پیگیری مردان و زنان وابسته به کوکائین با اختلال شخصیت ضد اجتماعی

Abstract Long-term outcomes following drug treatment were examined for cocaine-dependent men (N = 453) and women (N = 254) with and without antisocial personality disorder (ASP). In-depth assessments were conducted at treatment intake in 1991–93 and at 1 and 5 years following treatment discharge. Overall, 47.2% of the males and 34.3% of females were diagnosed with ASP using DSM-III-R criteria derived from the Diagnostic Interview Schedule. All groups reduced their cocaine, marijuana, and alcohol use; reduced their levels of psychological distress; and improved in functioning (e.g., employment, arrests, residential status). At Year 5 ASP was associated with an increased likelihood of heavy alcohol use and additional substance abuse treatment among men, whereas women with ASP were more likely to report psychological problems and to receive mental health treatment and other services than either women without ASP or men with ASP. The findings suggest the need to address the specific treatment needs of male and female cocaine abusers with ASP.

. Introduction Both clinical and epidemiological studies have documented high rates of co-occurrence of adult antisocial personality (ASP) disorder and substance use disorders among individuals in drug treatment Alterman & Cacciola, 1991, Flynn et al., 1996, Kleinman et al., 1990 and Rounsaville et al., 1991 and in the general population (Kessler et al., 1996). Studies have also shown that the rates of comorbidity of ASP with substance use disorders differ by gender. Men with ASP are three times as likely to abuse alcohol and five times as likely to abuse drugs as men without ASP. These ratios are even higher for women with ASP compared to women without ASP: 13 times for alcohol and 12 times for drugs (Robins, Tipp, & Przybeck, 1991). Since the rates of ASP among individuals in drug treatment are consistently high, there is considerable interest in the prognostic significance of ASP for drug treatment response. Previous research with male opiate users showed that a diagnosis of ASP predicted poorer outcomes to psychotherapy, although patients with both ASP and depression responded more favorably (Woody, McLellan, Luborsky, & O'Brien, 1985). Antisocial personality disorder has also been associated with higher rates of treatment drop-out among substance abusers in an inpatient dual diagnosis unit (Greenberg, Otero, & Villanueva, 1994) and with poorer outcomes at 1 year after inpatient treatment for alcoholism (Hesselbrock, 1991). The characteristic behaviors and personality traits associated with ASP, such as lack of motivation, disruptiveness, impulsivity, and general disregard for others, are assumed to conflict with the ability to engage in and respond positively to treatment, resulting in lower rates of treatment retention and completion and poorer posttreatment outcomes. Several studies have shown that greater severity of psychopathology and drug use are associated with poorer treatment outcomes among cocaine abusers (Carroll, Power, Bryant, & Rounsaville, 1993), yet findings regarding the relationship of ASP with treatment outcomes for cocaine abusers are mixed. McKay, Alterman, Cacciola, Mulvaney, and O'Brien (2000) showed that a diagnosis of ASP among cocaine-dependent males did not differentiate rates of treatment retention, substance use outcomes, social functioning outcomes, or responses to two types of continuing care interventions over a period of 12 months. Patients with ASP, however, did have more severe medical and psychiatric problems, both before and after treatment. Similarly, Cacciola, Alterman, Rutherford, and Snider (1995) reported no difference in treatment response in several functional domains among cocaine- and/or alcohol-dependent men with ASP over a posttreatment period of 7 months. In another study, patients with and without ASP