4 Special Populations

Women

Sex Differences in Substance Use Disorder Treatment

NIDA (2020, April 1). Sex Differences in Substance Use. Retrieved from https://nida.nih.gov/publications/research-reports/substance-use-in-women/sex-differences-in-substance-use.

There are more men than women in treatment for substance use disorders.^[33] However, women are more likely to seek treatment for dependence on sedatives such as anti-anxiety and sleep medications. In addition, although men have historically been more likely to seek treatment for heroin use, the rate of women seeking treatment has increased in recent decades.^[34]

Substance use disorders may progress differently for women than for men. Women often have a shorter history of using certain substances such as cocaine,^[35] opioids,^[36] marijuana,^[37][38][39] or alcohol.^[40][41][42] However, they typically enter substance use disorder treatment with more severe medical, behavioral, psychological, and social problems. This is because women show a quicker progression from first using the substance to developing dependence.^[43]

Many women who are pregnant or have young children do not seek treatment or drop out of treatment early because they are unable to take care of their children; they may also fear that authorities will remove their children from their care. The combined burdens of work, home care, child care, and other family responsibilities, plus attending treatment frequently, can be overwhelming for many women. Successful treatment may need to provide an increased level of support to address these needs.^[44]

Women and Smoking Cessation Treatment

Research shows that women are less likely to try to quit smoking and more likely to relapse if they do quit.^[45] Nicotine-replacement options, such as the patch or gum, are not as effective for women as for men, and nicotine withdrawal may be more intense for women.^[46][47] Nicotine craving^[48] and withdrawal vary across the menstrual cycle, which may further complicate a woman’s attempts to quit.^[49]

Some women continue to smoke because they are afraid they will gain weight. However, research shows only a modest weight gain after quitting. The average smoker gains 6 to 10 pounds after quitting smoking, but certain diet and lifestyle changes can reduce the risk of weight gain. If a person does gain weight, the average person loses much of the extra weight within 6 months.^[50] In fact, long-term quitters gain, on average, only 2 pounds.^[51] Most importantly, the health benefits of quitting smoking far exceed the risks of gaining a few pounds. Quitting also decreases risks for various types of cancers, heart attack, and lung disease.^[52]

Substance Use Disorder Treatment for Mothers and Their Babies While Pregnant or Breastfeeding

A pregnant woman should ask for medical help to stop her drug use. If she attempts to suddenly withdraw from addictive drugs and alcohol without medical assistance, she could be putting her fetus at risk.^[53]

Intensive outpatient treatment, which provides a higher treatment level than traditional outpatient programs but does not require structured residential living, has produced positive results for pregnant women. Pregnant women are more likely to stay in these treatment programs if they provide services such as child care,^[54] parenting classes, and vocational training.^[55][56]

In general, it is neither recommended nor necessary for pregnant women to cease methadone or buprenorphine treatment.^[57][58] However, newborns exposed to methadone during pregnancy can require treatment for withdrawal symptoms.

Some studies suggest that buprenorphine (Suboxone, Subutex) has some advantages over single-dose methadone as a treatment for opioid use disorder in pregnant women. Infants born to mothers treated with buprenorphine had fewer symptoms of dependence and reduced length of hospital stay compared to those treated with methadone.^[59]

Pregnant women who take buprenorphine for opioid use disorder during pregnancy should be aware that the amount of buprenorphine passed through breast milk may be inadequate to prevent opioid withdrawal in their infant. In some cases, treatment of the infant may be required.^[60]

Pregnant women who are addicted to opioids, even if they are in treatment, should monitor their babies for drowsiness, inadequate weight gain, and failure to meet developmental milestones—especially in younger, exclusively breastfed infants. Although unlikely, if a breastfed baby of a woman on buprenorphine therapy shows signs of increased sleepiness, difficulty feeding or breathing, or limpness, a health care provider should be contacted immediately. Infants should be observed for withdrawal signs if breastfeeding is abruptly stopped.^[61]

