A R T I C L E

RACIAL/ETHNIC DIFFERENCES IN SOCIAL VULNERABILITY AMONG WOMEN WITH CO-OCCURRING MENTAL HEALTH AND SUBSTANCE ABUSE DISORDERS: IMPLICATIONS FOR TREATMENT SERVICES
Hortensia Amaro
Northeastern University

Mary Jo Larson
New England Research Institutes

Joanne Gampel
Center for Substance Abuse Treatment, Substance Abuse and Mental Health Services Administration

Erin Richardson
New England Research Institutes

Andrea Savage
Hunter College

Debra Wagler
ETR Associates

This study was funded under Guidance for Applicants ~GFA! No. TI 00003 entitled Cooperative Agreement to Study Women with Alcohol, Drug Abuse and Mental Health (ADM) Disorders Who Have Histories of Violence: Phase II from the Department of Health and Human Services, Public Health Service, Substance Abuse and Mental Health Services Administrations three centers: Center for Substance Abuse Treatment, Center for Mental Health Services, and Center for Substance Abuse Prevention ~March, 2000!. The assistance of project staff at the following participating sites ~listed in alphabetical order by state! is gratefully acknowledged: PROTOTYPES Systems Change Center ~Los Angeles, CA!, Vivian Brown, Principal Investigator; Allies: An Integrated System of Care ~Stockton, CA!, Jennie Heckman, Principal Investigator; Arapahoe HouseNew Directions for Families ~Thornton, CO!, Nancy VanDeMark, Principal Investigator; District of Columbia Trauma Collaboration Study ~Washington, DC!, Roger Fallot, Principal Investigator; Triad Womens Project ~Avon Park, FL!, Margo Fleisher-Bond, Co-Principal Investigator, Colleen Clark, Co-Principal Investigator; Boston Consortium of Services for Families in Recovery ~Boston, MA!, Hortensia Amaro, Principal Investigator; Women Embracing Life and Living ~WELL! Project ~Cambridge, MA!, Norma Finkelstein, Principal Investigator; Franklin County Womens Research Project ~Greenfield, MA!, Rene Andersen, Principal Investigator; Portal Project ~New York, N Y !, Sharon Cadiz, Principal Investigator. The Coordinating Center was operated by Policy Research Associates ~PRA!, located in Delmar, New York, in coordination with the National Center on Family Homelessness of Newton, Massachusetts, and the Cecil G. Sheps Center for Health Services Research at the University of North Carolina ~UNC! in Chapel Hill, North Carolina.

JOURNAL OF COMMUNITY PSYCHOLOGY, Vol. 33, No. 4, 495511 (2005) 2005 Wiley Periodicals, Inc. Published online in Wiley InterScience (www.interscience.wiley.com). DOI: 10.1002/jcop.20065

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Little attention has been given to racial0ethnic differences in studies of co-occurring disorders among women. In this article, we present findings from analyses conducted on the influence of racial0ethnic differences on the demographic and clinical profiles of 2,534 women in the Substance Abuse and Mental Health Services Administration-sponsored Women, Co-Occurring Disorders and Violence Study. Black and Hispanic women demonstrated more disadvantaged economic and social life conditions than White women. After controlling for socioeconomic differences, Hispanic women experienced more criminal justice involvement than others did, and both Black and Hispanic women were more likely to be exposed to community violence although they did not demonstrate more severe clinical symptoms than White women. In the design and delivery of services racial0ethnic differences should be considered, and research questions regarding underlying explanatory factors raised. 2005 Wiley Periodicals, Inc.

