Risk Factors for Treatment Dropout Among Women with Co-Occurring Substance Use Disorders and PTSD

Background: Co-occurring Substance Use Disorder (SUD) and Posttraumatic Stress Disorder (PTSD) are common, particularly among women. Research has shown that those with both disorders have a more severe clinical profile than those with just one of these disorders. The comorbidity of SUD and PTSD has a significant negative effect on the course of treatment and treatment outcomes. These include poor treatment outcomes, poor treatment engagement and retention, higher frequency of relapse and treatment drop-out (Hien et al., 2000; Hien, Cohen & Campbell, 2005; Najavits et al., 1997; Zweben et al.1994). The purpose of the current study was to identify factors associated treatment dropout in the Women and Trauma Study recently completed by the NIDA Clinical Trials Network.

Methods: The Women and Trauma Study used a randomized, repeated measures design to assess the effectiveness of a trauma focused group therapy (Seeking Safety) compared with a control treatment (Women's Health Education), on PTSD symptoms and substance use outcomes (Hien et al., 2009). Participants (n=348) were women receiving treatment at outpatient substance abuse programs at one of the seven community based sites across the U.S. All participants met the DSM-IV criteria for PTSD, reported substance use within the past 6 months, and had a current diagnosis of drug or alcohol abuse or dependence. The sample included women between the ages of 18-65 (mean=39.2 sd=9.3) and was 46% White; 34% African American; 14% biracial and multiracial; and 7% Latina. Logistic regression models were used to examine factors that influenced early treatment dropout (attending zero group sessions).

Results: Although participants completed an average of 6.1 out of the 12 group-therapy sessions (sd= 4.4), 64 women (18% of the sample) did not attend any sessions. Results indicate that women who did not attend any sessions were significantly more likely to be of a racial/ethnic minority, report abuse from a dating partner as an adolescent (physical or sexual), and report use of cocaine and marijuana. Treatment dropout was not significantly associated with randomization assignment (control or experimental), level of education, employment, access to transportation, legal problems, abuse as an adult (physical or sexual), use of alcohol or opiates, and children living with the participant.

Conclusions: Results suggest logistical barriers to treatment (e.g. transportation, childcare) were not significant factors associated with early treatment dropout and that other issues may have greater influence on treatment attendance. Findings related to abuse during adolescence suggest that women who experience partner violence at an early age may be particularly difficult to engage in treatment. Results also suggest that use of alcohol, opiates, cocaine, and marijuana were differentially associated with early treatment dropout. These findings provide insight into the characteristics of women who are less likely to follow through with treatment for co-morbid PTSD and SUD and may need additional supports in order to begin treatment. Additional research is needed to consider factors not assessed by this study that may have also influenced women's early dropout. These factors may include social support, age of onset for SUD and age of onset for PTSD.