As for infants born with NAS due to opioids, recovery can require hospitalization and possibly treatment with morphine or methadone to relieve symptoms;^[62] researchers have also studied buprenorphine for this purpose.^[63] There is some evidence that buprenorphine is superior to morphine in treating infants with opioid-related NAS. A NIDA-funded study published found that treating NAS babies with sublingual buprenorphine resulted in a shorter duration of treatment than oral morphine. It also resulted in a shorter length of hospital stay, with similar rates of adverse events.^[64]

Co-Occuring Mental Health Disorders

Many women with substance use disorders are also diagnosed with other mental disorders. This is important because interactions between illnesses can worsen the course of both. Patients who have both a substance use disorder and another mental health condition often have symptoms that are more persistent, severe, and resistant to treatment compared with patients who have either disorder alone. Both disorders should be treated at the same time to improve the likelihood of success. Although men are more likely than women to report both a mental health and substance use disorder within the past year,^[65] women are more likely to suffer from certain mental health conditions, such as depression,^[66] anxiety, post-traumatic stress disorder (PTSD),^[67] and eating disorders.^[68] Some women report using substances to relieve stress or negative emotions.^{[69][70][71][72]} In addition, women are more vulnerable to developing substance use or other mental health disorders following divorce, loss of child custody, or the death of a partner or child.^[73]

Women, Violence, and Substance Abuse

More than 1 in 3 women have experienced physical violence at the hands of an intimate partner, including a range of behaviors from slapping, pushing, or shoving to severe acts such as being beaten, burned, raped, or choked.^[74] Victims of violence are at increased risk of chronic health conditions, including obesity, chronic pain, depression, and substance use.^[75] In recognition of the severity of violence against women and the need for a national strategy to address this issue, in 1994 Congress enacted the Violence Against Women Act to hold offenders accountable and to provide services to victims.^[76] In 2013, President Obama reauthorized the Act to expand programs for reaching especially vulnerable populations.^[77]

The Institute of Medicine and the U.S. Preventive Services Task Force (USPSTF) have recommended that clinicians screen and counsel for interpersonal violence. To help meet that need, the Affordable Care Act of 2010 (Section 2713) requires that health insurance providers cover all preventive services recommended by the USPSTF without copays or deductibles. However, improved prevention and screening guidelines are needed to help clinicians identify those who need help and link them to the care they need.^[78]

Race and Ethnicity

Women of color may face unique issues with regard to drug use and treatment needs. For example, African-American and American Indian/Alaska Native women are more likely than women of other racial and ethnic groups to be victims of rape, physical violence, and stalking by an intimate partner in their lifetime. As discussed above, these issues are risk factors for substance use and should be addressed during treatment.

Gender and Use of Substance Abuse Treatment Services

Carla Green, Ph.D, MPH

Green, C. A. (2006). Gender and use of substance abuse treatment services. Alcohol Research and Health, 29(1), 55-62. https://pmc.ncbi.nlm.nih.gov/articles/PMC6470905/.

Women are more likely than men to face multiple barriers to accessing substance abuse treatment and are less likely to seek treatment. Women also tend to seek care in mental health or primary care settings rather than in specialized treatment programs, which may contribute to poorer treatment outcomes. When gender differences in treatment outcomes are reported, however, women tend to fare better than men. Limited research suggests that gender-specific treatment is no more effective than mixed-gender treatment, though certain women may only seek treatment in women-only programs. Future health services research should consider or develop methods for (1) improving care for women who seek help in primary care or mental health settings, (2) increasing the referral of women to specialized addiction treatment, (3) identifying subgroups of women and men who would benefit from gender-specific interventions, and (4) addressing gender-specific risk factors for reduced treatment initiation, continuation, and treatment outcomes.

