Methamphetamine Use by Incarcerated Women: Comorbid Mood and Anxiety Problems

Women’s Health Issues 17 (2007) 256 –263

METHAMPHETAMINE USE BY INCARCERATED WOMEN: COMORBID MOOD AND ANXIETY PROBLEMS Peter W. Vik, PhD* Department of Psychology, Idaho State University, Pocatello, Idaho Received 28 March 2006; revised 8 September 2006; accepted 22 December 2006

Objective. Methamphetamine’s (MA) impact on psychiatric functioning is not well understood, especially among women. Efforts to understand MA’s impact are complicated by the use of other drugs. The purpose of this study is to untangle the relative contributions of MA versus other drugs on psychiatric symptoms. Method. Incarcerated women (N ⴝ 100) completed diagnostic interviews and a symptom measure to establish psychiatric status. Findings. Nearly all women (83%) had lifetime dependence on >1 drugs. The most common drug of dependence was MA (67%), followed by alcohol (32%), cannabis (19%), and cocaine (15%). Over half met lifetime criteria for an affective disorder (53%), and nearly half (46%) met lifetime criteria for an anxiety disorder. Lifetime dependence on MA and a nonstimulant drug was related to current psychiatric symptoms and lifetime mood and anxiety disorder. Lifetime mood and anxiety disorders were generally unrelated to recent MA use. Conclusion. Findings highlight the impact of MA use on psychiatric presentation among women. Results suggest that MA impacts psychiatric symptoms independent of lifetime psychiatric diagnoses. Of note was the high incidence of drug dependence and mood and anxiety disorders among this sample of incarcerated women from a rural state. Findings imply important treatment implications for women in prison settings.

T

he impact of methamphetamine (MA) on psychiatric symptoms is poorly understood, especially among women. Some evidence reveals acute and prolonged psychiatric effects of MA, including psychotic, anxiety, and mood symptoms (London et al., 2004; Sekine et al., 2001). Consumption of alcohol and other drugs by MA users, however, likely complicates efforts to discern MA-specific effects on mood and anxiety. The surge in MA use by women over the past 2 decades (Anglin, Burke, Perrochet, Stamper, & Dawud-Noursi, 2000; Murray, 1998) highlights the need to untangle the clinical effects of MA and other drug use on mood and anxiety among women. Co-occurrence of psychiatric and drug problems is more common for women than for men (Nelson-

* Correspondence to: Peter Vik, PhD, Department of Psychology, Idaho State University, Pocatello, ID 83209-8112; Phone: 208-2823541; fax: 282-4832. E-mail: [email protected] Copyright © 2007 by the Jacobs Institute of Women’s Health. Published by Elsevier Inc.

Zlupko, Kauffman, & Dore, 1995). Drug abusing women experience emotional distress, depression, powerlessness, and low self-esteem (Wallen, 1992; Zweben, 1996), and diagnoses of posttraumatic stress disorder (PTSD) increase with drug abuse (Grice, Brady, Dustan, Malcolm, & Kilpatrick, 1995). Women in particular encounter psychosocial conditions (e.g., child rearing, financial dependence, education access) that exacerbate psychiatric complications due to MA use (Vik & Ross, 2003). Further, psychiatric symptoms and problems that are concurrent with drug use can negatively impact the clinical course and treatment of substance use disorders among women (Connors, Donovan, & DiClemente, 2002; Myrick, Cluver, & Swavely, 2004; Rosenthal & Westrich, 1999). Given their greater vulnerability to MA use, their increased risk for comorbid psychiatric disorders, and the treatment complications caused by psychiatric problems, it is important to know and describe psychiatric sequelae of MA dependence among women. 1049-3867/07 $-See front matter. doi:10.1016/j.whi.2006.12.004

