gender differences in treatment needs, services, utilization, and outcomes karol kaltenbach, phd...

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

Karol Kaltenbach, PhD

Department of Pediatrics

Jefferson Medical College

Thomas Jefferson University

APA Disclosure StatementAPA Disclosure Statement

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

OverviewOverview

History of specialized services for women

Assessing comprehensive needs of women

Complexity of needs and treatment outcomes

History of Specialized Services for WomenHistory of Specialized Services for Women

NIDA 1974

Research demonstration projects for women’s treatment

Women’s special needs and the delineation of gender specific treatment strategies were identified over 20 years ago

Beschner, Reed, & Mondanaro (Eds) 1981Treatment services for drug dependent women

History of Specialized Services for WomenHistory 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 women’s treatment services in the late 80’s –’90’s

Specialized Treatment Services for Women 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)

Services: Models for Women’s TreatmentServices: Models for Women’s Treatment

Finnegan, Hagan, Kaltenbach (1991)Scientific foundation of clinical practice: Opiate use in

pregnant womenJansson, Svikis, et al (1996) Pregnancy and addiction: A comprehensive care

modelKaltenbach & Comfort (1996) Comprehensive treatment for pregnant substance

abusing womenFinkelstein, Kennedy, Thomas, Kearns (1997) Gender

specific substance abuse treatment

Woman Centered Treatment ModelWoman Centered Treatment Model

Comprehensive treatment approach that addresses – Addiction– Medical/Psychiatric – Psychosocial– Parenting– Educational/Vocational

issues of both women and their children

Specialized ProgramsSpecialized Programs

Women-only programs more likely to provide:Pregnancy, pediatric and children’s servicesClient advocacy/case managementClasses on social skills, practical skills, parenting, anger managementAssistance with housing and transportationPeer support groups and social outings

(Grella et al., 1999)

Effectiveness of Specialized Treatment ServicesEffectiveness of Specialized Treatment Services

Residential– Women in women-only programs had

More time in treatment

More likely to complete treatment

(Grella, 1999)

Effectiveness of Specialized Treatment ServicesEffectiveness 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)

Effectiveness of Woman Centered TreatmentEffectiveness 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)

Assessing Comprehensive Treatment Needs of WomenAssessing 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 malesAcceptable levels of reliability and validity with a number of populations

Limited in assessing critical areas for women

Assessing Comprehensive Needs of WomenAssessing Comprehensive Needs of Women

ASI limited in assessing

Medical issues related to pregnancy Care-giving responsibilities Child and partner relationships Victimization

Assessing Comprehensive Needs of WomenAssessing 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

Complexity of NeedsComplexity 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)

Personal and Family CharacteristicsPersonal and Family Characteristics


Currently Receiving

Public Assistance 84% 81%

Relationship status

Married 6% 17%

Not Married 84% 53%

Long-term

relationship 10% 30%



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%


Substance Use by Partner

No use 31% 33%Drug and/or alcohol use 42% 42%Recovery 27% 25%D/A TreatmentEver 41% 40%Currently 15% 25%


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%

Personal CharacteristicsPersonal Characteristics

VictimizationResidential Outpatient

One/more types of victimization 73% 89%

Domestic violence 45% 65%

Rape 43% 54%

Childhood abuse/neglect 32% 39%

Personal CharacteristicsPersonal Characteristics

Legal Status Residential Outpatient

Family legal problems 45% 31%

Requested order of protection 22% 23%

Ever arrested 32% 23%

Ever incarcerated 23% 13%

Treatment OutcomesTreatment 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


We know relatively little of the relationship between women’s characteristics/needs and treatment outcome.


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)


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


Summary of FindingsRetention predicted by

Personal Stability

Opiate Dependence

Fewer Psychiatric and Medical Problems

Multiple Family Problems(multiple R2=.153, p<.0001)


Summary of Findings

Abstinence predicted byLower scores on High-Risk Lifestyle (trend)

(multiple R2=.035, p=.059)


Summary of Findings

Utilization of Required ServicesLower scores on Multiple Family Problems(multiple R2=.069, p=.021)

Utilization of Specialized Services Psychiatric and Medical Services (trend)(multiple R2=.045, p=.061)


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)


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


Summary: Outpatient

– The most noteworthy predictors for women in outpatient treatment were differing combinations of

Social supportLife stressorsLevels of past substance abuseChronic medical conditions


Summary: Residential

– The most significant predictors for women in residential treatment reflected lower levels of personal risk factors

Partner abuseProstitutionHomelessnessDepression


– More responsibilitiesCare-giving responsibilities

Less financial assistance from family


Conclusion– No simple predictors of women’s

substance abuse treatment outcomes– Assessment areas of particular value

Social support Chronic medical problemsDaily stressors Childbirth historyLife satisfaction Childcare responsibilitiesPartner abuse Engagement in treatmentPsychiatric history

Predictors of Program Completion for Women in Residential TreatmentPredictors 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)

Predictors of Program Completion for Women in Residential Treatment Predictors of Program Completion for Women in Residential Treatment

Predictors of treatment completion– Education– Recent arrests– Peer deviance

(Knight et. al. 2001)

Predictors of Program Completion for Women in Residential TreatmentPredictors of Program Completion for Women in Residential Treatment

Noteworthy trendsWomen 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)

Treatment for WomenTreatment for Women

In summary, limited research on gender specific treatment

Biopsychosocial characteristics of women

Treatment utilization and retention

Psychiatric co-morbidity

Treatment for WomenTreatment 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

gender differences in treatment needs, services, utilization, and outcomes karol kaltenbach, phd...

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