In the 1970s and 1980s, practitioners and researchers began to call attention to how little was known about providing appropriate care for women with substance abuse problems, particularly alcoholism (Schmidt and Weisner, 1995). Research traditionally had focused on how men fared in substance abuse treatment, and treatment programs were ill-equipped to help women. In response, government organizations began to support research and treatment for women, and significant numbers of researchers and practitioners focused on understanding and addressing gender differences in treatment access, treatment provision, and outcomes (Schmidt and Weisner, 1995). Researchers began examining the characteristics and social circumstances of women with substance abuse problems, identifying factors that interfered with detecting and diagnosing women who needed help. They also studied the barriers that prevented women from entering treatment and gender-specific issues related to women’s success in treatment. These efforts have resulted in a large body of research addressing gender differences in treatment-seeking, access to care, retention in care, and treatment outcomes.

Over this same period, many treatment programs also began to pay greater attention to the women in their programs and their special needs. Today many (although not all) treatment programs offer gender-specific or gender-sensitive services, such as gender-matching with counselors, mixed-gender treatment groups led by male and female co-leaders, gender-specific treatment groups, and gender-specific treatment content. Many programs also provide ancillary or wraparound services, such as child care and parenting groups, which facilitate women’s treatment entry and continuation. In addition, significant numbers of treatment programs serve women only, target pregnant women or adolescent girls, or offer specialized parenting services for women and their children.

These profound changes in research and treatment programs have occurred at the same time as other important social changes in the United States, such as women’s increased participation in the workforce, greater similarities in men’s and women’s patterns of substance use, and increased public knowledge about substance-abuse-related problems and their treatment. As a result, health services researchers who study gender and substance abuse treatment are finding it difficult to know whether findings from earlier research are still applicable in current settings. Consequently, the following review sometimes specifically distinguishes earlier research findings (i.e., from the 1970s and the 1980s) from more recent research findings.

This article examines gender differences in the prevalence of substance use and related problems, the identification of such problems, treatment-seeking and access, retention in treatment, and treatment outcomes.

Gender and the prevalence of substance use and substance-related problems

Research on how gender influences substance use and substance-abuse-related problems has established clear differences between women and men in several important areas. Women typically consume less alcohol than men when they drink, drink alcohol less frequently, and are less likely to develop alcohol-related problems than men (Fillmore et al. 1997). Similarly, women are less likely than men to use illicit drugs and to develop drug-related problems (Greenfield et al. 2003a).

Conversely, when women do develop substance abuse problems, they tend to develop them faster than men do. For example, although women tend to be older than men, on average, when they begin a pattern of regular drunkenness, women’s drinking-related problems (e.g., loss of control over drinking, negative consequences of drinking) appear to progress more quickly than those of men (Randall et al. 1999). This faster progression also means that women experience shorter intervals than men between onset of regular drunkenness and first encountering the negative consequences of drinking, which include physical problems, interpersonal difficulties, negative intrapersonal changes (such as in personality or self-esteem), poor impulse control, and reduced ability to maintain normal social roles and responsibilities. Women also experience shorter intervals between first loss of control over drinking and onset of their most severe drinking-related consequences, and shorter intervals between onset of regular drunkenness and treatment-seeking (Randall et al. 1999). Women report more severe problems and experience more health-related consequences from substance use (Bradley et al. 1998), and their substance-related problems interfere with functioning in more life domains compared with men (Fillmore et al. 1997).

Recent narrowing of the differences in men’s and women’s substance use patterns and attitudes (McPherson et al. 2004) raises additional concerns because of women’s greater susceptibility to substance-related problems. Based on recent U.S. prevalence estimates, women make up about one-third of people with alcohol problems and slightly less than half of those who have problems with other drugs (Greenfield et al. 2003a).