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Mood and anxiety disorders are common among stimulant users (Brady & Sonne, 1999; Riehman, Iguchi, & Anglin, 2002; Zweben et al., 2004). Reiger et al. (1990) estimated that one third of stimulant-dependent individuals had a comorbid mood or anxiety disorder. Rates were higher in the National Comorbidity Survey, where 39.1% of drug-dependent individuals had a lifetime mood disorder, and 54.4% had a lifetime anxiety disorder (Kessler, Crum, Warner, & Nelson, 1997). Chronic MA use has been related to high rates of depressive symptoms (London et al., 2004; Riehman et al., 2002), greater severity of depressive symptoms and suicidal ideation (Kalechstein et al., 2000; Zweben et al., 2004), and depressive, anxious, paranoid, and psychotic symptoms (Zweben et al., 2004). Of the few published studies describing psychiatric disorders among incarcerated women, it appears that the odds of a lifetime mood disorder were 2– 4 times greater for incarcerated women than for nonincarcerated women (Daniel, Robins, & Wilfley, 1988; Jordan, Schlenger, Fairbank, & Caddell, 1996; Teplin, Abram, McClelland, 1996). Further, these studies of incarcerated women reported rates of depression that ranged from 19 –24%, mania from 3– 4%, dysthymia from 10–13.5%, generalized anxiety disorder from 3.5– 4.6%, PTSD at 35%, and panic from 3– 8.7%. Mood and anxiety disorders, especially PTSD, are significant issues among women in prison. Alternative causal (and noncausal) factors might describe how drug use and psychiatric symptoms are related (Weiss, Najavits, & Mirin, 1998). First, a psychiatric condition might increase vulnerability for drug abuse. Second, acute and protracted drug effects might mimic or produce psychiatric sequelae (e.g., generalized anxiety and depressed mood). Third, drug use can trigger or exacerbate an independent psychiatric vulnerability in a premorbid individual. Finally, the 2 conditions might independently co-occur. Establishing diagnostic independence and temporal precedence is key to studying the relationship between drug use and psychiatric conditions. Women face greater risk for comorbid drug and other psychiatric problems than men, yet research on MA’s unique effects on women’s psychiatric functioning is limited. The present study of incarcerated women addressed this research void by examining the relationship between MA use and psychiatric problems. Data on lifetime mood, anxiety, and drug dependence diagnoses; recent drug use (during the 12 months before incarceration); and current psychiatric symptoms were collected from a sample of 100 incarcerated women. Lifetime mood and anxiety diagnoses were used to predict lifetime drug dependencies and recent drug use. Lifetime MA dependence was used to predict lifetime mood and anxiety diagnoses and current psychiatric symptoms. To establish drug and

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psychiatric diagnostic independence, psychiatric diagnoses were assigned only when criteria were met during a period of protracted (i.e., ⬎3 months) abstinence from all drugs.

Method Participants Participants were 100 women, aged 18 – 49 (mean ⫽ 31.12, SD ⫽ 8.26), who were newly incarcerated in a state prison in Idaho. Eligible women were those targeted for the prison’s Rider Unit. Women assigned to the Rider program are typically first time, nonviolent offenders who will be evaluated for early release and probation in lieu of serving their full, fixed sentences. Demographics of this sample are consistent with inmates on the Rider Unit of this prison and are presented in Table 1. A subgroup of 89 women completed the Brief Symptom Inventory (BSI) to assess current psychiatric symptoms. Of the 11 women who did not complete the BSI, 2 had transferred to another prison before completing the questionnaires, and 9 withdrew from the study after the interview but before completing the questionnaires. Procedure This study was conducted with the approval of the prison’s warden and the human subjects committee at Idaho State University. All inmates consecutively admitted to the prison and assigned to the Rider Unit were invited to participate. Those who agreed were

Table 1. Sample demographics Ethnicity Caucasian Latina Native American Asian Education No degree Graduate Equivalency Degree (GED) High school graduate College degree Marital status Married Long-term partner Divorced or separated Never married Widowed ⱖ1 child Mean number of children (those with a child) Mean number of times previously jailed Charges Possession/delivery Theft/forgery Probation/parole violation Other

80% 16% 3% 1% 30% 30% 36% 4% 27% 9% 33% 30% 1% 85% 2.51 (1.22) 5.03 (6.68) 47% 18% 19% 16%

