Blending Perspectives and Building Common Ground. Co-Occurring Health and Social Factors


Particularly among women, mental illness and substance abuse are often intertwined.  Over one third of females with problem drug use have experienced a major depressive episode in the past year, and 45 percent have experienced at least one of several mental health problems including panic attacks and anxiety disorders.  These rates are more than double those for men with similar levels of substance use (HHS/SAMHSA, 1997d).  Chavkin and her colleagues (1993) found that most crack cocaine using women reported psychiatric symptoms, and nearly a third had histories of psychiatric medication or hospitalization.  Half reported having been sexually abused as children.  Merikangas and Stevens (1998) present a comprehensive review of the literature on psychiatric comorbidity in women with substance use disorders.  It has been hypothesized that for many women with both substance abuse and other affective disorders, drug use may in part represent self-medication, that is, drugs are being used to alleviate psychiatric symptoms (Dackis and Gold, 1992).  To the extent this is the case, abstinence alone will not solve the problem.  If the underlying psychiatric problem is not addressed, the factors causing the drug problem have not gone away (at least in part) and relapse is likely to result.  Dually diagnosed clients (those with both substance abuse and other mental illnesses) are known to have higher relapse rates than other clients (HHS/SAMHSA, 1994).  Diagnosis of co-occurring mental and addictive disorders can be difficult but is extremely important for effective treatment and recovery.  Because alcohol and drug abuse may mask other symptoms, it is often several months into sobriety before additional diagnoses can be made.

The nation's AIDS epidemic is also closely intertwined with problems of substance abuse.  Two thirds of AIDS cases among women are the result of either intravenous drug use or sexual relations with an intravenous drug user (Selwyn and Gorevitch, 1998).  Women with substance abuse problems are more likely both to have high risk sexual partners and to have multiple sexual partners than are women without such problems.  The vast majority of women diagnosed with HIV or AIDS are between the ages of 15 and 44 (the childbearing years).  Many of these women have children who may be born with HIV themselves, or are likely to be orphaned as their mothers succumb to the disease, although prenatal HIV treatments have reduced mother-infant transmission rates substantially.  Between 72,000 and 125,000 U.S. children are expected to be orphaned because of parents' AIDS by the year 2000 (Levine and Stein, 1994).  Women are likely to be diagnosed with HIV or AIDS at later stages than are men and are less likely to receive health care for their infections (Selwyn and Gorevitch, 1998).

The relationship between domestic violence and substance abuse is well documented (HHS/SAMHSA, 1997b) and recent consensus panels held by SAMHSA conclude that "failure to address domestic violence issues interferes with treatment effectiveness and contributes to relapse" (HHS/SAMHSA, 1997b, page 5).  In up to 70 percent of all incidents of domestic violence, the victim, the batterer, or both, had been drinking.  Women who are alcoholics are more likely to have been beaten than non-alcoholics and are more likely to have partners who also drink heavily.  Miller (1998) reports that 88 percent of women in a drug treatment program for women had experienced severe partner violence in their lifetimes, and 26 percent had experienced such violence in the past six months.  The most common forms of severe partner violence were being hit with a fist, beaten up, hit with an object, or choked.  Women in substance abuse treatment had much higher rates of partner violence than women in comparative community samples -- often 2, 3, or 4 times higher depending on the specific type of violence.  In these women, substance abuse may be related to victimization either because alcohol and drugs are used as a general coping mechanism, or to deal with post traumatic stress disorder resulting from the violence (Miller et al, 1997).

Women with substance abuse problems are frequently involved with men who are also substance abusers.  In fact, women are often introduced to substance abuse by male partners.  These men may feel threatened by their partners' efforts to get clean and may actively or tacitly undermine the goals of her treatment.  A woman's efforts to separate from an abusive partner during recovery may also place her at risk for further violence.  Treatment programs which fail to recognize this dynamic may inadvertently contribute to escalating violence.  Child welfare agencies, too, must acknowledge these risks and recognize potential danger to the mother, as well as the children, as they intervene with families.

Women who abuse alcohol and other drugs have often been the victims of violent crimes, either as children or adults.  According to several research studies, between 41 percent and 74 percent of women in treatment for alcohol and other drugs reported being childhood or adult victims of sexual abuse, including incest (Wilsnak, 1991).  A number of researchers have found significantly higher proportions of histories of sexual and/or physical abuse among women in treatment as opposed to comparison groups of women (Bergman et al, 1989).

Preliminary data from a cross-site evaluation of demonstration grants funded by SAMHSA's Center for Substance Abuse Treatment finds that 76 percent of clients in treatment programs for women with children report a personal history of abuse, neglect or trauma.  About a fourth report physical abuse by a parent, a third report emotional or psychological abuse by a parent, and slightly over 10 percent report sexual abuse by a parent.  Many more report physical, emotional or sexual abuse by a non-parent (over three-quarters report physical and emotional abuse and about one-half report sexual abuse).  Clearly, many of these women have experienced severe stress which may affect their basic abilities to function socially and emotionally and especially as a parent.  (Dowell and Roberts, 1998)

Finally, substance abuse is also related to increased involvement of women in the criminal justice system.  Sales of illicit drugs and drug use have contributed to the enormous 386 percent rise in the female prison population between 1980 and in 1994 (Wilsnack, 1995).  The average percent of arrested women who tested positive for drugs in 20 cities in 1996 was 64 percent (U.S. Department of Justice, National Institute of Justice, 1997).