Gender and the identification of substance abuse problems

A person’s sex has the potential to affect several critical junctures along the pathway to seeking substance abuse treatment. Identification of a problem is the first step toward treatment, whether by the person needing treatment, or by a family member, health care professional, employer, or government agency. The likelihood that a person’s substance abuse problem will be identified appears to differ by gender in some settings. For example, compared with men, substance abuse problems among women, particularly older women (National Center on Addiction and Substance Abuse 1998), are less likely to be identified in health care settings (Brienza and Stein 2002). Women with substance abuse are more likely than men to be identified through contacts with child protective services (Fiorentine et al. 1997; Grella and Joshi 1999). Women also are less likely than men to be referred for substance abuse treatment by their employers or schools (Morgenstern and Bux 2003) and are more likely to have family members, friends, and partners who use drugs and support their substance use (Bendtsen et al. 2002; Grella and Joshi 1999; Center for Substance Abuse Treatment 1994; Kelley et al. 1996; Kline 1996).

Treatment-Seeking

Once people realize they have a substance abuse problem, they must decide or be convinced that they need help—through personal reflection, feedback from others, or legal, employer, or family mandates. Information about possible differences in how men and women go through these processes is limited. Little is known about how families interact when a family member has substance abuse problems, about how the gender of that person influences how families or employers communicate about or manage these problems (see Room et al. 2004 for an intriguing exception), or about how gender might influence reflection prior to treatment-seeking.

Researchers have determined that employed women seeking treatment for alcohol problems are less likely than men to be married and, if married, are less likely to have had spouses who played a role in referral to treatment (Blum et al. 1995). Men who receive suggestions to cut down or stop drinking are more likely to enter treatment, whereas such suggestions do not appear to predict treatment entry for women (Weisner 1993). Early research suggested that women were discouraged by family members from seeking treatment (Beckman and Amaro 1986), and an older Swedish study (Dahlgren and Myrhed 1977) found that women were more likely than men to enter treatment after serious acute complications of their substance use (e.g., unconsciousness, suicide attempts). Women and men do not appear to differ, however, in their perceptions about the need for treatment (Wu and Ringwalt 2004).

In the context of mandated treatment, sources of mandates differ for men and women (Grella and Joshi 1999), with men more likely to be mandated to treatment by employers, through the criminal justice system, and by their families. Women, in contrast, are more often referred by a social worker, suggesting family service agency involvement in their treatment entry (Grella and Joshi 1999). To date, researchers have not directly addressed how gender affects the processes leading to such mandates.

Barriers to Treatment

Once people recognize that they have a substance abuse problem and decide to seek treatment, they still must overcome a variety of barriers to finding and accessing treatment resources. Many studies provide evidence for gender differences in the type, strength, and number of barriers people encounter as they consider and attempt to access treatment. For example, Brady and Ashley (2005) reported that women are more likely than men to experience economic barriers when seeking treatment. They also are more likely to have trouble finding the time to attend regular treatment sessions because of family responsibilities and must overcome problems with transportation. Both men and women must overcome the stigma associated with seeking treatment, but women are particularly susceptible to feeling stigmatized (Brady and Ashley 2005).

Limitations in everyday functioning caused by substance abuse and dependence and common co-occurring conditions, such as mental illness, also can prevent people from accessing treatment. Although both men and women are likely to experience these functional limitations, anxiety and depressive disorders tend to be more prevalent (Hesselbrock and Hesselbrock 1997) and more severe among women with substance abuse problems. For this reason, women may be less likely to seek or follow through with care (Brady and Ashley 2005). Lack of information about treatment options—their availability and likelihood of success—is another barrier. Few studies have investigated whether men and women differ significantly in their knowledge in these areas.

Finally, women from some ethnic groups (such as Hispanic women) may experience cultural barriers (e.g., language problems [U.S. Department of Health and Human Services 2001]) to seeking treatment (Weiss et al. 2003). Moreover, older women are more likely than younger women to encounter physicians who do not believe substance abuse treatment is effective for them, and to have insurance carriers that deny them coverage for treatment (National Center on Addiction and Substance Abuse 1998).

In sum, women are more likely than men to encounter multiple barriers to treatment entry, making them less likely to seek care for their substance-related problems (Brady and Ashley 2005).

