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40]

64 Original article

Psychiatric and social profile of recovering substance-

dependent women
Magd S. Abola, Rania Mamdouha,b, Sherine El Mekawya, Sally El Sheikhc
a
Addiction Unit, Psychiatry Department, School
of Medicine, Cairo University, Cairo, Egypt,
b
Serenity Girls Center for Psychiatric and
Addiction Management, Mokattam, cKasr Al
Maadi Center for Addiction, Maadi, korniche
Correspondence to Rania Mamdouh, MD, MSc
Psychiatry, Mokattam, strret 19 from street 9,
villa 587, PO box 11571. Mob: 01141770072;
e-mail: rania.mamdouh.rm@gmail.com
Received 13 August 2018
Accepted 6 September 2018
Egyptian Journal of Psychiatry 2019,
40:64–73
Objectives
The objective of this article is to estimate the presence of psychiatric disorders
among a group of recovering substance-dependents female patients and to assess
the degree of social competence and support of the recovering substance-
dependent women throughout the process of recovery.
Patients and methods
A total of 30 recovering substance-dependent women were selected as
consecutive samples from private hospitals, private clinics, and private
rehabilitation centers in Greater Cairo. Moreover, 30 controls were included who
were nonsubstance-dependent volunteer women. All participants gave written
consent and were subjected to the following interviews, assessments, and
investigations: informed consent, Structured Clinical Interview for DSM axis I,
Addiction Severity Index for cases, Social Support Questionnaire, Social
Competence Scale, and urine sampling for cases.
Results
Most recovering substance-dependent women were single, mostly divorced, and
unemployed. Benzodiazepines were the most common substance of abuse
followed by opiates and alcohol. The period of sobriety was 6 months to 1 year
in half of the cases. The addiction severity index revealed most cases had severe
drug and alcohol use, severe psychiatric problems, and severe problems in their
social relationships owing to drug dependence, and approximately half of the cases
had severe medical and legal problems owing to drug dependence. Most of the
recovering substance-dependent women showed low social competence and had
limited to fair level of social support in their recovery. All recovering substance-
dependent women had a psychiatric diagnosis. Major depressive disorder and
posttraumatic stress disorder are the two most common psychiatric disorders found
in recovering substance-dependent women.
Conclusion
There is a high prevalence of psychiatric disorders among recovering substance-
dependent female patients. Their social competence is low, and they tend to have
limited to fair social support throughout the process of recovery.

Keywords:
addiction, competence, dependence, females, recovery, social support, substance, women
Egypt J Psychiatr 40:64–73
© 2019 Egyptian Journal of Psychiatry
1110-1105

250 million people, equivalent to ∼4% of the global

Introduction
population aged 15–64 years. Of that number, as
Substance dependence is as much a disorder of the
many as 38 million people are drug dependent
brain as any other neurological or psychiatric illness.
[United Nations Office on Drug and Crime
The worldwide effect of the production and
(UNDOC), 2009]. The National Research on
consumption of illicit drugs is one of the gravest
Addiction Program conducted in Egypt in 2009
problems facing societies and governments today. It
revealed that the prevalence of substance misuse in
takes the form of disease, crime, corruption, political
Egypt was 9.6% of the population and 1.6% are
and social instability, and the erosion of many values
substance dependents. The results also showed that
that ordinary people take for granted as part of a
13.2% of men misused substance in comparison
dignified and secure life. Substance-dependence
with 1% of women, which makes the approximate
treatment needs a comprehensive, multidisciplinary
approach including both pharmacological and
psychosocial interventions (Commission of the
European Communities, 2006). The World Drug This is an open access journal, and articles are distributed under the terms
of the Creative Commons Attribution-NonCommercial-ShareAlike 4.0
Report of the United Nations Office on drug License, which allows others to remix, tweak, and build upon the work
control and crime prevention in 2009 estimates the non-commercially, as long as appropriate credit is given and the new
total number of people using illicit drugs at upward of creations are licensed under the identical terms.

© 2019 Egyptian Journal of Psychiatry | Published by Wolters Kluwer - Medknow DOI: 10.4103/ejpsy.ejpsy_17_18
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ratio 13 : 1 (National Research of Addiction, Egypt,
2009). A total of 15.8 (12.9%) million women
aged 18 years or older have used illicit drugs in the
past year (SAMHSA, 2004). Although the rates of
substance abuse among adolescent girls remain
somewhat lower than for their male counterparts,
substance use remains a significant but under-
researched problem among many young girls (Van
Etten et al., 1999).
