Women with co-occurring substance use and mental disorders, such as anxiety, depression and post-traumatic stress disorder (PTSD), pose complex practice and service delivery issues. Dual disorders are associated with poor treatment outcomes and pose special treatment challenges. Challenges include poor treatment adherence and difficulty accessing separate service systems. This NIDA funded pilot study examined barriers to substance abuse and mental health services among 86 women in residential and outpatient substance abuse treatment.

Methods

Using a cross sectional survey design, data were collected from 41 women in residential and 45 women in outpatient substance abuse treatment. 96.2% of the eligible women agreed to participate in the interview. Current substance use and mental disorders were assessed using the Computerized Diagnostic Interview Schedule. Perceived service barriers were measured with the Allen Barriers to Treatment Inventory (ABTI). As adapted in this study, the ABTI consisted of 46 alcohol and drug and 39 mental health treatment barriers. Chronbach's alpha for the scales were .90 and .95 respectively. Self reported use of substance abuse and mental health services over the past six months was collected.

Results

Of the 86 respondents, 44% had a substance use disorder only and 56% had a co-occurring substance use and mental disorder: 41% major depressive episode, 28% PTSD, 21% manic episode and 14% generalized anxiety. Mean age was 34 years. 81% identified as African-American. Of those women with a mental disorder, 48% had not used or sought mental health services. “Fear of losing children” was the number one barrier to both substance abuse (36%) and mental health (27%) services. Most frequently reported barriers to alcohol and drug services were: “need alcohol/drugs for stress relief” (34%), “unable to stay clean in the past” (30%), “community expects alcohol/drug use” (28%), and “poor treatment experiences in the past” (21%). Most frequently reported barriers to mental health services were: “no health insurance” (21%), “feeling ashamed” (21%), “no transportation” (21%) and “waiting for opening” (21%). There were few differences in perceived barriers between the co-occurring disorder and substance use disorder groups with one exception: “fear of losing friends if alcohol/drug free” (2% vs. 21%). While there were no overall differences in the mean ABTI score, t-tests indicated statistically significant differences in particular items between the residential and outpatient settings including: “feeling ashamed” (29.3% vs. 4.4%), “community expects alcohol/drug use” (39.0% vs. 17.8%), "unable to stay clean in the past" (47.4% vs. 13.6%), “need alcohol/drugs for stress relief” (46.3% vs. 22.2%) and “feeling situation is hopeless” (19.5% vs. 6.7%). There were a greater number of differences between the residential and outpatient groups in substance abuse treatment barriers as opposed to mental health treatment barriers.

Implications for Practice

Compared with outpatient women, residential women reported significantly greater amounts of shame and self-deprecation and reported higher needs for alcohol/drug use as a stress release. Residential treatment staff need to be aware of and address these issues if women are going to successfully return to the community.