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entered into the study within 2 weeks of entering the prison. Upon providing informed consent to participate, women were individually administered the 2 diagnostic interviews. After completing both interviews, women completed a questionnaire packet that included the BSI. Women were not compensated for their involvement in the study. Measures Brief Symptom Inventory. The BSI (Derogatis, 1993) is a 53-item self-report measure that assesses current psychological symptom patterns. Previous estimates of internal consistency ranged from .71–.85 depending on the subscale, and test–retest reliability for the global indices ranged from .80 –.90 (Derogatis, 1993). The BSI has demonstrated good predictive validity when screening for psychiatric illnesses, and good convergent validity when correlated with the Minnesota Multiphasic Personality Inventory (Derogatis, 1993). The BSI yields 3 global scores. The Global Severity Index (GSI) indicates general severity of psychiatric symptoms. The Positive Symptom Total (PST) is a count of how many symptoms an individual endorses. The Positive Symptom Distress Index indicates the severity of symptoms endorsed by the respondent. The 9 BSI clinical scales are depression, anxiety, obsessive-compulsive, phobic anxiety, interpersonal sensitivity, hostility, psychoticism, paranoid ideation, and somatization. Customary Drinking and Drug Use Record. The Customary Drinking and Drug Use Record (CDDR; Brown et al., 1998). The CDDR is a structured interview that provides current and lifetime indices of drug use, and renders dependence diagnoses for alcohol and other drugs. The CDDR has demonstrated internal consistency (range, .72–.89), convergent validity (correlations from .68 –.74 with timeline measures, and .56 with the Alcohol Dependence Scale), and diagnostic specificity (Brown et al., 1998). Clinical interview. A brief structured interview was developed for this study. The structure of the interview reflected common approaches to structured diagnostic interviews (e.g., Diagnostic Interview Schedule [Robins, Helzer, Croughan, & Ratcliff, 1981]; Schedule for Affective Disorders and Schizophrenia [Endicott & Spitzer, 1978]), and diagnostic symptoms from the fourth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV; American Psychiatric Association, 1994) were used. This interview assessed lifetime incidence of 3 major mood (major depression, dysthymia, and bipolar affective disorder) and 3 anxiety (generalized anxiety disorder, panic attack, and PTSD) disorders. The interview format applied a gating strategy in which women were first

screened for possible diagnoses and then asked detailed diagnostic questions only for diagnoses for which they screened positive. Specifically, participants were first asked a series of screening questions, based on primary DSM-IV symptoms, to identify potential diagnoses. If the primary symptom of a disorder was endorsed (e.g., sad, blue, despondent, down in the dumps for a period of ⱖ2 weeks), ages of onset and symptom duration were probed and specific DSM-IV criteria were assessed for each potential disorder. Finally, detail was gathered about alcohol and other drug use during episodes of the potential disorder. A diagnosis was assigned only when a psychiatric episode occurred during protracted (ⱖ3 months) abstinence from drug use. This conservative strategy was used to reduce the chance that an apparent episode reflected substance use effects (Reiger et al., 1990; Schuckit, 1994). Advanced clinical psychology doctoral students (4th year) individually administered each interview and coded each participant’s responses. Their coded responses were then used to generate mood and anxiety diagnoses based on DSM-IV criteria.

Results Forty-five percent of these incarcerated women met lifetime criteria for dependence on ⱖ2 drugs, and 38% were dependent on 1 drug. Only 17% were not dependent on any drugs. MA (67%) and alcohol (32%) were the most common drug dependencies in this sample, followed by cannabis (19%) and cocaine (15%). Fewer women had lifetime dependence on opiates (10%) or hallucinogens (9%), and only 2 women were dependent on other amphetamines. Half of the sample met criteria for an affective disorder (53%), and half met criteria for an anxiety disorder (46%). Rates for specific disorders were as follows: major depression (31%), dysthymia (23%), bipolar affective disorder (19%), generalized anxiety disorder (24%), panic disorder (23%), and PTSD (29%). Lifetime Comorbidity Between Mood/Anxiety Disorders and MA Dependence Diagnostic comorbidity can be examined from 2 perspectives: 1) Does a psychiatric diagnosis increase risk for MA dependence? and (2) Does MA dependence increase risk of psychiatric diagnosis? Both approaches were used in this study to tease out the relationships between MA dependence and mood and anxiety disorders. Does Psychiatric Disorder Predict MA Dependence? Women were grouped according to lifetime affective and anxiety diagnoses. Thirty-eight women did not meet lifetime criteria for any affective or anxiety

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Table 2. Specific lifetime drug dependencies according to lifetime affective and/or anxiety disorder Alcohol Dependent

Mood/Anxiety Diagnoses No diagnosis (n ⫽ 38) Mood, no anxiety (n ⫽ 16) Mood ⫹ anxiety (n ⫽ 37) ␹2 (df ⫽ 2; n ⫽ 91) P of type I error

