Older Women and Co-Occurring Disorders

1. California Women, Children & Families (CalWCF) and The American Society on Aging (ASA) Technical Assistance Projects funded by the California Department of Alcohol & Drug Programspresent Older Women and Co-Occurring Disorders Verda Bradley, PhD, LCSW, M.ED

2. Learning Objectives • Recognize the importance of assessment for alcohol and drug use and mental health within the older women population. • Understand older women have unique factors that contribute to the effects of co-occurring disorders. • Understand older women are more vulnerable to depression and may attempt to self medicate with Alcohol and other drugs. • Recognize that COD treatment works.

3. COD Overview

4. Co-occurring disorders is a broad term indicating the simultaneous presence of two independent medical disorders of mental illness and substance use. • Mental disorder is any clinically significant behavior or psychological pattern that is associated with present distress/disability or with significant increased risk of suffering pain, disability, loss of freedom or death.

5. Substance Abuse is a pattern of substance use causing recurrent and significant adverse consequences related to repeated use. • Multiple Vulnerabilities is a term used to describe other psychosocial factors that may exacerbate co-occurring disorders, i.e.., trauma, medical problems, financial problems, relationships and etc.

6. Multiple Vulnerabilities – It can be difficult to Know What is What • AOD use can cause psychiatric symptoms • AOD use can initiate or exacerbate • AOD use can mask psychiatric symptoms • AOD withdrawal can cause psychiatric symptoms • Psychiatric Behaviors can mimic AOD Use Coexistence compromises management of both conditions AND … • Health Problems further complicate matters.

7. Current Cost & Demographic Projections • COD costs accounted for 7.6 percent of all U.S. health care expenditures in 2001, $85 billion for mental health care and $18 billion for substance abuse services • Projections indicate persons over the age of 65 will increase from 13 % to 20 % by the year 2030 • In 2030, older adults with substance abuse or mental illness is expected to more than double to an estimated 15 million individuals

8. Women… • with SMI or AOD disorders have higher levels of health problems than other • with Psychiatric Problems have 3% to 93% chance of having medical problems misdiagnosed or ignored. • What may be even more significant is getting appropriate care.

9. Alcohol Use … • Telescoping Effect - women do not metabolize alcohol as efficiently as men do, and so they develop health problems with lower use in less time—commonly known as “telescoping” of consequences. • When alcohol and prescription drugs are used simultaneously, severe medical problems can result, including alcohol poisoning, unconsciousness, respiratory depression, and sometimes death.

10. Post Menopausal • Those who had less than one drink a day had a 7 percent increased risk of breast cancer compared to teetotalers • Women who drank one to two drinks a day had a 32 percent increased risk, and those who had three or more glasses of alcohol a day had up to a 51 percent increased risk of breast cancer.

11. Normal Brain

12. The Brain on Alcohol

13. Areas of the Brain

14. Limbic System • Bonding/nesting instincts - current research has demonstrated that females, on average, have a larger deep limbic system than males. • This gives females several advantages and disadvantages. Due to the larger deep limbic brain women are more in touch with their feelings, they are generally better able to express their feelings than men. • They have an increased ability to bond and be connected to others (which is why women are the primary caretakers for children - there is no society on earth where men are primary caretakers for children) BUT …

15. Women are Vulnerable • Having a larger deep limbic system leaves women more susceptible to depression, especially at times of significant hormonal changes • Women attempt suicide three times more than men • Women report that they drink or use drugs because they feel bad either psychologically or physically, or because they need to keep going in impossible life circumstances • Depression and shame can interfere with women’s ability to recognize health problems

16. Health Problems • Women with co existing, chronic health problems may discontinue clinically effective treatments because they appear to increase psychiatric symptoms or because self-medication with AOD reduces pain and discomfort faster.

17. Screening for Co-Occurring Disorders

18. Prevention programs • that screen and address risk factors, promote resiliency, and strengthen protective factors can help older adults weather the unique circumstances that contribute to the development and/or deterioration of substance abuse and mental health problems.

19. Screening • Many geriatric cases are not properly identified; and present screening and diagnostic methods for alcohol use disorders lack adequate validation for older persons.

20. Women with COD may Isolate • Women are less likely to drink alone in public places or be visible in the community with alcohol or other drug intoxication: they are less likely to be identified with an alcohol or substance abuse problem; and are less likely to seek treatment. • Many women believe that they are not worthy of feeling better or receiving competent medical treatment, and thus affect the likelihood of their seeking assistance or advocating for appropriate care.