had similar rates of treatment completion and reductions in drug use following treatment in two therapeutic community conditions that differed in length of inpatient and outpatient treatment over a period of 12 months (Messina, Wish, & Nemes, 1999). These subjects (N = 338) were predominantly heroin and/or cocaine abusers, and about 27% were female. A recent experimental study compared the efficacy of two treatment approaches (cognitive behavioral and contingency management) for cocaine dependence among methadone-maintained patients with and without ASP (N = 108). Patients with ASP performed better in the contingency management condition and had higher rates of posttreatment abstinence for a period of up to 1 year, compared to those without ASP (Messina, Farabee, & Rawson, 2003). Perhaps because of the mixed findings from prior treatment studies of substance abusers with ASP, there is disagreement about the prognostic significance of ASP Brooner et al., 1998 and Brooner et al., 1992. Moreover, previous studies have been limited in the degree to which they can fully address the outcomes of individuals with ASP. First, most studies have assessed posttreatment response for brief periods, usually no more than 1 year. Second, most studies have been conducted with either all-male or predominantly male samples with small sample sizes that have precluded analyses of interactions of gender and ASP. There is reason to believe that cocaine-dependent women and men with ASP may respond differently to treatment, since women with ASP are more likely to have other comorbid psychiatric disorders (e.g., anxiety disorders; Kessler et al., 1994). Further, women with ASP may have more severe drug-use histories and greater severity of symptoms, since the behaviors characteristic of ASP (e.g., criminality, aggression, impulsivity) are considered to be more socially deviant in women than in men. Previous studies of cocaine abusers Griffin et al., 1989, Halikas et al., 1994, Kosten et al., 1993 and Weiss et al., 1997 have shown more severe symptoms and problems in functioning among women than men, and the addition of a diagnosis of ASP may further exacerbate these differences. Moreover, treatment/services utilization may differ for men and women with ASP. Our previous work has shown that a diagnosis of ASP was associated with a history of prior drug-treatment utilization among women, but not men, in drug treatment (Grella & Joshi, 1999). This article presents data from the Drug Abuse Treatment Outcome Studies (DATOS), a multisite prospective study of drug treatment outcomes sponsored by the National Institute on Drug Abuse. We utilized this large-scale study of individuals admitted to community drug treatment programs in the United States in the 1990s in order to address three questions regarding the relationship of gender and ASP to drug treatment outcomes: (1) Are there differences in the characteristics of cocaine-dependent men and women with ASP? (2) Are there differences in rates of drug use and other areas of functioning over a 5-year period for cocaine-dependent men and women with ASP, as compared with cocaine-dependent patients without ASP? (3) Is ASP differentially related to 5-year posttreatment outcomes for men and women? To address these questions, we examine patient characteristics and treatment outcomes across several domains (i.e., substance use, psychological distress, level of functioning), and patterns of treatment and services utilization following the index DATOS treatment episode for four subgroups of patients: men and women, with and without ASP.