10 4 17

Cannabis Dependent

26.3% 25.0% 45.9%

6 3 8

3.927 .140

Cocaine Dependent

15.8% 18.8% 21.6%

1 2 12

.420 .811

MA Dependent

2.6% 12.5% 26.1%

24 9 34

7.714 .021

63.2% 56.3% 70.3% 1.044 .140

Abbreviations: df, degrees of freedom; MA, methamphetamine.

among the MA Only group (3.7%), compared with not MA dependent (20.7%) and MA ⫹ other drug (27.5%). There was a trend as well for dysthymia to be greater among the MA ⫹ other drug group.

disorder (no diagnosis), 16 met criteria for an affective disorder but not an anxiety disorder (mood, no anxiety), and 37 met criteria for both an affective disorder and an anxiety disorder (mood and anxiety). Nine women had a lifetime anxiety disorder but no affective disorder; these 9 women were removed from this set of analyses rather than try to force them into another category. Lifetime mood/anxiety groups were compared on rates of lifetime alcohol, cannabis, cocaine, and MA dependence (Table 2). Lifetime mood and anxiety was related only to increased rates of cocaine dependence. Table 2 reveals a linear trend between cocaine dependence and mood/anxiety disorders: cocaine dependence was rare (2.6%) for women with no diagnosis, more common for women with a mood disorder (12.5%), and most common for women with both anxiety and mood disorders (32.4%).

Lifetime Mood/Anxiety Predict Recent MA Use Lifetime affective and anxiety disorder was used to predict recent MA use. Thirty women denied MA use during the year, 34 claimed to have used only MA (i.e., no other drugs), and 27 used other drugs in addition to MA. Psychiatric diagnostic groups were the same as were used in Table 2. Results are presented in Table 4. Lifetime mood and anxiety diagnosis did not predict drug use during the year before incarceration. Lifetime MA Dependence Predicts Current Psychiatric Symptoms Of the 96 women who were grouped according to lifetime MA dependence, 85 completed the BSI. The lifetime MA dependence groups were the same as used in Table 3. Groups were compared on the 3 global severity indices and 8 subscales using a 1-way analysis of variance (ANOVA; Table 5). MA dependence was statistically related to 2 of the 3 global indices (GSI and PST) and 4 of the 8 BSI clinical scales (hostility, obsessive-compulsive, paranoid ideation, and psychoticism). Tukey least significant difference post hoc analyses revealed that the MA ⫹ other drugs group scored higher than the other groups on both global indices and on hostility, obsessive-compulsive, and psychoticism scales. The MA ⫹ other drugs group scored higher than the MA-only group on paranoid ideation. Statistical trends were also observed for 3 of the BSI clinical scales (anxiety, depression, and interpersonal sensitivity).

Does MA Dependence Predict Mood/Anxiety Disorder? Three groups were defined by lifetime MA dependence: women not dependent on stimulants of any kind (no stimulant; n ⫽ 29), women dependent only on MA (MA only; n ⫽ 27), and women dependent on MA and at least one other drug (MA ⫹ other drugs; n ⫽ 40). To preserve the integrity of the nonstimulant versus MA comparisons, 4 women dependent on cocaine but not MA were excluded from this set of analyses. ␹2 analyses compared rates of specific lifetime mood and anxiety diagnoses across these 3 drug use groups (Table 3). MA dependence predicted rates of generalize anxiety disorder and PTSD. In both cases, the disorder was most common for the MA ⫹ other drug group. Bipolar affective disorder also differed according to MA dependence: bipolar was uncommon

Table 3. Lifetime methamphetamine (MA) dependence and lifetime affective and/or anxiety disorders Depression No stimulant* (n ⫽ 29) MA only (n ⫽ 27) MA ⫹ other drugs (n ⫽ 40) ␹2 (df ⫽ 2; n ⫽ 96) P

9 9 11

31.0% 33.3% 27.5% .274 .872

Dysthymia 5 4 14

17.2% 14.8% 35.0% 4.634 .099

Bipolar 6 1 11

20.7% 3.7% 27.5% 6.094 .047

GAD 3 5 15

10.3% 18.5% 37.5% 7.415 .025

Panic 5 5 13

17.2% 18.5% 32.5% 2.759 .252

PTSD 5 3 20

17.2% 11.1% 50.0% 14.660 .001

*Four subjects who were not dependent on methamphetamine but were dependent on cocaine were excluded from these analyses.