Research had shown that a woman’s family
background has an important influence on
substance misuse. The behavior of other family
members can influence a woman’s own behavior;
therefore, research has shown that having a family
background of heavy drinking or drug misuse can
increase the likelihood of a woman having problems
with substance misuse herself [National Institute on
Alcohol Abuse and Alcoholism (NIAAA), 1990].
Women can become addicted quickly to certain
drugs, such as (crack) cocaine. Therefore, by the
time they seek help, their addiction may be difficult
to treat. Women who use drugs often have other
serious health problems, sexually transmitted
diseases, and mental health problems, such as
depression. Many women who use drugs have had
troubled lives. Studies have found that at least
70% of women drug users have been sexually
abused by the age of 16 years. Most of these
women had at least one parent who abused alcohol
or drugs. Often, women who use drugs have low
self-esteem, little self-confidence, and feel
powerless. They often feel lonely and are isolated
from support networks [National Institute on Drug
Abuse (NIDA), 2006]. The prevalence of psychiatric
disorders is at least doubled in the presence of
substance dependence. The relation between
psychiatric comorbidity and substance dependence
might be related to that one of them causes the
other or both substance dependence and psychiatric
disorders occur at the same time (Hamdi et al., 2009).
Moreover, comorbid psychiatric symptoms
complicate treatment of drug dependence and are
associated with higher rates of relapse following
completion of substance use treatment programs
(Regier et al., 1999). Substance-dependent women
were significantly more likely than men to have
experienced a major depressive episode, have
dysthymia (Kessler et al., 1994), and present with
behaviors consistent with borderline personality
disorder [American Psychiatric Association (APA),
1994]. Of all the anxiety disorders, posttraumatic
stress disorder (PTSD) is viewed as a key obstacle
to improving substance-dependence treatment
Psychiatric and social profile Abol et al 65
outcome among women (Breslau et al., 1991,
1997a, 1997b; Kessler et al., 1995).
Women are often not well supported by partners,
family, and others in their recovery efforts compared
with men. Inadequate referral systems and lack of
appropriate services present additional barriers for
those women who do seek assistance (Wilsnack and
Wilsnack, 2003).
Social support for abstinence has been found to be
associated with positive treatment outcome among
drug court participants. Different types of social
support from family, friends, and significant others
influence women’s treatment and recovery.
Specifically, emotional, practical, informational,
financial, and socializing supports were assessed
using the Social Support Behaviors Scale (Rogers
and McMillin, 1989).
Patients and methods
Research design
This research is a case–control study. Each participant
was subjected to psychometric tests to assess the severity
of addiction status in cases, psychiatric health, social
competence level, and the social support degree.
Patients
The study was carried out on 60 participants who were
classified into cases and controls:
Cases included 30 recovering substance-dependent
women who were selected as consecutive samples
from private hospitals, private clinics, and private
rehabilitation centers in Greater Cairo during the
period from November 2009 till April 2010.
Controls included 30 nonsubstance-dependent
volunteer women. They were selected by snow
balling from relatives of both groups.
Inclusion criteria included being of Egyptian
nationality, aged between 18 and 45 years old,
accepting to participate in the research by a written
consent, recovering psychoactive substance dependents
for at least 6 months for case participants, and known
to be free from psychiatric disorders and psychoactive
substance dependency for controls.
Exclusion criteria included mental subnormality,
organic brain syndromes, any history of intake
during the last 6 months for case participants, and a
history of known psychoactive substance dependency
for controls.
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66 Egyptian Journal of Psychiatry, Vol. 40 No. 2, May-August 2019
Methods and procedures
All participants gave written consent and were subjected
to the following interviews, assessments, and
investigations: informed consent, Structured Clinical
Interview for DSM (SCID) axis I, Addiction Severity
Index (ASI) for cases, Social Support Questionnaire,
Social Competence Scale, and urine sampling using
Drug Screening Strips applied to cases for at least
every month during the first 6 months of recovery and
just before the research study. The clinical interview and
psychological assessments were performed individually
by the researcher.
Structured clinical Interview for DSM-IV axis I disorders
(First et al., 1997)
SCID-I is a semistructured interview used to determine
Diagnostic statistical manual IV (DSM-IV) axis I disorders
(major mental disorders). There are many published
studies in which the SCID was the diagnostic
instrument used. Major parts of the SCID had been
translated into other languages, including Danish,
French, German, Greek, Hebrew, Italian, Portuguese,
Spanish, Swedish, Turkish, Zulu, and Arabic.