. Results First, findings are presented for differences between the four groups on demographic/ background characteristics and in DATOS treatment received. Next, we discuss the main effects and interactions of ASP, gender, and time for each outcome variable. Lastly, we present findings from the multivariate logistic regression models predicting each of the treatment outcomes at Year 5. 3.1. Patient characteristics Overall, 42.6% of the total sample was diagnosed with ASP, with significantly higher rates among men than women (47.2% vs. 34.3%, χ2 [1] = 11.2, p < .001). As seen in Table 1, a greater proportion of individuals with ASP were 30 years of age or younger, and women were younger than men. There was also a gender difference with regard to ethnicity, with a greater proportion of women who were African American. There were no significant differences among groups in marital status or criminal justice status; however, a greater proportion of individuals with ASP had less than a high school degree. Table 1. Demographic/background characteristics and DATOS treatment received by gender and ASPa Variable Men Women Total (N = 707) Log linear/ANOVA results ASP (n = 214) Non-ASP (n = 239) ASP (n = 87) Non-ASP (n = 167) Age, % <20–30 41.1 29.3 62.1 38.3 39.0 A***, G*** 31–40 46.7 56.5 33.3 52.7 49.8 >40 12.2 14.2 4.6 9.0 11.2 Ethnicity, % White 35.1 38.1 21.8 29.3 33.1 G* African American 54.7 49.8 62.1 64.1 56.2 Hispanic 8.9 8.8 9.2 4.8 7.9 Other 1.4 3.4 6.9 1.8 2.8 Married or living as married, % 28.0 36.8 28.7 25.8 30.6 NS Education, % Less than high school 31.8 20.5 39.1 29.3 28.3 A** High school degree or GED 44.4 46.0 42.5 41.9 44.1 Some college 23.8 33.5 18.4 28.7 27.6 Under legal supervision, % 54.2 42.9 43.7 40.4 45.8 NS Psychiatric disorders (lifetime), % Major depressive disorder 13.6 6.3 16.1 12.0 11.0 A* Generalized anxiety disorder 6.5 2.1 5.8 2.4 4.0 A* Heroin dependence 29.0 18.0 19.5 13.8 20.5 A*, G* Alcohol dependence 65.9 56.1 50.6 43.1 55.3 A*, G*** Cannabis dependence 38.3 32.6 25.3 15.6 29.4 A*, G*** Age first used any drug (SD) 13.7 (3.3) 16.1 (4.1) 14.7 (4.8) 17.3 (5.1) 15.5 (4.5) A***, G** Age first used cocaine (SD) 20.3 (5.6) 23.7 (6.7) 20.5 (5.2) 23.1 (6.1) 22.1 (6.3) A*** No. of drugs ever tried (SD) 5.8 (2.1) 5.0 (1.8) 4.9 (1.9) 4.7 (2.1) 5.2 (2.0) A**, G***, AxG* Age at first drug treatment (SD) 28.8 (7.4) 31.5 (7.6) 26.2 (6.1) 30.0 (6.8) 29.7 (7.4) A***, G*** No. of prior drug treatments (SD) 2.1 (3.8) 1.4 (2.7) 2.7 (3.2) 1.9 (3.8) 1.9 (3.4) A**, G* Type of DATOS modality, % LTR 47.7 27.2 47.1 41.3 39.2 A**, G* STI 22.0 39.3 17.2 22.8 27.4 ODF 30.4 33.5 35.6 35.9 33.4 Stayed in treatment for threshold level, % 72.9 64.4 69.0 71.9 69.3 NS a ASP = antisocial personality disorder, LTR = long-term residential, STI = short-term inpatient, ODF = outpatient drug-free treatment, A = main effect of ASP, G = main effect of gender, A x G = interaction of ASP and gender, NS = non-significant. Threshold levels were 90 days or more for LTR and ODF, and 21 days or more for STI treatment. *** p < .001. * p < .05. ** p < .01. Table options Individuals with ASP displayed signs of more severe drug use, with earlier initiation of any drug use, of cocaine use, and of drug treatment, and a higher average number of substances used. In addition, women generally were older at drug use initiation (although there was no difference with regard to initiation of cocaine use), but younger at the age of first drug treatment, as compared with men. There was a significant interaction between gender and ASP for number of drugs ever used, with a greater difference between males with and without ASP. Both men and women with ASP had a higher average number of prior drug treatment episodes than those without. With regard to other psychiatric disorders, individuals with ASP had higher rates of major depressive disorder and generalized anxiety disorder, as well as dependence on alcohol, cannabis, and opiates. Men also had higher rates of dependence on these substances as compared with women. 