SUDs in Women and the Importance of Tailored Treatment Approaches

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CLINICAL CONVERSATIONS

Psychiatric Times® sat down with Gil Angela Dela Cruz, MSc, of the Centre for Addiction and Mental Health in Toronto, Ontario, Canada, to discuss substance use disorders (SUDs) in women, their connections to intimate partner violence (IPV), and the most effective approaches to treatment.

Psychiatric Times (PT): What are the unique biological, psychological, and social factors that contribute to SUDs in women? How can understanding these factors inform tailored treatment approaches?

Gil Angela Dela Cruz, MSc: Women’s substance use can be defined as a unique experience compared with that of men. For example, biologically speaking, physiological processes like addiction progression, effects on the brain, and drug metabolism all differ between sexes.

Moreover, to be a woman extends past these factors and includes many gendered psychosociocultural experiences. This includes the increased rate of concurrent SUD, mental illness (eating disorders, anxiety, depression), and, notably, posttraumatic stress disorder (PTSD). These are exacerbated by increased rates of childhood abuse, sexual abuse, and intimate partner violence.

Furthermore, stigma and lack of knowledge on the harms of substance use block women from seeking treatment. Often, women are not even able to seek or attend treatment in the first place because of the disproportionate impacts of housing instability, lack of transportation, and need for childcare.

Understanding how these factors play into one another is crucial to creating tailored treatment for women. Integrating SUD treatment with mental illness treatment allows clinicians to address how substances may be used as a coping mechanism for challenging experiences and mental illness. Training clinicians to be trauma-informed prevents retraumatization and allows for the creation of a better therapeutic relationship with patients.

This includes having the option for women-only treatment to address patient feelings of safety, as well as encourage mutual support between patients. Having available clinicians who are women is critical for this, especially for patients with previous experiences of trauma related to men.

Creating spaces where women can feel safe can be empowering and allow for patients to feel like they have a voice within treatment, especially as they are in positions that often feel out of their control. Providing support for transportation and childcare and postpartum care are all suggested ways to encourage recovery not only within treatment, but long-term.

PT: Given the complex interplay between SUDs and co-occurring mental health conditions in women, what evidence-based strategies or therapeutic modalities do you find most effective in addressing both issues concurrently within a clinical setting?

Dela Cruz: Having a holistic approach to care is key to encouraging good outcomes for women seeking recovery. Look at this review paper¹ focused on evaluating gender-responsive and integrated treatments for a more in-depth analysis of existing services. Overall, it is useful to include gender-responsive elements and integrated, trauma-informed programming.

PT: Research suggests that women experiencing IPV are at a heightened risk for SUDs. How can mental health clinicians effectively screen for and address substance use in this vulnerable population, considering the intersectionality of IPV, trauma, and addiction?

Dela Cruz: Overall, I think that a trauma-informed approach is best with this population, especially considering the links between IPV and PTSD. As I suggested, an integrated approach that is sensitive to concurrent SUD and mental illness is ideal, but collaboration with interdisciplinary teammates is also key.

Service providers like social workers, nurses, and other clinicians are all important to the development of goals and personalized support for these women. Having clear care pathways that can provide services like access to shelters or job support can make a difference in how safe they feel.

When my colleagues and I were writing our CME article² on IPV and SUD in women for Psychiatric Times, I could not emphasize the importance of effective training enough—and the earlier the training, the better. This not only helps service providers to better identify women in dangerous situations, but also creates a more comfortable space for the patients. Overall, the priority is to support safety for this population.

PT: Cultural competence and sensitivity are paramount in providing equitable and effective care for women from diverse backgrounds who struggle with substance use. What steps can psychiatrists take to ensure their clinical practice is inclusive and responsive to the unique needs and experiences of women from various cultural, ethnic, and socioeconomic backgrounds?

Dela Cruz: Research shows that women of color (WoC) are less likely to seek substance use treatment compared with men.³ This may be due to a reduced perception of problematic use or wish to stop using substances on their own, but sometimes it is the perception that SUD treatment is not culturally competent. Clinicians must be aware of challenges that WoC share.

For example, in the qualitative study I conducted for my master’s thesis, 1 WoC participant shared how complex language was a barrier to her engagement, especially since English was her second language. Some cultures differ so much that their languages do not have words to describe certain mental health symptoms.

Additionally, stigma is more prevalent in minority populations, reducing treatment seeking and increasing personal guilt.⁴ Culturally competent training can prepare clinicians to face patient experiences with more sensitivity through exposure to more diverse patient experiences with a mentor or understanding of the role of certain cultures so as not to alienate.

Even with the training, patients often want to receive care from their same culture. There is a sense of comfort when you know the person you are speaking to knows what you are going through and feels familiar. It makes you feel like you are not being judged, and that you are safe.

As a daughter of immigrants, I can understand the difficulty of bridging the gap and providing welcoming care for all, but I think that, especially in diverse countries like Canada and the United States, it is important to take these into account as service providers. A good read is the article⁵ we wrote for Psychiatric Times on the topic of providing culturally competent mental health care for women.

Ms Dela Cruz is a research analyst at the Centre for Addiction and Mental Health (CAMH) in Toronto, Ontario, Canada, and is a graduate of the Institute of Medical Science at the University of Toronto.

References

1. Johnstone S, Dela Cruz GA, Kalb N, et al. A systematic review of gender-responsive and integrated substance use disorder treatment programs for women with co-occurring disorders. Am J Drug Alcohol Abuse. 2023;49(1):21-42.

2. Dela Cruz GA, Sorkhou M, Zhang M, et al. Intimate partner violence victimization: how it relates to substance use in women. Psychiatric Times. November 21, 2023. Accessed March 27, 2024. https://www.psychiatrictimes.com/view/intimate-partner-violence-victimization-substance-use-women

3. Pinedo M. A current re-examination of racial/ethnic disparities in the use of substance abuse treatment: do disparities persist?Drug Alcohol Depend. 2019;202:162-167.

4. Misra S, Jackson VW, Chong J, et al. Systematic review of cultural aspects of stigma and mental illness among racial and ethnic minority groups in the United States: implications for interventions. Am Community Psychol. 2021;68(3-4):486-512.

5. Kant T, Sorkhou M, Dela Cruz GA, et al. Mental health care for women of color: risk factors, barriers, and clinical recommendations. Psychiatric Times. July 5, 2023. Accessed March 27, 2024. https://www.psychiatrictimes.com/view/mental-health-care-for-women-of-color-risk-factors-barriers-and-clinical-recommendations

How do you identify, treat, and manage substance use disorders (SUDs) like OUD and addictive behaviors in your patients? Write to us at PTEditor@MMHGroup.com for a chance to be featured in our April content series on addiction and SUDs.