Addiction severity index (Mc Lellan et al., 1992)
The ASI is a semistructured interview designed to
provide a multidimensional assessment of problems
presented by patients with substance use disorders to
guide initial treatment planning and to allow monitoring
of patient’s progress over time. It is designed for use in
inpatient and outpatient alcohol and drug abuse
treatment settings. It gathers information on seven
functional areas often affected by medical status,
employment and support, drug use, alcohol use, legal
state, family and social status, and psychiatric status.
Each section includes questions about the frequency,
duration, and severity of problems over the patient’s
lifetime and in the past 30 days.
Social competence questionnaire (Sarason and
Sarason, 1985)
The questionnaire was designed to measure the level of
the social competence in a sample of teenagers and
adults. It was translated into Arabic by Abd El-Kerim
(1990). The results of the questionnaire had proved to
be an indicator of the psychological well-being of an
individual by measuring how competent he/she is in
the society
Social support inventory (Timmerman et al., 2000)
The items are scored on a five-point scale: 1=much too
little support, 2=too little support, 3=enough support,
4=too much social support, and 5=much too much
support. Three global categories can be interpreted
as follows: 1=much dissatisfaction with support,
2=dissatisfaction with support, and 3=satisfaction
with support. The inventory consists of six subscales:
everyday emotional support (four items), social support
by problems (eight items), informative support (four
items), instrumental support (seven items), social
companionship scale (five items), and the final
subscale, esteem support (six items), and another
eight items that are not part of a subscale. A total
measure of social support can be obtained by
summation of all 42 items.
The scale was translated into Arabic and prepared,
validated, and standardized by the research hospital
psychologist and research team.
Statistical analysis
Contingency table
A contingency table is a way of summarizing the
relationship between variables, each of which can
take only a small number of values. It is a table of
frequencies classified to the values of the variables in
question.
A contingency table is used to summarize category
data. It may be enhanced by including the percentages
that fall into each category.
χ 2 test of association
The χ 2 test of association allows the comparison of two
attributes in a sample of data to determine if there is
any relationship between them.
The idea behind this test is to compare the observed
frequencies with the frequencies that would be expected
if the null hypothesis of no association/statistical
independence was true. By assuming the variables are
independent, we can also predict an expected frequency
for each cell in the contingency table.
If the value of the test statistic for the χ 2 test of
association is too large, it indicates a poor agreement
between the observed and expected frequencies, and
the null hypothesis of independence/no association is
rejected when value less than 0.05 was used.
Results
Table 1 shows that the age of 80% (n=24) of the cases
ranged between 20 to 35 years, whereas the age of
16.7% (n=5) of the controls ranged from more than
30–35 years. Half of the cases (50%, n=15) were
divorced compared with 3.3% (n=1) of the controls.
Most cases (63.3%, n=19) and half of the controls
(50%, n=15) were highly educated, but the difference
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Psychiatric and social profile Abol et al 67

Table 1 Distribution of demographic data

Demographic data Cases no. (N=30) [n (%)] Controls no. (N=30) [n (%)] Total no. (N=60) [n (%)] P value
Age range (years)
<20 0 (0) 4 (13.3) 4 (13.3) 0.01
20–30 13 (43.4) 12 (40) 25
30–35 11 (36.7) 5 (16.7) 16
>35 6 (20) 9 (30) 15
Marital status
Single 8 (26.7) 11 (36.7) 19 0.01
Married 7 (23.3) 18 (60) 25
Divorced 15 (50) 1 (3.3) 16
Educational level
Primary school 0 (0) 1 (3.3) 1 0.205
Preparatory school 2 (6.7) 2 (6.7) 4
Secondary school 9 (30) 12 (40) 21
High education 19 (63.3) 15 (50) 69
Occupation
Working 14 (46.7) 22 (73.3) 36 0.000
Not working 16 (53.3) 8 (26.7) 24
P value less than 0.05 is significant. Bold values means significant values differences between both groups. There was a significant
difference in the cases group between the women aged from 20 to 35 who were representing the majority of the case group. The number
of divorced women in case group is significantly higher than the control group. The number of married women in case group is
significantly lower than the control group. The number of not working women in case group is significantly higher than the control group.

