A growing body of research is showing that when it comes to treatments for alcohol use disorders, women’s needs are different from men’s. Scientists who recently presented studies at the Research Society on Alcoholism are exploring gender differences in alcohol treatment and moving beyond a one-size-fits-all strategy.
“Women have different barriers to treatment than men,” says Elizabeth Epstein, PhD, Research Professor in the Clinical Division of the Center of Alcohol Studies at Rutgers University in New Brunswick, NJ. “They are less likely to seek alcohol treatment in a dedicated alcohol facility, and more likely to seek treatment with a general practitioner or psychiatrist for depression or fatigue.” However, many of these doctors don’t routinely screen for an alcohol or drug use problem, she explains.
“We know that 85 percent of people who have alcohol problems in their lifetime don’t seek treatment for it, so we are focusing most of our treatment research resources on the 15 percent who do,” according to Dr. Epstein. “We need to look beyond that, to who is struggling without treatment.” More training in alcohol use disorders is needed for emergency department physicians, obstetrician/gynecologists and family practitioners, she states. “We need to develop interventions that allow doctors to screen for alcohol use problems, since we know that women are not likely to come in and say they drink too much.”
Alcohol tends to affect women more than men for several reasons. Dr. Epstein explains, “A woman who weighs the same as a man and consumes the same amount of alcohol over the same length of time is likely to have a higher blood alcohol level. Women have less body water than men, leading to a higher blood alcohol concentration, and they also have less lean muscle mass and fewer enzymes in the stomach that break down alcohol. That means more ethanol is going into the bloodstream and directly to organs like the heart, brain and liver, and doing damage.”
She notes that women develop a host of alcohol-related health problems more quickly than men, even though they tend to start drinking later. “Older womens’ bodies are not processing anything as well as younger women, including alcohol,” she says. “And we are seeing younger women’s drinking patterns catching up with men’s, which is not a good thing. That means that as this generation progresses, we’ll see more and more older women with alcohol problems.”
Success With Individual Therapy
Dr. Epstein is leading the Rutgers Women’s Treatment Project at the Center of Alcohol Studies. This five-year clinical research study, funded by the National Institute of Alcohol Abuse and Alcoholism, is testing the effectiveness of therapies for women with drinking problems.
She and her colleague, Dr. Barbara McCrady, looked at marital therapy combined with alcohol therapy for women, testing it against individual alcohol therapy for women. “The women in both groups did very well, reducing their drinking days from an average of about 70 percent before the study, to 20-30 percent while in and after treatment,” states Dr. Epstein. The coupled treatment conferred a slight advantage in terms of maintaining the gains in the year following treatment. That study required women to be in a committed relationship or marriage to a male to be eligible. Many women didn’t want to sign up, because their spouse had to be involved.
Both doctors then offered a choice of either individual therapy or couples therapy in a two-armed clinical research study to treat alcohol use disorders. For that study, women had to be in a committed relationship, but did not need to bring their partner in if they chose individual therapy. Most women in that study chose individual therapy. Women who chose individual therapy were randomly assigned to regular cognitive behavioral therapy (CBT) or female-specific CBT. In CBT, emphasis is placed on the importance of breaking the drinking habit and learning coping skills.
The female-specific treatment also emphasized womens’ rights to care for themselves, and helped them feel more self-confident and less sensitive to what other people thought about them. The treatment provided assertiveness training and helped women address how to deal with a partner who drinks heavily, and with anxiety and depression. Women learned about anger management and how to make connections with sober people who treat them well and don’t abuse them.
While women in both groups showed improvement in their drinking, Dr. Epstein and her colleagues found that women who chose individual therapy were more likely to stick with therapy than those who chose couples therapy.
Currently Dr. Epstein is investigating the effectiveness of female-specific-CBT treatment delivered in women-only groups. She explains, “We want to be able to develop treatments for a broad range of women, which could be integrated into community-based therapy.”
Trauma and Substance Abuse Linked
Many women with substance abuse disorders also suffer from post-traumatic stress syndrome (PTSD), resulting from interpersonal violence, says Denise Hien, PhD, ABPP, who presented data at the meeting about promising treatments for women who suffer from PTSD and substance use disorders. “They drink in response to trauma,” says Dr. Hien, Professor at the City University of New York, and Adjunct Senior Research Scientist at Columbia University College of Physicians and Surgeons in New York.
Dr. Hien compared a type of CBT called “Seeking Safety” for substance abuse and PTSD with a relapse prevention treatment. “Seeking Safety” is a short-term treatment for both trauma and substance abuse in women. Both disorders are treated at the same time by the same clinician. Secondary analyses indicate that trauma therapy may be most effective for women who are also receiving some type of self-help, such as being part of a 12-step group. “If a person is not affiliated with a self-help group, she may actually get worse from trauma therapy alone,” Dr. Hien says.
Last year, she published a study in the American Journal of Psychiatry that found if you treat the PTSD symptoms first, in women who suffer from both substance abuse and PTSD, it led to a reduction in substance abuse. The study found little evidence that treating substance abuse first improved PTSD symptoms. Currently, patients who suffer from both disorders often are not treated for PTSD until they receive addiction treatment and stop using drugs and alcohol. This sequence is based on the assumption that addressing trauma could worsen a person’s substance abuse.
Dr. Hien is also conducting a clinical trial that is examining whether adding the antidepressant sertraline HCI (Zoloft) to trauma therapy benefits women with PTSD and alcohol misuse or alcohol use disorders.