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Table 4. Lifetime affective and/or anxiety disorder predicts recent methamphetamine (MA) use MA Use 12 Months Before Incarceration Diagnostic Group No diagnosis (n ⫽ 38) Mood, no anxiety (n ⫽ 16) Mood ⫹ anxiety (n ⫽ 37)

None 10 5 15

MA Use Only 26.3% 31.3% 40.5%

16 4 14

42.1% 25.0% 37.8%

MA ⫹ Other Drugs 12 7 8

31.6% 43.8% 21.6%

␹2 (df ⫽ 4; n ⫽ 91) ⫽ 3.977; p ⫽ .400.

The results presented in Table 5 provide evidence that MA dependence exacerbates psychiatric symptom presentation: however, psychiatric diagnostic history might confound the relationship between MA dependence and current psychiatric symptoms. To address this possibility, a series of 2-by-2 ANOVAs was conducted in which lifetime psychiatric diagnosis (mood and/or anxiety versus no diagnosis) and lifetime MA dependence (yes versus no) were used to predict psychiatric symptoms (Table 6). Not surprisingly, main effects for mood/anxiety diagnoses were found for all 3 global indices and 7 of the 8 clinical scales (anxiety, depression, interpersonal sensitivity, obsessive-compulsive, paranoid ideation, phobic anxiety, and psychoticism). Controlling for lifetime psychiatric diagnosis, lifetime MA dependence predicted PST, obsessive-compulsive, and paranoid ideation. There were also trends for MA dependence to predict GSI and psychoticism. None of the interactions were significant.

Discussion Mood and anxiety symptoms and disorders were common among these drug-using incarcerated women.

Prevalence of disorders in this study was slightly higher than in general epidemiologic samples (Regier et al., 1990), but generally consistent with comorbidity studies (Kessler et al., 1994; Kessler et al., 1997; Merikangas et al., 1998). Drug use was extensive among these women, particularly MA. Two out of 3 newly incarcerated women met criteria for a lifetime diagnosis of MA dependence. Such high rates of drug abuse, psychiatric symptoms, and psychiatric conditions underscores the importance of studying the interrelationship between psychiatric presentation and drug use. Although causal conclusions cannot be drawn from this cross-sectional study, these preliminary findings can be used to formulate temporal hypotheses for future studies. The findings suggest that drug dependence influences psychiatric presentation. Lifetime MA dependence predicted both current psychiatric symptoms and lifetime psychiatric diagnoses. In contrast, lifetime mood and/or anxiety disorder had little impact on lifetime drug dependence and did not increase risk of MA use during the year before incarceration. After controlling for lifetime mood and anxiety diagnoses, MA dependence still predicted global psychiatric symptoms as well as obsessive-compulsive and paranoia symptoms. In essence, these findings

Table 5. Current brief symptom inventory psychiatric symptom means (Standard Deviations) by lifetime methamphetamine (MA) dependence groups*

†

GSI PST† PSDI Anxiety Depression Hostility† Interpersonal sensitivity Obsessive-compulsive† Paranoid ideation‡ Phobic anxiety Psychoticism†

No Stimulant n ⫽ 26

MA Only n ⫽ 22

MA ⫹ Other Drugs n ⫽ 37

F (2,82); P

.61 (.57) 18.20 (11.76) 1.63 (.72) .79 (1.00) 1.06 (1.04) .22 (.24) .65 (.73) .56 (.75) .47 (.51) .28 (.55) .61 (.69)

.63 (.51) 18.50 (11.76) 1.53 (.69) .73 (.81) .95 (.72) .12 (.18) .75 (.81) .60 (.57) .82 (.69) .38 (.54) .75 (.66)

1.06 (.61) 28.54 (12.94) 1.86 (.60) 1.22 (.94) 1.47 (.85) .58 (.65) 1.11 (.89) 1.40 (.97) .96 (.70) .42 (.46) 1.20 (.87)

6.31; .003 7.31; .001 1.98; .144 2.59; .081 2.89; .061 8.43; ⬍.001 2.68; .075 10.52; ⬍.001 4.44; .015 .57; .567 5.09; .008

