using the Social Support Behaviors Scale (Podkopacz et al., 2006).

The finding of our study is consistent with the study done by Boyd and Mieczkowski (1990), which reported that among a sample of crack abusers in residential treatment, 30% of women reported that no one within their social network would provide them with support for being in recovery, compared with only 19% of men. This is important, as social support that encouraged abstaining from drug use significantly predicted positive outcomes among drug court participants of both sexes especially for women (Podkopacz et al., 2006).

According to the results of the study, there is a positive statistical significant difference between the study groups on the level of psychiatric status.

The findings of our study are consistent with the study done by Merikangas et al. (1998), which stated that in general, there was a strong association between mood and anxiety disorders as well as conduct and antisocial personality with substance disorders at all site. The results also suggest that there is a continuum in the magnitude of comorbidity as a function of the spectrum of substance use category (use, problems, dependence), as well as a direct relationship between the number of comorbid psychiatric disorders and increasing levels of substance use disorders. Finally, although there was no specific temporal pattern of onset for mood disorders in relation to substance disorders, the onset of anxiety disorders was more likely to precede that of substance disorders in all countries (Merikangas et al., 1998).

It is also consistent with many other studies that had found that compared with men, women with substance use problems reported higher rates of psychiatric disorders, most commonly anxiety, depression (though sex differences in rates of depression among individuals with substance use problems are smaller than among the population in general), borderline personality disorder, and eating disorders (Bogenschutz and Geppert, 2003).

The findings are also consistent with the study done by Shantna et al. (2009) which stated that many substance-dependent women often had comorbid psychiatric conditions, which needed to be treated to maximize treatment compliance. The conditions include major depression, bipolar disorder, schizophrenia, and disorders of personality. The experience of trauma can lead to the development of PTSD, or other mental health problems. Rates of PTSD among women in substance abuse treatment range from 30 to 59%.

The results of the study are consistent with the research done by Fiorentine and colleagues which stated that women in substance-dependence treatment had much higher rates of traumatic experiences and PTSD than the general population. Studies of both residential and outpatient treatment programs that served both middle class insured and indigent populations showed high levels of childhood abuse and adult trauma among women in drug-dependence treatment (Fiorentine and Anglin, 1997).

 Conclusion



Most of recovering substance-dependent women were single, mostly divorced, and not working, and most of them chose cannabis as the substance of onset of abuse at an age of onset between 15 and 25 years and were substance dependent for a duration between 5 and 15 years. Half of the recovering substance-dependent women had been sober from 6 months to 1 year, and all of them received the same type of treatment in the form of hospitalization and going through twelve-step facilitation. Benzodiazepines were the most commonly used substance followed by opiates and alcohol. Substance dependence in this study was accompanied by mild to severe medical complications, mild to severe occupational problems, moderate to severe drug use, mild to moderate family history, mild to severe legal problems, moderate to severe social problems, and mild to severe psychiatric problems on the ASI. Most of recovering substance-dependent women show low social competence and have limited to fair level of social support in their recovery. Major depressive disorder and PTSD are the two most common psychiatric disorders found in recovering substance-dependent women.[53]

Recommendations

Further research studies, of wider population sample, are required to assess the demographic and environmental factors inducing substance-dependence problem.More epidemiological studies are needed to assess the trend of substance dependence and recovery among special groups, especially women and comorbid mentally ill patients.Studies are needed to reveal the barriers women find in getting treatment from substance dependence and treating their comorbid psychiatric disorders.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

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