Table 2 Details of substance history Table 3 Types of substances most commonly used according
to addiction severity index
n (%)
Type of substance most commonly used n (%)
Age of onset of substance intake in years
<15 1 (3.3) Cannabis 12 (19.7)
15–25 24 (80) Narcotic analgesic (tramadol) 3 (4.9)
>25 5 (16.7) Benzodiazepines 20 (32.7)
Substance of onset Alcohol 5 (8.1)
Alcohol 7 (23.3) Opiates 18 (29.5)
Cannabis 16 (53.3) Cocaine 3 (4.9)
Narcotic analgesics (tramadol) 0 (0)
Benzodiazepines 7 (23.3) years, representing 46.7% (n=14) of the cases, and 50%
Duration of substance intake (years) (n=15) of the cases had been sober from 6 months to 1
<5 4 (13.3) year compared with 6.7% (n=2) who had been sober for
5–10 12 (40) more than 5 years.
10–15 14 (46.7)
>15 0 (0) All cases (100%, n=30) received the same type of
Period of sobriety
treatment in the form of hospitalization and going
6 months–1 year 15 (50)
through twelve-step facilitation.
1–5 years 13 (43.3)
>5 years 2 (6.7)
Type of treatment Table 3 shows that benzodiazepines were the most
Hospitalization 30 (100) commonly used substance (32.7%), followed by opiates
Twelve-step facilitation 30 (100) (29.5%) and alcohol (8.1%).
Rehabilitation 18 (60)
Table 4 shows that 40% (n=12) of cases had severe
was not statistical significant. Almost half of the cases medical deterioration and 53.3% (n=16) had mild
(53.3%, n=16) were not working, whereas 73.3% occupational deterioration. Most cases (90%, n=27)
(n=22) of controls were working. showed severe drug and alcohol use, more than half of
the cases (53.3%, n=16) had severe problems in their
Table 2 shows that 50.0% (n=15) of cases started social relationships owing to substance dependence,
taking drugs at the age ranging from 15 to 20 years, 66.7% (n=20) of the cases had severe psychiatric
and 53.3% (n=16) of cases used cannabis as their drug problems owing to substance dependence, almost
of onset. A large proportion of cases were dependent on half of cases (56.7%, n=17) had mild family history
substances for a period ranging between 10 and 15 of alcohol and drug use and 30% (n=9) of the cases
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68 Egyptian Journal of Psychiatry, Vol. 40 No. 2, May-August 2019

Table 4 Distribution of the case group according to the addiction severity index
Addiction Medical Occupational Drug and Social Psychiatric Family history of drug Legal
severity status [n deterioration [n alcohol use [n relationships state [n (%)] and alcohol use [n (%)] state [n
index (%)] (%)] (%)] [n (%)] (%)]
Mild 6 (20) 16 (53.3) 0 (0) 0 (0) 2 (6.7) 17 (56.7) 5 (16.7)
Moderate 12 (40) 11 (36.7) 3 (10) 14 (46.7) 8 (26.7) 11 (36.7) 16 (53.3)
Severe 12 (40) 3 (10) 27 (90) 16 (53.3) 20 (66.7) 2 (6.7) 9 (30)

had severe legal problems owing to substance Table 5 Distribution of the studied groups according to the
dependence. social competence scale
Social competence scale Cases [n (%)] Controls [n (%)]
Table 5 shows a statistical significant difference High 9 (30.0) 30 (100.0)
between cases and controls regarding social Low 21 (70.0) 0 (0)
competence. Overall, 70% (n=21) of cases had low Total 30 (100.0) 30 (100.0)

social competence compared with no controls (n=0), χ 2=56.182. P value=0.00 (<0.05) significant.
and only 30% (n=9) of cases had high social
competence compared with controls, where all Table 6 Distribution of the studied groups according to the
participants (100%) had high social competence. social support
Social support Cases [n Controls [n Total [n
questionnaire (%)] (%)] (%)]
Table 6 shows a statistically significant difference
between cases and controls regarding social support. Limited 13 (43.3) 0 (0) 13 (21.7)
Overall, 43.4% (n=13) of cases had limited level of Fair 15 (50.0) 0 (0) 28 (46.7)
More than fair 2 (6.7) 30 (100.0) 49 (54.4)
social support compared with none of the controls
Total 30 (100.0) 30 (100.0) 90 (100.0)
(0%), who all showed high level of social support.
χ 2=24.985. P value=0.00 (<0.05) significant.

