Evidence-Based Reviews

Alcohol dependence in women: Comorbidities can complicate treatment

Current Psychiatry. 2009 June;8(6):52-59

References

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5. Stewart SH, Gavric D, Collins P. Women, girls, and alcohol. In: Brady KT, Back SE, Greenfield S, eds. Women and addiction: a comprehensive handbook. New York, NY: Guilford Press; 2009.

6. Mann K, Ackermann K, Croissant B, et al. Neuroimaging of gender differences in alcohol dependence: are women more vulnerable? Alcohol Clin Exp Res. 2005;29(5):896-901.

7. National Institute of Alcohol Abuse and Alcoholism. Helping patients who drink too much: a clinician’s guide. Bethesda, MD: National Institute of Alcohol Abuse and Alcoholism; 2005. NIH Publication No. 07-3769.

8. Blume SB, Zilberman ML. Addiction in women. In: Galanter M, Kleber H, eds. Textbook of substance abuse treatment. 3rd ed. Washington, DC: American Psychiatric Publishing, Inc; 2004:539-546.

9. Grant JD, Heath AC, Bucholz KK, et al. Spousal concordance for alcohol dependence: evidence for assortative mating or spousal interaction effect? Alcohol Clin Exp Res. 2007;31(5):717-728.

10. Kendler KS, Bulik CM, Silberg J, et al. Childhood sexual abuse and adult psychiatric and substance use disorders in women: an epidemiological and co-twin control analysis. Arch Gen Psychiatry. 2000;57:953-959.

11. Miller BA, Wilsnack SC, Cunradi CB. Family violence and victimization: treatment issues for women with alcohol problems. Alcohol Clin Exp Res. 2000;24(8):1287-1297.

12. Kilpatrick DG, Resnick HS, Saunders BE, et al. Victimization, posttraumatic stress disorder, and substance use and abuse among women. In: Wetherington CL, Roman AB, eds. Drug addiction research and the health of women. Rockville, MD: U.S. Department of Health and Human Services; 1998. NIH 98-4290:285-307.

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17. Center for Substance Abuse Treatment. Detoxification and substance abuse treatment. Treatment Improvement Protocol (TIP) Series 45. Rockville, MD: Substance Abuse and Mental Health Services Administration, 2006. DHHS (SMA) 06-4131.

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20. Connor KR, Hesselbrock VM, Meldrum SC, et al. Transitions to, and correlates of, suicidal ideations, plans, and unplanned and planned suicide attempts among 3,728 men and women with alcohol dependence. J Stud Alcohol Drugs. 2007;68:654-662.

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Therefore, when assessing and treating alcohol-dependent women, screen for trauma history as well as mood and anxiety disorders. To optimize outcomes, treat these disorders simultaneously with the alcohol use disorder.²⁴

Treatment planning

Underuse of treatment programs. Women with alcohol dependence are more likely to seek treatment in primary care or mental health settings, rather than in alcohol treatment settings.^25,26 Women’s underuse of alcohol treatment programs is likely related to:

greater stigma associated with alcohol use for women as compared with men
socioeconomic factors, including pregnancy, child care, and concerns about child custody issues.²⁵

Even so, women who enter treatment for alcohol use disorders appear to benefit as much as men, with similar outcomes, retention, and relapse rates.^25,26

Gender-specific treatment? Women-only treatment programs have been studied because of observed differences in men’s and women’s interaction styles and the hypothesis that men’s traditional societal dominance could negatively affect women in mixed-gender groups.²⁵ Better treatment outcomes have been hypothesized if treatment is tailored to address women’s unique issues: risk factors for alcohol dependence, course of disease progression, medical problems associated with alcohol dependence, and reasons for relapse.

Gender-specific treatment may provide an environment where women—particularly those with a history of trauma from a male perpetrator—feel safe discussing issues related to their alcohol problems. For practical purposes, these programs also may be more likely to address women’s needs for on-site child care, prenatal care, and mental health programming.

Clinical Point

Women who enter treatment for alcohol use disorders appear to benefit as much as men, with similar outcomes, retention, and relapse rates

Results from investigations of women-specific treatments have been mixed. Some data suggest that women-focused outpatient and residential treatment programs have higher rates of treatment completion compared with traditional programs.²⁷ Residential programs that allow women to bring their children may have higher rates of retention—a good predictor of better treatment outcomes.

A recent study compared a manual-based 12-session women’s recovery group with mixed-gender, manualized group drug counseling (GDC). The women’s recovery group focused on gender-specific topics such as relationships, the caregiver role, trauma, comorbid psychiatric conditions (including eating, mood, and anxiety disorders), and the effects of drug and alcohol use on women’s health. The women’s recovery group was:

as effective as mixed-gender GDC in reducing substance use during the 12-week treatment
significantly more effective during the 6-month post-treatment phase.²⁸

Pharmacologic treatment. Few studies have investigated potential gender differences in response to pharmacologic treatments for alcohol dependence. One trial found long-acting injectable naltrexone less effective in women than men,²⁹ but other studies—primarily with small numbers of women—found no gender difference in naltrexone’s efficacy.³⁰ Family history, medication compliance, and side effect profiles need to be studied in greater detail to determine potential gender effects on treatment outcomes with pharmacologic agents.

CASE CONTINUED: Developing a treatment plan

Ms. F identifies 3 triggers for her alcohol use: a stressful day at school, arguments with her ex-husband, and feeling lonely. Because these are high-risk situations for relapse, you incorporate strategies to deal with them into her treatment plan. Other factors to consider:

whether she requires detoxification
an FDA-approved medication for alcohol dependence (acamprosate, oral or injectable naltrexone, or disulfiram)
cognitive-behavioral therapy and medication for major depression and social phobia
referral to psychosocial support groups (such as Alcoholics Anonymous).

You encourage Ms. F to explore support from her employer, such as an employee assistance program that may help her resume teaching after successful treatment.

Three factors determine the need for detoxification: the course of previous alcohol withdrawals (alcoholic hallucinosis, seizures, or delirium tremens), elevated vital signs or other evidence of autonomic hyperactivity such as diaphoresis or tremors, and the patient’s general medical condition. During early recovery, monitor patients closely to assess mood and anxiety symptoms. Blood alcohol tests or GGT and CDT are useful to monitor self-reported abstinence.

Clinical Point

During early recovery, monitor patients closely to assess mood and anxiety symptoms

Educate patients about common withdrawal symptoms and the typical course of recovery. Refer them to a primary care physician for assessment of medical comorbidities of alcohol dependence. With patients’ permission, involve their social support network (family or close friends) in treatment.

Related resources

National Clearing House for Alcohol and Drug Information. Publications and materials on women and substance abuse. Substance Abuse and Mental Health Services Administration. http://ncadistore.samhsa.gov/catalogresults.aspx?h=drugs&topic=11.
National Institute on Drug Abuse (www.nida.nih.gov). Articles that address women’s health and gender differences. www.drugabuse.gov/NIDA_Notes/NN0013.html.

Drug brand names

Acamprosate • Campral
Disulfiram • Antabuse
Fluoxetine • Prozac
Naltrexone • Vivitrol, ReVia

Disclosures

Drs. Payne, Back, Wright, and Hartwell report no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing products.