3.2. DATOS treatment participation A greater proportion of individuals with ASP received treatment in LTR programs (approximately 47%), and fewer were treated in STI programs (about one fifth), as compared to those without ASP. Approximately one third of each group received treatment in ODF programs. Also, women had higher rates of treatment in LTR programs as compared with men. There were no differences, either by gender or ASP, in treatment retention; overall, 69% of the sample stayed in treatment for the modality-specific threshold periods. 3.3. Outcomes across ASP, gender, and time Rates of drug use, psychological distress, social functioning, and treatment/services utilization for men and women, with and without ASP, across time are shown in Table 2 There were significant main effects of ASP for all outcomes, except for stable housing, independent living, mental health treatment, 12-step participation, and use of comprehensive services. There were significant main effects of gender for alcohol use, trouble controlling one's temper, being troubled by emotional problems, employment, mental health treatment, substance abuse treatment, 12-step participation, and use of comprehensive services following treatment. Time was a significant main effect in all of the outcome models. Below, we discuss the differences among the four ASP/gender groups for each of the four outcome domains and interactions among ASP, gender, and time. Table 2. Drug use, psychological distress, level of functioning, and treatment/service utilization (in percent) by gender, ASP, and timea Men Women Total (N = 707) ASP (n = 214) Non-ASP (n = 239) ASP (n = 87) Non-ASP (n = 167) T1 T2 T3 T1 T2 T3 T1 T2 T3 T1 T2 T3 T1 T2 T3 Drug/Alcohol Use Any cocaine use 81.2 45.3 46.7 82.4 35.3 40.2 90.8 52.9 41.4 88.0 27.0 37.7 84.4 38.5 41.7 Weekly cocaine use 67.6 27.1 28.0 66.1 16.6 21.3 78.2 33.7 28.7 71.7 15.3 23.4 69.4 21.6 24.8 Any marijuana use 62.6 33.2 37.4 55.2 22.6 34.9 62.1 35.6 34.5 49.7 17.4 28.7 57.0 26.2 34.1 Heavy alcohol use 47.2 22.0 22.4 40.6 14.2 13.4 32.2 18.4 16.1 34.7 9.0 9.6 40.2 15.8 15.6 Psychological Distress Trouble controlling temper 27.1 12.3 18.7 15.6 5.9 9.2 39.5 20.9 18.4 23.4 12.6 16.8 23.8 11.2 15.0 Suicidal thoughts/attempts 26.8 16.4 16.4 18.4 8.4 10.0 32.2 11.5 18.4 21.6 13.2 16.2 23.4 12.3 14.4 Troubled by emotional problems 63.7 49.8 51.9 47.0 31.7 43.3 65.1 51.7 63.2 58.4 46.1 55.7 57.0 43.0 51.3 Level of Functioning Any arrests 49.2 32.7 22.9 35.8 17.2 16.3 42.3 24.4 16.1 37.1 16.6 16.8 41.1 23.0 18.4 Employment 63.6 73.9 78.0 78.3 77.1 81.5 34.5 42.5 65.5 47.3 53.3 71.3 61.1 66.2 76.1 Stable housing 74.3 81.4 83.6 83.2 86.4 85.8 79.3 83.9 89.7 80.7 84.2 86.2 79.4 84.1 85.7 Independent living 38.7 53.2 60.8 49.8 61.2 65.7 43.7 60.9 71.3 45.1 60.8 71.9 44.6 58.7 66.3 Treatment/Service Utilization Mental health treatment 10.3 15.9 22.4 10.0 12.6 19.7 24.1 28.7 32.2 18.0 20.4 27.0 13.7 17.4 23.8 Drug/alcohol treatment 29.9 14.2 25.7 22.2 12.7 18.0 60.9 24.7 20.7 32.3 20.5 17.4 31.7 16.4 20.5 12-step participation 55.1 38.4 47.7 55.7 33.8 42.1 71.3 47.6 44.8 61.7 43.8 49.1 58.8 39.2 46.0 Comprehensive services n/a 32.1 41.6 n/a 24.9 39.8 n/a 47.1 55.2 n/a 38.3 54.5 n/a 32.9 45.7 ASP χ2(df = 1) Gender χ2(df = 1) Time χ2(df = 2) ASP × Time χ2(df = 2) Gender × Time χ2(df = 2) ASP × Gender χ2(df = 2) Drug/Alcohol Use Any cocaine use 7.8** 1.3 256.5*** 8.2* 8.7* 1.2 Weekly cocaine use 11.5*** 1.0 228.8*** 8.2* 5.3 0.3 Any marijuana use 11.4*** 1.3 144.4*** 7.3* 0.2 0.8 Heavy alcohol use 7.5** 7.6** 101.7*** 5.8* 0.03 0.4 Psychological Distress Trouble controlling temper 10.3*** 8.4** 4.3* 0.5 1.6 2.0 Suicidal thoughts/attempts 7.2** 2.0 35.1*** 0.2 0.9 0.8 Troubled by emotional problems 13.8*** 9.8** 30.8*** 2.0 0.8 1.6 Level of Functioning Any arrests 8.5** 2.0 75.3*** 3.7 0.2 2.3 Employment 9.4** 54.8*** 55.3*** 4.5 11.8** 0.01 Stable housing 0.9 0.6 11.6** 1.9 0.9 2.2 Independent living 2.2 2.3 73.8*** 0.6 3.3 1.7 Treatment/Service Utilization Mental health treatment 3.1 17.4*** 27.0*** 0.6 2.3 0.4 Drug/alcohol treatment 13.9*** 13.6*** 52.2*** 