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Both clinicians and researchers have become progressively more aware of the specific characteristics and distinct treatment needs of women with substance use disorders. According to epidemiologic data, the lifetime prevalence of substance use disorders in North American women is approximately 5% to 8% (1–3). The onset-age of substance use has decreased, and there is evidence for a more marked decrease among adolescent girls than among boys, potentially leading to an increased risk of progression to substance dependence (4). Women with substance use disorders differ from men with the same diagnosis in various ways. For instance, women are more sensitive than men to the physiological effects of substances. In the case of alcohol, they develop higher plasma concentrations from the same amount of ingested alcohol. The progression from first use to the appearance of substance-related problems and seeking treatment for these problems is significantly faster among women, as is the development of medical consequences of substance use. In addition to the increased morbidity and mortality reported among women with substance use disorders, it has been observed that they are less likely to seek specialized addiction treatment and more likely to seek primary and psychiatric care. Also, addiction in women has a high impact on pregnancy, on the neonate, and ultimately, on the whole family (5,6). Extensive sex differences have also been described in psychiatric comorbidity, with potentially important etiological and treatment implications (7). This article reviews sex differences in psychiatric comorbidity among individuals with substance use disorders and, in particular, the clinical significance of these differences for treatment outcome. The article also critically analyzes the findings. MethodWe performed a computerized search of the literature in English since 1990, using as key words alcohol, drugs, comorbidity, treatment, women, and gender. We examined the following databases: Medline, Psycinfo, CINAHL, Best Evidence, Healthstar, Cochrane Database of Systematic Reviews, and Dissertation Abstracts. To enhance the search, we drew prior relevant articles from the reference lists. We attempted to establish how sex impacts on psychiatric comorbidity, as it relates to treatment and treatment outcome. ResultsPrevalence Rates of Psychiatric Comorbidity With Alcohol Use Disorders General Population Samples. Using data for the general population between the ages of 15 and 54 years, taken from the US National Comorbidity Survey (NCS), Kessler and colleagues (8) investigated the lifetime co-occurrence of alcohol abuse or dependence with the following lifetime psychiatric conditions: anxiety, mood, drug use, and conduct disorders (CDs); adult antisocial behaviour; and antisocial personality disorder (APD). (Other diagnoses were not included in this analysis.) In this study, women suffering from alcohol abuse presented significantly higher lifetime prevalence of psychiatric comorbidity than did men (72% vs 57%), while the sex difference for alcohol dependence was nonsignificant (86% vs 78%). It was documented that women who abuse alcohol exhibit significantly more anxiety disorders (specifically, social phobia, simple phobia, and posttraumatic stress disorder [PTSD]), mood disorders (specifically, depression and mania), and drug dependence. Conversely, their male counterparts exhibit more antisocial behaviour. It was also observed that women present higher rates of multiple comorbidity (for example, 32% of women in this group had 3 psychiatric diagnoses in addition to alcohol abuse, compared with 14% of men). For alcohol dependence, no significant sex differences in psychiatric comorbidity were described, except for a higher prevalence of drug use disorders among women, compared with men. This last finding seems to be related to the use of tranquilizers by women (9,10). Helzer and colleagues observe that, in the Epidemiologic Catchment Area Study (ECA) of adults aged 18 years and over, higher rates of psychiatric comorbidity are described for women suffering from either alcohol abuse or alcohol dependence than for men with the same diagnoses (65% vs 44%) (1). For frequent diagnoses, such as major depression and phobic disorders, this finding is associated with higher comorbidity ratios for women than for men (that is, the prevalence in individuals with alcohol use disorders divided by the prevalence in individuals without these diagnoses). Further, diagnoses such as APD, mania, drug use disorders, schizophrenia, and panic disorder also display higher comorbidity ratios in women than in men with alcohol use disorders. Conversely, men with alcohol use disorders present higher comorbidity ratios for obsessive–compulsive disorder (OCD), dysthymia, and cognitive impairment (1). A recent study of US adults found strong comorbidity between alcohol dependence and pathological gambling, with an odds ratio (OR) of 23.1 (that is, the prevalence in individuals with alcohol dependence divided by the prevalence in individuals without alcohol dependence); however, no sex effect was reported (11). Comorbidity between alcohol use disorders and PTSD is relevant for women. A community sample of war veterans registered 29% of women with current PTSD and lifetime alcohol abuse (12). Another study of a similar population registered 33% lifetime PTSD and alcohol abuse or dependence (13). Treatment Samples. Different studies derived from treatment samples have also reported sex differences in psychiatric comorbidity among patients with alcohol use disorders. Psychiatric comorbidity is reported to be higher in women for mood, anxiety, and eating disorders and higher in men for APD (14–19). Comorbid pathological gambling is also reported to be higher in men (20). Women with alcohol use disorders present higher-than-expected rates of bulimia nervosa, but not of anorexia nervosa (21), with the risk being higher when other psychiatric disorders (particularly depression or PTSD) are also present (22,23). Summary. Both general population and treatment samples show that rates of psychiatric comorbidity are significantly higher for women with alcohol use disorders than for men with alcohol use disorders (except for the nonsignificant higher rates of comorbidity found among women with alcohol dependence in the NCS). Specifically, comorbidity rates are higher for mood disorders, such as mania and depression, and anxiety disorders, such as phobias and PTSD. Additionally, drug use disorders that are probably associated with tranquilizer use are more frequent among women with alcohol dependence than among men with the same diagnosis.
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