Table 7 shows that 16.7% (n=5) of cases had bipolar I
disorder, 33.3% (n=10) had major depressive disorder,
and 30% (n=9) had PTSD compared with none of the
controls (0%) who had these disorders. The table also
showed that 100% of cases had psychiatric disorders in
their recovery process compared with none of the
controls (0%).
Discussion
The aim of this study is to estimate the presence of
psychiatric disorders among recovering substance-
dependent women, as well as to assess the degree of
social competence and social support.
Most controls (60%, n=18) were married compared with
only seven (23.3%) cases, and also 50% (n=15) of
recovering substance-dependent women were
divorced. The finding of this study was consistent
with the study done by Snell and Morton (1991) who
stated that the effect of drug abuse was enormous for
women during addiction, treatment and also through
recovery. Under the influence of drugs, women lose their
spouses, their children, and their lives.
A huge body of literature supports the findings that
women may not be well supported by their family, peers,
and partner compared with men or nonsubstance-
dependent women, and they face many barriers to
enter treatment (Astley et al., 2000).
Differences in rates of occupation between cases and
controls were statistically significant in the direction
denoting that recovering females are the least working
compared with controls.
This finding was consistent with Wickizer (2000) who
compared between the work status, job skills, and job
readiness between recovering substance-dependent
women and nondependent women. The study found
that the percentage of women who worked after
treatment program was only 10% compared with
nonsubstance-dependent women, which was 42%.
Overall, 50.0% of the recovering substance-
dependent women started taking drugs at the age
ranging from 15 to 20 years. This is consistent with
the Situation Analysis Report of Drug Abuse in Egypt,
which found that the age of initiating drug use in Egypt
is usually from 15 to 20 years old [The World Health
Organization/East Mediterranean Regional Office,
Cairo (WHO/EMRO), 2005].
The findings are also consistent with the study of
Abdel-Wahab (2003), in which it gathered
information on drugs of onset of abuse and those
used at the terminal destinations of drug addiction
in Egypt and reported that cannabis and narcotics are
mostly the drugs of onset used in Egypt. It is also
consistent with the results of a study done by the
Ministry of Health and Population that confirmed
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Table 7 Distribution of the studied groups according to Structured Clinical Interview for DSM axis I disorders
SCID Cases [n (%)]
Bipolar I disorder 5 (16.7)
Dysthymic disorder 2 (6.7)
Generalized anxiety disorder 2 (6.7)
Major depressive disorder 10 (33.3)
Obsessive compulsive disorder 2 (6.7)
Posttraumatic stress disorder 9 (30.0)
No psychiatric diagnosis 0 (0)
Total 30 (100.0)
SCID, Structured Clinical Interview for DSM Axis I Disorders. χ 2=40.906. P value=0.00 (<0.05) significant.
an increase of cannabis abuse in Egypt and stated that
the onset of drug abuse had decreased from the age of
25 years to the age of 15 years (CAPMS-Egypt, 2006).
Overall, 46.7% (n=17) of the cases were dependent on
drugs for a period ranging from more than 10 to 15
years. The duration of abuse for all the participants
ranged from 1 to 30 years, whereas the mean duration
was 9.5±6.6 years (Hafeiz, 1995).
Moreover, 50% (n=15) of cases had been sober from 6
months to 1 year, assuming the social and psychological
barriers recovering women face in our society to
complete recovery and stay sober. Of the cases,
100% (n=30) had been hospitalized, followed by
100% (n=30) who had taken the 12-step program
and 60% (n=18) who had been through rehabilitation.
This is consistent with Vaillant (1998) and American
Society of Addiction Medicine (ASAM, 2003)
who support that the modes of treatment mostly
used by substance-dependent patients are hospital
detoxification, followed by short stay in hospital and
relapse prevention programs, and the last treatment
option used by patients was inspirational group
membership and therapeutic communities (Vaillant,
1998; Graham and Mayo-Smith, 2003).