4.6 16.5*** 1.5 12-step participation 0.3 8.4** 58.4*** 4.4 3.3 0.5 Comprehensive services 2.7 21.9*** 21.8 and 1.8b 0.05b 0.01 a ASP = antisocial personality, T1 = pretreatment, T2 = 1-year follow-up, T3 = 5-year follow-up, n/a indicates data not available. Heavy alcohol use is defined as drinking 6 drinks in one sitting at least weekly. Stable housing includes living in a house or apartment vs. unstable, which is in jail, prison, a treatment program, halfway house, hospital, hotel, shelter, or street. Independent living includes living with spouse and/or children or alone vs. living with parents or other family members, being institutionalized, or “other.” Mental health treatment includes inpatient, outpatient, or regular use of prescription medications for emotional problems. Drug/alcohol treatment includes inpatient, residential, outpatient drug-free, or detoxification. Comprehensive services include family, employment, educational, legal, housing, medical check-up, and crisis counseling. All variables refer to the previous 12 months. ** p < .01. *** p < .001. * p < .05. b df = 1 because of reduced number of observations. Table options 3.3.1. Drug/alcohol use Main effects of ASP indicated higher rates of alcohol, cocaine, and marijuana use among individuals with ASP, over time and gender. The only main effect of gender was that males had higher rates of alcohol use across time and diagnostic group. There were significant reductions in cocaine use, marijuana use, and heavy alcohol use from treatment entry to the 5-year followup for all groups. There were significant interactions between ASP and time for cocaine, marijuana, and alcohol use, with higher rates of use among both men and women with ASP. There was a significant interaction between gender and time for use of cocaine, with ASP women having the highest rate of use at treatment admission and men with ASP having the highest rate of use at Year 5. 3.3.2. Psychological distress There were significant main effects for ASP across time for psychiatric symptoms, such as having trouble controlling one's temper, having suicidal thoughts or making suicidal attempts, and being troubled by emotional or mental problems. There were main effects of gender for trouble controlling one's temper and being troubled by emotional problems, with higher rates among women than men. There were also significant reductions in all three psychological measures from pretreatment to Year 5. There were no significant interactions among ASP, gender, and time for any of the measures of psychological distress. 3.3.3. Level of functioning There were significant main effects of ASP across time for arrests and employment, with the ASP group having higher rates of arrest and lower rates of employment. There was a main effect of gender for employment as well as a significant interaction between gender and time on employment, such that women had lower rates of employment at all time points, but greater increases in employment over time. There were significant main effects for time for all four variables in this outcome domain, with a decrease in the rate of arrest and increases in the rates of employment, stable housing, and independent living situations. There were no differences by gender or ASP status in stable housing or independent living over time. 3.3.4. Treatment/services utilization There was a significant main effect of ASP for drug/alcohol treatment, and marginally significant main effects for mental health treatment and use of comprehensive services, with higher rates of use among individuals with ASP. There were main effects of gender for all forms of treatment/services utilization, with women having higher rates of utilization regardless of ASP status. There were significant main effects of time for the four measures of treatment/services utilization, with increases in receipt of mental health treatment from pretreatment to