Treatment Access

Consistent with these concerns, early research suggested that women with substance abuse problems were less likely to seek help than men with similar problem severity. More recent research suggests that rates of treatment access have improved, with women seeking care at rates similar to those of men, at least in the years following problem onset (Dawson 1996). Similar rates of treatment entry, however, may indicate that women continue to have reduced access compared with men because women consistently use more medical services in other settings than men do (Bertakis et al. 2000). Furthermore, although women’s access appears to have improved generally, some studies continue to find fewer admissions to substance abuse treatment among women (Westermeyer and Boedicker 2000; Arfken et al. 2002).

Various barriers experienced by women, particularly those related to stigma, may influence where women seek help, and whether they seek it from a health professional, a self-help group, or from another source, such as a member of the clergy. Women have been more likely than men to seek help in mental health and primary care settings rather than in substance abuse treatment settings (Weisner and Schmidt 1992). Recent research suggests that care obtained in these nonspecialty settings can lead to poorer treatment outcomes than those achieved at specialty treatment settings. For example, Mojtabai (2005) found that people receiving specialty substance abuse treatment services were less likely to continue substance use than those receiving mental health services. Other recent studies show that, consistent with the greater severity of women’s alcohol-related problems when seeking treatment, women have longer inpatient stays than men, and increasingly are more likely to use self-help programs such as Alcoholics Anonymous (with or without formal treatment) (Timko et al. 2002). Women also are more likely to benefit from these self-help programs than men are (Timko et al. 2002).

In sum, research findings indicate that help-seeking for substance abuse, dependence, and substance-related problems is affected by gender and gender-related characteristics (Weisner and Schmidt 2001). Research is needed to determine the relative value of improving substance abuse treatment services for women in the settings in which they currently seek care (such as in mental health and primary care settings) compared with the value of working to increase referrals to specialty addiction treatment. Improving the latter may be particularly important, given women’s greater needs upon entering treatment: Mental health and primary care settings may be significantly less prepared to manage women’s ancillary service needs and the complexity of their disorders.

Gender differences upon treatment entry

Research has found that women seeking treatment for alcohol or other drug problems have more severe problems (Arfken et al. 2001), are younger, have lower education levels (Wechsberg et al. 1998), and have lower incomes (Brady et al. 1993) than men seeking treatment. Women are more likely to have experienced emotional, physical, and sexual abuse (Wechsberg et al. 1998); to have more severe depressive symptoms when depressed (Pettinati et al. 1997); and to be more hostile than men upon treatment entry (Robinson et al. 2001). Women also report more physical and mental health problems (Brady et al. 1993) and greater concerns about child-related issues (Wechsberg et al. 1998) than men do. In addition, women entering treatment for alcohol-related problems are more likely than men to identify factors other than drinking (e.g., stressful life events, mental health symptoms) as their primary problems and, at least as indicated by earlier studies, have been more likely to report shame and embarrassment at treatment entry (Thom 1987). These differences have led many to conclude that women would be less likely to seek, initiate, or complete treatment, and would therefore have poorer long-term outcomes.

Initiation, engagement, and retention in treatment

Once they have made contact with a source of help, people may or may not proceed to the next step in the process—initiating treatment. They have many choices about initiation, including choice of setting—that is, whether in a formal substance abuse treatment program, another health care setting, within a support group, or with an individual helper. After a recommendation for continuation (often following assessment in a substance abuse treatment setting), people must decide whether to continue along the path they have chosen, seek other services, or decline help. Those who continue then must repeatedly choose whether or not to continue their involvement. This is true even if they have been mandated to treatment. People who select a formal treatment setting must decide whether or not they will complete the treatment program as it has been designed. Research has begun to assess the ways that gender affects the different steps in the treatment process: initiation, engagement and continuation in treatment, completion of the program, and subsequent outcomes.