Abbreviations: GSI, Global Severity Index; PST, Positive Symptom Total; PSDI, Positive Symptom Distress Index. No stimulant ⫽ inmates not dependent on any stimulant drug; MA only were those who had lifetime dependence on methamphetamine only. MA ⫹ other drugs were inmates who met diagnostic criteria for methamphetamine and at least one other drug. Right hand column gives results of one-way ANOVAs (2 and 28 degrees of freedom) and probability (p) of type I error. *Clinical cutoffs were based on nonpatient adult female norms. Mean scores in bold typeface exceeded BSI clinical cutoffs. † No stimulant dependence ⫽ MA only ⬍ MA ⫹ Other Drugs. ‡ No stimulant dependence ⬍ MA ⫹ other drug dependence.

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Table 6. Current brief symptom inventory (BSI) psychiatric symptom means (Standard Deviations) predicted by lifetime methamphetamine (MA) dependence and mood/anxiety diagnosis

GSI* PST*† PSDI* Anxiety* Depression* Hostility Interpersonal sensitivity* Obsessive-compulsive*† Paranoid ideation*† Phobic anxiety* Psychoticism*

No MA Dx; No Psych Dx (n ⫽ 11)

Psych Dx; No MA Dx (n ⫽ 15)

MA Dx; No Psych Dx (n ⫽ 20)

MA Dx; Psych Dx (n ⫽ 39)

.27 (.24) 10.00 (7.60) 1.50 (.63) .15 (.25) .62 (.61) .18 (.24) .23 (.28) .17 (.31) .18 (.23) .02 (.06) .38 (.51)

.63 (.51) 24.20 (10.12) 1.72 (.78) 1.26 (1.09) 1.38 (1.18) .25 (.24) .97 (.81) .84 (.85) .68 (.55) .48 (.67) .79 (.78)

.43 (.40) 14.00 (11.59) 1.35 (.69) .36 (.47) .72 (.61) .22 (.44) .45 (.67) .58 (.81) .42 (.62) .11 (.28) .47 (.46)

1.14 (.55) 30.33 (10.56) 1.94 (.54) 1.38 (.90) 1.56 (.79) .50 (.61) 1.24 (.85) 1.37 (.87) 1.15 (.59) .56 (.51) 1.33 (.81)

Abbreviations: Psych Dx, lifetime mood or anxiety diagnosis; MA Dx, lifetime MA dependence diagnosis; PST, Positive Symptom Total; PSDI, Positive Symptom Distress Index. Scores in bold typeface exceeded BSI clinical cutoffs. Clinical cutoffs were based on nonpatient adult female norms. *Main effect, Psych Dx ⬎ No Psych Dx. † Main effects, MA Dx ⬎ Not MA Dx: PST (F[1,81] ⫽ 4.05, p ⫽ .048, sr2 ⫽ .031); obsessive-compulsive (F[1,81] ⫽ 5.76; p ⫽ .019, sr2 ⫽ .054); paranoid ideation (F[1,81] ⫽ 6.87; p ⫽ .01; sr2 ⫽ .058); GSI (F[1,81] ⫽ 3.34; p ⫽ .071; sr2 ⫽ .028); psychoticism (F[1,81] ⫽ 3.407; p ⫽ .069; sr2 ⫽ .031).

suggest that MA dependence exacerbates psychiatric distress among incarcerated women; the findings offer little evidence that women initiated MA use to manage or cope with mood and anxiety symptoms. The increased risk of a mood or anxiety disorder among MA-dependent women raised an important question about the independent effects of MA dependence and mood/anxiety diagnosis on current psychiatric symptoms. Namely, the association between MA dependence and current psychiatric symptoms might have been an artifact of mood or anxiety disorders. To address this question, both lifetime MA dependence and lifetime mood/anxiety disorders were tested as predictors of current psychiatric symptoms. Findings supported the role of MA dependence as an independent predictor of psychiatric symptoms; however, an interesting shift in specific symptoms associated with MA was observed. Whereas hostility, obsessive-compulsive, paranoid, and psychotic symptoms were related to MA dependence when not controlling for psychiatric history, only obsessive-compulsive symptoms and paranoid ideation remained associated with MA dependence after controlling for history of mood and anxiety disorder. The implication of this finding is that mood, anxiety, and interpersonal complaints by MA users may indicate presence of an independent (i.e., not drug- or withdrawal-induced) mood or anxiety disorders. In contrast, MA dependence may evoke disordered thinking (obsessions and paranoia) among incarcerated women. These distinctions warrant further research. The present findings revealed higher lifetime rates of pathology than previous studies (Daniel et al., 1988; Jordan et al., 1996; Teplin et al., 1996). Only PTSD rates