Year 5, as well as in use of comprehensive services from Year 1 to Year 5. There were also decreases in drug/alcohol treatment from pretreatment to Year 5, as well as in 12-step participation. Lastly, there was a significant interaction between time and gender for substance abuse treatment, with a greater decrease in the rate of treatment utilization among women over time as compared with men. 3.4. Outcomes at Year 5 Multivariate analyses were conducted in order to examine the independent contributions and interactions of ASP status and gender on the outcomes observed at Year 5. Separate logistic regression models for each of the dichotomous outcome measures were constructed, controlling for background variables (i.e., age, ethnicity, legal status), pretreatment level of the outcome variable (except for cocaine use, since the sample was selected on the basis of cocaine dependence), and type of treatment modality in DATOS. In the first set of models, gender was entered separately from ASP. In the second set, men with ASP were compared to men without ASP and, similarly, women with ASP were compared to women without ASP. In the last set of models, which consisted of the ASP subgroup only, men with ASP were compared with women with ASP. Therefore, the multivariate models allow for determining the independent and interactive effects of ASP and gender on posttreatment outcomes after other covariates have been taken into account with statistical adjustment. Controlling for ASP, men were less likely to be troubled or bothered by emotional problems, to have an independent living situation, and to have received mental health treatment or other types of comprehensive services in Year 5 (see Table 3). Men were, however, approximately 50% more likely to be employed than women. Among men, those with ASP were about twice as likely as those without ASP to use alcohol heavily and were about 60% more likely to have received substance abuse treatment in the previous year. Among women, those with ASP were nearly twice as likely as women without ASP to be troubled or bothered by emotional problems and approximately three fourths more likely to have received mental health treatment or other comprehensive services within the previous year. Finally, among the ASP subgroup, men were about half as likely as women to report being troubled or bothered by emotional problems or to have received either mental health treatment or comprehensive services in the past year. Table 3. Odds Ratios for gender and/or ASP as predictors of outcomes at 5-year follow-upa Outcome variable in logistic regression model Men vs. womenb (N = 707) OR (95% CI) Men with ASP vs. men without ASP (n = 453) OR (95% CI) Women with ASP vs. women without ASP (n = 254) OR (95% CI) Men with ASP vs. women with ASP (n = 301) OR (95% CI) Any cocaine use NS NS NS NS Any marijuana use NS NS NS NS Heavy alcohol use NS 2.09 (1.32, 3.31)** NS NS Trouble controlling temper NS NS NS NS Suicidal thoughts/attempts NS NS NS NS Troubled by emotional problems 0.58 (0.41, 0.81)** NS 1.90 (1.13, 3.16)* 0.56 (0.32, 0.99)* Any arrests NS NS NS NS Employed 1.49 (1.001, 2.23)* NS NS NS Stable housing NS NS NS NS Independent living 0.66 (0.46, 0.94)* NS NS NS Mental health treatment 0.61 (0.41, 0.90)* NS 1.78 (1.01, 3.11)* 0.51 (0.27, 0.97)* Drug/alcohol treatment NS 1.61 (1.07, 2.42)* NS NS 12-step participation NS NS NS NS Comprehensive services 0.58 (0.41, 0.82)** NS 1.77 (1.08, 2.89)* 0.48 (0.28, 0.83)** ***p < .001. a ASP = antisocial personality disorder, OR = odds ratio, CI = confidence interval, NS = non-significant, All models control for age, ethnicity, DATOS modality, criminal justice status at intake, and pretreatment level of outcome variable, except for pretreatment level of cocaine use, since the sample was selected on the basis of cocaine use. b Includes ASP (1 = yes, 0 = no) as a control variable. ** p < .01. * p < .05.