Benzodiazepines were the most commonly used
substance by cases (32.7%), followed by opiates
(29.5%) and alcohol (8.1%), which was consistent
with the studies done by Amodei et al. (1996) and
Jorm et al. (2000) that stated that women were more
likely than men to be prescribed benzodiazepines and
sleeping pills for nonmedical reasons such as coping
with grief or stress. They were prescribed these drugs
when adjusting to natural reproductive processes such
as menses, pregnancy, childbirth, and menopause,
which may cause pain and discomfort and interfere
with life events. Because of the multiple roles carried
out by many women in labor and domestic work they
perform, it was found consistent with the studies done
Psychiatric and social profile Abol et al 69
Controls [n (%)] Total [n (%)]
0 (0) 5 (8.3)
0 (0) 9 (15.0)
0 (0) 19 (31.7)
0 (0) 10 (16.7)
0 (0) 7 (11.7)
0 (0) 9 (15.0)
30 (100.0) 1 (1.7)
30 (100.0) 60 (100.0)
by Amodei et al. (1996) and Jorm et al. (2000), which
stated that women were more likely than men to be
prescribed benzodiazepines and sleeping pills for
nonmedical reasons such as coping with grief or
stress. The findings of the study correspond to the
study done by Abdel-Gawad (2002), which noted that
most of heroin users would use opioid analgesics such
as tramadol as a replacement drug in case heroin is not
available, or they may use tramadol as an analgesic
during their trials for self-abstinence (self-medication)
from heroin.
Regarding the ASI, all candidates were physically
deteriorated owing to substance dependence from
mild to severe form. The finding is consistent with
the studies which indicate that major health
consequences of opioid use include higher risk of
premature death and, when opioids are injected,
increased risk of blood borne infections such as HIV
and hepatitis B and C [The World Health
Organization (WHO), United Nations Office on
Drugs and Crime (UNDOC), UNAIDS, 2004b].
Individuals with opioid dependence who often inject
drugs of unknown potency and quality − in conjunction
with other substances − frequently experience overdose
with high risk of death. Longitudinal studies suggest
that ∼2–3% of them die each year. The mortality rate
for dependent heroin users is between 6 and 20 times
greater than that expected for those in the general
population of the same age and sex [The World
Health Organization (WHO), United Nations
Office on Drugs and Crime (UNDOC), UNAIDS,
2004c].
Substance dependence in this study was accompanied by
occupational deterioration ranging from moderate to mild
degrees in all cases. The study finding is consistent with
studies that indicate that substance dependence results in
significant costs to society through unemployment,
homelessness, family disruption, loss of economic
productivity, social instability, and criminal activities
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70 Egyptian Journal of Psychiatry, Vol. 40 No. 2, May-August 2019
[The World Health Organization (WHO), United
Nations Office on Drugs and Crime (UNDOC),
UNAIDS, 2004b].
Most cases (90%, n=27) had severe use of drugs and
alcohol, and no participant had mild use of drugs and
alcohol. This finding is consistent with data from
WHO which states that all psychoactive substances
can be harmful to health, depending on how they are
taken, in what amounts and how frequently [The
World Health Organization (WHO), 2005c].
All patients in this study were facing social problems
owing to substance dependence ranging from moderate
(46.7%, n=14) to severe (53.3%, n=16) degree. One of
the main social consequences to substance dependence
is the stigma and stereotypes against users and abusers.
It is the main barrier to treatment and care of people
with substance dependence and related problems [The
World Health Organization (WHO), 2005c]. Studies
in the countries of the east Mediterranean region have
shown that persons with drug dependence have the
highest stigma among a list of two dozen health
conditions. This stigma prevents the affected persons
from getting care. An example is the recent study from
Greater Cairo, where only 12% of those dependent on
drugs had received treatment at any time [United
Nations Office on Drugs and Crime (UNDOC),
2004].
All cases in the study had psychiatric problems owing
to drug dependence. Overall, 66.7% (n=20) had severe
psychiatric problems owing to substance dependence.
This is consistent with many studies which found that
drug intake especially opiates is associated with a broad
range of psychiatric manifestations ranging from
intensely dysphoric withdrawal symptoms,
depression, impulse control symptoms, intense
anxiety, psychotic symptoms especially paranoid
delusions and hallucinations, suicidal and self-
injurious behavior. These psychiatric disorders occur
in addition to tolerance, withdrawal and intoxication
symptoms of the different types of drugs [The World
Health Organization (WHO), Geneva, 2004c]. The
psychiatric manifestations co-occurring with substance
dependence were profoundly studied and were
interpreted as the long-term consequences of
neurobiological adaptations and the opioid system
regulation to prolonged drug use. These
phenomenon are a consequence of sustained-opioid
receptor stimulation by opiate drugs inducing
neurochemical adaptations in opioid receptor-bearing
neurons. The results extend well beyond reward circuits
to other brain areas, notably, those involved in learning
and stress response. Important regions are the
amygdala, hippocampus, and cerebral cortex, which
are all connected to nucleus accumbens (Kieffer and
Evans, 2002).