Most recent studies suggest that gender either has no effect on initiation, or that if it does have an effect, women are more likely than men to initiate treatment (Weisner et al. 2001; Green et al. 2002; Timko et al. 2002). Similarly, research indicates that changes in the provision of care seem to have allayed concerns that women’s continuing engagement in treatment might be hindered by programs’ insensitivity to women’s needs. Women now appear at least as likely as men to engage in and complete treatment, although women from certain subgroups may be at risk for not completing treatment. For example, African American women— as well as women with lower incomes who are unmarried, unemployed, or have psychological problems of greater severity—are less likely to continue with treatment (Mertens and Weisner 2000). Research is needed to identify (1) subgroups at risk for not continuing treatment, (2) modifiable barriers to treatment completion among members of these groups, and (3) appropriate remedies for these barriers.

Gender and treatment outcomes

Many recent research efforts have addressed gender differences in treatment outcomes (which are defined in various ways, including abstinence rates and number of days substances were used in a particular period). Despite concerns that women would fare worse than men, current evidence suggests that, overall, women’s substance abuse treatment outcomes are as good as, or better than, men’s treatment outcomes. For example, one recent study found that men and women were equally likely to complete treatment, but women who completed treatment were nine times more likely to be abstinent than women who did not complete, whereas men who completed treatment were only three times more likely to be abstinent than men who did not complete treatment (Green et al. 2004).

Research on the benefits of gender-specific treatment is less clear than evidence on the benefits of ancillary services, because few studies have compared gender-specific treatment with mixed-gender treatment (Orwin et al. 2001; Smith and Weisner 2000). One recent study randomly assigned female participants to women-only versus mixed-gender programs and found no differences in outcomes (Kaskutas et al. 2005).Researchers also have identified many factors that differ by gender and affect treatment outcomes in important ways—including income, education, employment, types of substances used, psychiatric disorders and symptoms, marital status, self-efficacy, history of sexual abuse, and children in the home (Green et al. 2004; Greenfield et al. 2003b, 2000, 1998, 2002). This suggests that addressing risks differentially, by gender, may help improve both the treatment process and outcomes for men and women. Recognizing these risks, and the potentially differential needs of men and women, has led to the development of gender-specific treatment programs and the provision of women-centered ancillary services. For example, evidence shows that providing services such as child care helps keep women in treatment (Brady and Ashley 2005).

Yet, as is true for other aspects of the treatment process, some subgroups of women may be more likely to benefit from gender-specific treatment. For example, substance-abusing women with post-traumatic stress disorder (PTSD) may benefit significantly more from gender-specific programs designed to address PTSD and addiction problems simultaneously. These programs provide gender-specific content and address, in a comfortable setting (i.e., with only female participants), traumatic experiences and sexual assault (Hien et al. 2004). (Men with PTSD resulting from combat experiences may similarly benefit from male-only groups.) Pregnant and perinatal women also have needs that may be more easily addressed in women-only programs. Although such programs are effective at improving outcomes (Orwin et al. 2001), important pregnancy, labor, delivery, and lactation concerns, as well as other needs (e.g., child care, service coordination, and mental health care) remain unaddressed among these women, particularly among those who also have mental health problems (Grella 1997). Finally, certain women may not seek treatment if women-only treatment programs are not available (Weisner 2005).

Rather than relying solely on gender-specific treatment, some researchers have examined ways to improve treatment by making it gender-sensitive. One approach is to match therapist and client gender or to match therapeutic modality to gender. Results of these efforts have been equivocal. Project MATCH found that matching gender and therapeutic modality had no effect on outcomes (Project MATCH Research Group 1997). Studies addressing therapist–client gender-matching have produced a range of outcomes—with some finding no effects, and others finding greater empathy and therapeutic alliance, longer treatment episodes, and higher rates of abstinence, but also more post-treatment psychiatric symptoms (Fiorentine and Hillhouse 1999; Sterling et al. 1998, 2001; McKay et al. 2003; Nurco et al. 1988). Additional research could help to determine the types of clients best served by same-gender or opposite-gender therapists, and to illuminate the mechanisms by which matching influences treatment process and outcomes.