21. 3 Questions for Mental Health: • Have you ever been worried about how you are thinking, feeling, or acting? • Has anyone ever expressed concerns about how you were thinking, feeling, or acting? • Have you ever harmed yourself or thought about harming yourself?

22. 3 Questions for Alcohol & Drug Use (Health Canada Best Practice Report): • Have you ever had any problem related to your use of alcohol or other drugs? • Has a relative, friend, doctor, or other health worker been concerned about your drinking or other drug use or suggested cutting down? • Have you ever said to another person, “No, I don’t have (an alcohol or drug problem,” when around the same time you questioned yourself and felt, maybe I do have a problem?

23. 3 Questions for Trauma/Domestic Violence: • Have you ever been in a relationship where your partner has pushed or slapped you? • Before you were 13, was there any time when you were punched, kicked, choked, or received a more serious physical punishment from a parent or other adult? • Before you were 13, did anyone ever touch you in a sexual way or make you touch them when you did not want to?

24. Scoring • If participant answers two questions Yes (1 mental health and 1 substance abuse or 1 substance abuse and 1 trauma), complete: • GAIN Short Screener (SS) or other assessment tool. Adapted from Collaborative Care Project, Canada and Co-Morbidity Screen, Boston Consortium

25. Considerations for Treatment

26. Appropriate Assessment • MAST-G in packets • Need to know big picture – health, mental health, alcohol/other drug, supports • Strengths and resources • Priorities • Incomplete assessments can prevent meaningful services. • Reassess after detoxification from alcohol and illicit drugs

27. Be Wary of Assumptions and How they Affect Treament • For example, psychiatrists often do not ask women about medication side effects, especially those of a sexual nature (eg, vaginal dryness), although they frequently ask men about ejaculation and other sexual performance issues.

28. Cultural and Age Sensitivity • Asking questions in a respectful manner. • Acculturation • Relationship between client and service • Gender and family roles • Historical experiences and trauma • How do you refer to your client? How do you want her to refer to you?

29. Psychotropic medications • Often a critical component of treatment for mental health disorders BUT … • May also complicate medical diagnoses • Have health related side-effects • Should not be mixed with alcohol • Effectiveness and side-effects may change as women age

30. Quality of Life and Wellness Goals • Housing • Life Purpose • Feeling of Contribution • Close relationships • Case Management

31. Appropriate Services? • Most older women with COD benefit from individual counseling, and case management. Other services may or may not be appropriate - • Detoxification • Medication • Case Management • Therapeutic or Educational Groups • Family Counseling • Recovery Support

32. Challenges to Integrated Care

33. Stigma • When medical treatments are not given to or are not effective in stigmatized groups, clients may be perceived as the source of the problem—relabeled as having psychiatric problems or being noncompliant. • Stigma and discrimination are common for both SMI and AOD disorders.

34. Categorical Treatment • Stigma and discrimination associated with these disorders are exacerbated by categorical treatment. • SMI and AOD problems are often not eligible for insurance reimbursement and are seriously underfunded with public monies as well.

35. Separate Systems • Treatment for more serious, chronic, and disabling mental health and AOD problems is provided through separate systems of care, and streams of public funding, usually on a restricted or limited basis, and often separated from general health services • The differences in their approaches to care and cost reimbursement among AOD, mental health, and health care agencies that many clients do not receive the assessment or assistance they need

36. Working Together • This conference is an example of progress towards breaking down barriers to working together. • Be aware of women’s multiple vulnerabilities • Ask questions • Screen for more than just your specialty service • Listen • Get to know other service providers and resource organizations in your area

37. Summary • What did we accomplish? • Defined COD/Mental illness, Addiction, Multi vulnerabilities, Stigma • Reviewed Women’s Limbic system • New Screening Tool from COJAC • Treatment considerations • Barriers … • Heard the Voices of Women

38. Contact Information: American Society on Aging Patrick C. Cullinane, MS, Director 833 Market St, Ste 511 San Francisco, CA 94103 415-974-9642 * pcullinane@asaging.org www.asaging.org/aod California Women, Children & Families TA Project Children and Family Futures Marta Ortegón Davis, MSW, Program Associate 4940 Irvine Blvd., Suite 202 Irvine, CA 92620 714.505.3525 * calwcf@cffutures.org www.cffutures.org/calwcf