Substance dependence in this study is accompanied by
family history of substance use ranging from mild to
severe degrees.
This finding is consistent with a huge body of literature
that asserts that one family member’s substance abuse is
often influenced by substance using behaviors of others
in the family, and these complex interrelationships
can profoundly affect their lives [Substance Abuse
and Mental Health Services Administration
(SAMHSA), 1999]. Dependence on other drugs
also shows a familial pattern. The increased risk is
partly owing to environmental factors (parental
modeling, neglect, and early child abuse), but
genetic factors are also important. Numerous studies
of laboratory animals have revealed genetically
transmitted differences in the reinforcing effects of
alcohol and various drugs such as cocaine and
opioids and show that genetic factors powerfully
influence sensitivity to toxic effects. The evidence for
genetic factors in human vulnerability to alcoholism
and other drug dependence is derived most
convincingly from twin and adoption studies, but
family studies are also revealing (Kaplan and Sadock,
2003).
Substance dependence caused many legal problems to
the cases from mild to severe degrees. This is consistent
with the study done by the Australian Institute of
Criminology, which stated that female detainees
were more likely than male ones to attribute their
crime to illicit drug use, and many women had
become regular users of illicit drugs before their first
arrest; this occurred on average at the age of 21 years.
The use of illicit drugs was associated, particularly in
female detainees, with property offending. Alcohol use
is more likely to be associated with violent crime than
with other crimes and regular and dependent alcohol
use increased women’s likelihood of being involved in
violent offending, although not to the same extent as it
did in men (Australian Institute of Criminology,
2009). It was demonstrated that female drug addicts
commit relatively fewer violent crimes compared with
male addicts and were more likely to engage in drug-
related crimes, such as property crimes and prostitution
(Chen, 2009). This finding is consistent with many
studies estimation that in some countries around three-
quarters of people in prison have alcohol or other drug-
related problems, and more than one-third may be
[Downloaded free from http://www.new.ejpsy.eg.net on Monday, August 12, 2019, IP: 182.1.208.40]
opioid dependent. Approximately one-third will have
been imprisoned for drug-related offenses. Some level
or continued drug use often occurs in prison and is
usually associated with high risk of HIV transmission
owing to sharing/reusing injecting equipment and drug
solution. On release, prisoners with opioid dependence
are at high risk of relapse and overdose. The costs of
law enforcement, court time and imprisonment
together contribute substantially to the social costs
associated with opioid dependence. In general,
studies indicate that pure justice interventions,
without associated opioid dependence treatment,
have very limited effect on drug using behavior and
reoffending among individuals with drug dependence
[The World Health Organization (WHO), United
Nations Office on Drugs and Crime (UNDOC),
UNAIDS, 2004d].
Most cases (70%, n=21) had low social competence
compared with controls (n=0), who had high level of
social competence. The finding of our study is
consistent with many studies that state that
substance abuse clearly impairs one’s ability to work
and to cope in the society, but little data are available to
indicate threshold levels that would clearly impair job
performance. Most states have adopted clinical
standards as a means of identifying those who
should receive treatment before work training
(Becker and Duffy, 2002).
It is also consistent with the study done by Rapheal and
Bryant (2004) which states that women are widely
disadvantaged by economic and social factors.
Women in the paid workforce consistently earn 20%
less than men. Women’s work in the home and
childrearing remains unpaid and unprotected by the
social safety net. Numerous concerns about systemic
economic and social discrimination experienced by
women have been stated. Poverty, wage disparities,
and social program reductions as well as lack of
childcare, lack of social housing, and ongoing
violence against women are some of the factors that
continue to negatively affect women (Rapheal and
Bryant, 2004).
It is also consistent with the study done by United
Nations Office on Drugs and Crime (UNDOC, 2004)
which states that women using drugs face much social,
personal, and cultural stigmatization. For female drug
users, the guilt and shame associated with drug use is
often also added to the stigma. Additionally, in
comparison with men, women seeking treatment
seem to be younger, with fewer resources, have
dependent children and often live with a drug-using
Psychiatric and social profile Abol et al 71
partner. They are more likely to have experienced
trauma and have higher rates of concurrent
psychiatric problems. All of these factors make it
even more difficult for women to access and stay in
treatment and difficult as well to cope in society
[United Nations Office on Drugs and Crime
(UNDOC), 2004].