Gender and Relapse

Not surprisingly, women who have stopped using substances relapse under different circumstances than men do. For example, women are more likely to relapse in the presence of a romantic partner than men are, and are less likely to relapse when they are alone (Rubin et al. 1996). Women also are more likely to report interpersonal problems before relapse (McKay et al. 1996). Consistent with findings of women’s better outcomes in other domains (e.g., post-treatment abstinence, retention in treatment), women are less likely than men to relapse overall (Rubin et al. 1996), and women tend to have better long-term recovery outcomes (Dawson et al. 2005; Weisner et al. 2003). Such results suggest that future research on gender differences in treatment outcomes should focus on improving the understanding of the underlying factors which differ by gender and predict better outcomes (such as better therapeutic alliances among women in treatment) and reduced relapse. Such a focus might further improve treatment outcomes for both men and women.

Summary and Conclusions

Over the past two decades, health services researchers have successfully identified gender differences in patterns of substance use, health and social effects of substance use, pathways to treatment for substance abuse problems, and substance abuse treatment processes and outcomes. As a result of the efforts of treatment programs to address women’s needs, and the efforts of researchers to document the effectiveness of treatment for women, it is known that, in general, specialty addiction treatment is at least as effective for women as it is for men.

At the same time, this work has identified both different and common predictors of treatment access and outcomes for men and women. Now it is possible to target gender-specific factors that increase the risks that substance abuse problems will go undetected or lead to reduced treatment initiation and treatment completion. It also is possible to identify factors that could reduce relapse and improve outcomes. For example, because women continue to seek substance abuse treatment in primary care and mental health settings, care providers in these settings could be trained to identify and refer women to specialty addiction services. Conversely, integrated programs could be developed to provide care to women in places other than specialized treatment agencies or departments (e.g., primary care or mental health settings). Similarly, men who have been victims of domestic violence or forced sex might benefit from approaches developed for women with such histories.

Finally, this body of research suggests that a large proportion of men and women do well in mixed-gender treatment settings, and for these people, such settings will likely be more cost-effective than providing gender-specific treatment. However, some individuals or subgroups (female and male) may benefit in important ways from gender-specific treatment. Adequate assessment and appropriate treatment—whether in gender-sensitive mixed-gender programs or gender-specific programs—are critical to improving clinical outcomes for many people who currently are not well served.

National Alliance on Mental Illness (2017, August). Dual Diagnosis. https://namimetro.org/related-conditions/dual-diagnosis/. 

Dual diagnosis (also referred to as co-occurring disorders) is a term for when someone experiences a mental illness and a substance use disorder simultaneously. Either disorder—substance use or mental illness—can develop first. People experiencing a mental health condition may turn to alcohol or other drugs as a form of self-medication to improve the mental health symptoms they experience. However, research shows that alcohol and other drugs worsen the symptoms of mental illnesses. The professional fields of mental health and substance use recovery have different cultures, so finding integrated care can challenging.

How Common Is Dual Diagnosis?

According to a 2014 National Survey on Drug Use and Health, 7.9 million people in the U.S. experience both a mental disorder and substance use disorder simultaneously. More than half of those people—4.1 million to be exact—are men.

Symptoms

Because many combinations of dual diagnosis can occur, the symptoms vary widely. Mental health clinics are starting to use alcohol and drug screening tools to help identify people at risk for drug and alcohol abuse. Symptoms of substance use disorder may include:

• Withdrawal from friends and family
• Sudden changes in behavior
• Using substances under dangerous conditions
• Engaging in risky behaviors
• Loss of control over use of substances
• Developing a high tolerance and withdrawal symptoms
• Feeling like you need a drug to be able to function

Symptoms of a mental health condition can also vary greatly. Warning signs, such as extreme mood changes, confused thinking or problems concentrating, avoiding friends and social activities and thoughts of suicide, may be reason to seek help.

How Is Dual Diagnosis Treated?

The best treatment for dual diagnosis is integrated intervention, when a person receives care for both their diagnosed mental illness and substance abuse. The idea that “I cannot treat your depression because you are also drinking” is outdated—current thinking requires both issues be addressed.