were similar between this study (29%) and the rates reported by Teplin et al. (35.1%). Quite possibly, the higher rates of psychopathology found in this current study reflected changes in the demographics of incarcerated women, with more women entering prison for drug dependence and abuse than in the past. In the prior studies, abuse of or dependence on a drug other than alcohol ranged from 26 –72%; in the present sample, 83% were dependent on ⱖ1 drugs. Given the historical research emphasis on substance use by men, it is important to learn more about psychiatric comorbidity of women who use MA. When developing services, planners must consider treatment and sociocultural issues relevant to women (Connors et al., 2002; Ramlow, White, Watson, & Leukefeld, 1997; Vik & Ross, 2003; Zweben, 1996). Furthermore, because comorbid psychopathology impacts the clinical course of substance use disorders (Rosenthal & Westrich, 1999), treatment efforts must address the psychiatric presentation of drug abusing women. Prisons are not immune to this responsibility; prison may be a woman’s first exposure to drug abuse treatment (Powis, Griffiths, Gossop, & Strang, 1996; Vik & Ross, 2003). The present findings document the salience of mood and anxiety symptoms among stimulant-dependent incarcerated women. The results have important implications for effective drug abuse treatment. High levels of affect, interpersonal intensity, and confrontation that characterize traditional treatment approaches are likely to overwhelm incarcerated women who are experiencing severe psychiatric symptoms in addition to coping with prison life. Confrontational approaches are therefore ill advised, whereas slower, structured, and less rigid treatment

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approaches will likely benefit stimulant-dependent women with comorbid anxiety or affective problems (Connors et al., 2001). The results of this study must be regarded as preliminary. Most notably, the small size and the geographic restriction of the sample limit generalizability of the findings. Additionally, methodologic issues necessitate some caution when interpreting and generalizing these findings. First, this study lacked collateral diagnostic information to corroborate women’s interview responses. Procedures were implemented, however, to increase the accuracy of these self-reports. Data were based on interview as well as questionnaire responses (multimodal method); some interview questions were reworded and repeated to detect inconsistencies in responses, and participants were repeatedly reminded and reassured of the confidentiality, and ultimate anonymity, of their responses. Such procedures have been shown to enhance the reliability of self-report substance abuse assessments (Babor & Del Boca, 1992; Del Boca & Noll, 2000). Second, the quasi-experimental design of this study limits causal conclusions regarding direct effects of MA use on psychopathology and vice versa. Uncontrolled, third-variable effects cannot be ruled out as explanations for the differences observed between the groups. Finally, the ethnicity of prison-incarcerated women in Idaho does not reflect national rates of ethnic minority incarceration. Although the present sample overrepresents ethnic minority women relative to Idaho’s predominantly Caucasian population, this “overrepresentation” does not reflect national incarceration rates of minorities. Specifically, the absence of AfricanAmerican women limits generalization of findings to incarcerated groups that include African-American women. Despite these limitations, these data yield important preliminary information that can guide and inform future study of psychopathology among MA-dependent women. Important future research on MA-dependent women should address issues such as symptom course and resolution, diagnostic implications of symptom presentation, and psychosocial and sociocontextual implications for treatment. Results of this and future studies are important for informing policy and programming efforts for women while in prison, and guide development of optimal postrelease support and intervention resources.

Acknowledgments Funded by a Humanities and Social Science grant from Idaho State University, awarded to Peter Vik, PhD. Appreciation is extended to Bona Miller, Dan Copeland, and David Brasuel for assistance establishing this project at the prison, and to Heather Nash, PhD, and Kayleen Islam-Zwart, PhD, for data collection.

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Author Description Peter W. Vik received his PhD in clinical psychology from the University of Colorado at Boulder. He completed a predoctoral internship and postdoctoral fellowship in the department of psychiatry at the University of California, San Diego School of Medicine. He is currently a professor of psychology at Idaho State University.