Overall, 43.4% of cases had limited level of social
support compared with none of participant (n=0) of
control group, who all had high level of social
support. The finding of this study is consistent
with the study done by Podkopacz et al. (2006)
which stated that social support for abstinence has
been found to be associated with positive treatment
outcome among drug court participants, after
assessing how different types of social support
from family, friends, and significant others
influenced client progress through a Minnesota
Drug Court. Specifically, emotional, practical,
informational, financial, and socializing supports
were assessed using the Social Support Behaviors
Scale (Podkopacz et al., 2006).
The finding of our study is consistent with the study
done by Boyd and Mieczkowski (1990), which
reported that among a sample of crack abusers in
residential treatment, 30% of women reported that
no one within their social network would provide
them with support for being in recovery, compared
with only 19% of men. This is important, as social
support that encouraged abstaining from drug use
significantly predicted positive outcomes among drug
court participants of both sexes especially for women
(Podkopacz et al., 2006).
According to the results of the study, there is a positive
statistical significant difference between the study
groups on the level of psychiatric status.
The findings of our study are consistent with the study
done by Merikangas et al. (1998), which stated that in
general, there was a strong association between mood
and anxiety disorders as well as conduct and antisocial
personality with substance disorders at all site. The
results also suggest that there is a continuum in the
magnitude of comorbidity as a function of the
spectrum of substance use category (use, problems,
dependence), as well as a direct relationship between
the number of comorbid psychiatric disorders and
increasing levels of substance use disorders. Finally,
although there was no specific temporal pattern of
onset for mood disorders in relation to substance
disorders, the onset of anxiety disorders was more
[Downloaded free from http://www.new.ejpsy.eg.net on Monday, August 12, 2019, IP: 182.1.208.40]
72 Egyptian Journal of Psychiatry, Vol. 40 No. 2, May-August 2019
likely to precede that of substance disorders in all
countries (Merikangas et al., 1998).
It is also consistent with many other studies that had
found that compared with men, women with substance
use problems reported higher rates of psychiatric
disorders, most commonly anxiety, depression
(though sex differences in rates of depression among
individuals with substance use problems are smaller
than among the population in general), borderline
personality disorder, and eating disorders
(Bogenschutz and Geppert, 2003).
The findings are also consistent with the study done by
Shantna et al. (2009) which stated that many substance-
dependent women often had comorbid psychiatric
conditions, which needed to be treated to maximize
treatment compliance. The conditions include major
depression, bipolar disorder, schizophrenia, and
disorders of personality. The experience of trauma can
lead to the development of PTSD, or other mental health
problems. Rates of PTSD among women in substance
abuse treatment range from 30 to 59%.
The results of the study are consistent with the research
done by Fiorentine and colleagues which stated that
women in substance-dependence treatment had much
higher rates of traumatic experiences and PTSD than
the general population. Studies of both residential and
outpatient treatment programs that served both middle
class insured and indigent populations showed high
levels of childhood abuse and adult trauma among
women in drug-dependence treatment (Fiorentine
and Anglin, 1997).
Conclusion
Most of recovering substance-dependent women were
single, mostly divorced, and not working, and most of
them chose cannabis as the substance of onset of abuse
at an age of onset between 15 and 25 years and were
substance dependent for a duration between 5 and 15
years. Half of the recovering substance-dependent
women had been sober from 6 months to 1 year,
and all of them received the same type of treatment
in the form of hospitalization and going through
twelve-step facilitation. Benzodiazepines were the
most commonly used substance followed by opiates
and alcohol. Substance dependence in this study was
accompanied by mild to severe medical complications,
mild to severe occupational problems, moderate to
severe drug use, mild to moderate family history,
mild to severe legal problems, moderate to severe
social problems, and mild to severe psychiatric
problems on the ASI. Most of recovering substance-
dependent women show low social competence and
have limited to fair level of social support in their
recovery. Major depressive disorder and PTSD are
the two most common psychiatric disorders found in
recovering substance-dependent women.
Recommendations
(1) Further research studies, of wider population
sample, are required to assess the demographic
and environmental factors inducing substance-
dependence problem.
(2) More epidemiological studies are needed to assess
the trend of substance dependence and recovery
among special groups, especially women and
comorbid mentally ill patients.
(3) Studies are needed to reveal the barriers women
find in getting treatment from substance
dependence and treating their comorbid
psychiatric disorders.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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