Research in mental health ~U.S. Department of Health and Human Services @DHHS#, 1999!, substance abuse ~Arroyo, Miller, & Tonigan, 2003; Weiss, Kung, & Pearson, 2003!, and medical care ~Smedley, Stith, & Nelson, 2003! indicates that racial and ethnic differences are important factors to consider in the design of services. Yet little attention has been paid to racial and ethnic variations that may have important implications for service needs and service delivery for women with the triple jeopardy of a history of trauma and co-occurring mental health and substance abuse disorders. Social status associated with race and ethnicity in the United States typically results in disadvantaged life circumstances and increased social vulnerability for African American and Hispanic women. Their greater social vulnerability is evidenced in lower levels of educational attainment and financial resources, fewer job skills, and limited employment opportunities ~McKinnon, 2003; Ramirez & de la Cruz, 2002!. Moreover, they experience higher mortality and morbidity ~Lillie-Blanton, Parson, Gayle, & Dieveler, 1996; Vega & Amaro, 1998; Williams, 2002!; increased barriers to and discriminatory treatment in substance abuse, mental health and medical services ~Smedley et al., 2003!; and greater risk for involvement with the criminal justice and child welfare systems ~The Sentencing Project, 2003!. One emerging framework for understanding the interplay between societal forces and individual outcome is that of social and personal vulnerabilities. Social vulnerabilities are contextual factors ~e.g., gender relations; racial discrimination; and political and economic circumstances, including poverty! that differentially and adversely impact various populations. Personal vulnerabilities are the factors in an individuals development and environment that influence her risk of any specific negative consequence ~Engender Health, 2003; United Nations, 2003!. Within this framework, racial0 ethnic discrimination is a social vulnerability that can increase the likelihood of exposure
The interpretations and conclusions contained in this publication do not necessarily represent the position of the WCDVS Coordinating Center, participating study sites, participating consumer0survivor0recovering persons, or the Substance Abuse and Mental Health Services Administration and its three centers ~Center for Substance Abuse Treatment, Center for Mental Health Services, and Center for Substance Abuse Prevention!. Correspondence to: Hortensia Amaro, Bouve College of Health Sciences, 360 Huntington Avenue, Stearns Suite 503, Boston, MA 02115. E-mail: h.amaro@neu.edu

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to further social vulnerabilities ~e.g., poverty and diminished access to education! and intensify personal vulnerabilities to substance abuse, trauma, and mental illness ~e.g., through stress!. For example, because of their lower socioeconomic resources, Black and Hispanic women are more likely to live in communities burdened by drugs and violence, which increases their risk of witnessing or being a victim of violence. Residing in those communities and being Black or Hispanic may increase the likelihood of scrutiny by police and other authorities, leading to increased risk of criminal justice system involvement and intervention from child welfare services. From this perspective, one would expect to observe more severe social vulnerability and greater severity of substance abuse, mental health disorders, and trauma history among Black and Hispanic women in the general population and among those entering treatment for co-occurring disorders. However, several studies of the general population have not found that Hispanics and African Americans have higher rates of substance abuse, mental health problems, or intimate interpersonal trauma than Whites ~Alegria et al., 2002; Amey & Albrecht, 1998; Medrano, Zule, Hatch, & Desmond, 1999!. Yet, for some groups this may be changing since according to the most recent National Household Survey on Drug Abuse ~Substance Abuse and Mental Health Services Administration @SAMHSA#, 2002!, the rates for illicit drug abuse or dependence were highest for Hispanics ~7.8%!, followed by Whites ~7.5%!, then Blacks ~6.2%!. Studies on interpersonal violence also have reported contradictory findings ~Bassuk, Perloff, & Garcia-Coll, 1998; Romero, Wyatt, Loeb, Carmona, & Solis, 1999; Sorenson, 1996; Straus & Gelles, 1990; West, 1998! that may be attributable to methodological differences. However, studies of national probability samples have found higher rates of interpersonal violence among Hispanics or Hispanic subgroups ~Caetano, Cunradi, Clark, & Schafer, 2000; Kantor, Jasinski, & Aldarondo, 1994!. Attempts to reconcile these disparate findings have produced speculation that protective factors such as cultural norms and interpersonal supports in some of these communities may mediate the negative effects of social vulnerabilities ~Snowden, 1998; Stack, 1974; Vega & Rumbaut, 1991!. Among clinical populations ~i.e., those seeking services!, however, there may be significant and consistent racial0ethnic differences in social vulnerability and clinical profile that need to be considered in the design and delivery of services. For example, some studies of women in substance abuse treatment have shown that Blacks and Hispanics have significantly lower educational attainment, economic resources, and job-related skills than their White counterparts ~Amaro, Nieves, Johannes, & Cabeza, 1999; Amaro, Beckman, & Mays, 1987; Wallen, 1998!. However, no study to date has systematically examined race0ethnic differences in social vulnerability and clinical severity among women with co-occurring disorders, a group that has been understudied despite the high rates of co-morbidity in clinical populations ~Najavits, Weiss, & Shaw, 1997; Ouimette, Kimerling, Shaw, & Moos, 2000!. The present study was designed to shed light on these issues. It tests the following hypotheses based on the existing literature that compared to White women, Hispanic and Black women in treatment who have co-occurring disorders and trauma histories will: 1. Have significantly lower socioeconomic resources. 2. Be at greater risk for other social vulnerabilities including community violence, criminal justice involvement, and greater system scrutiny as indicated by more child welfare involvement, even when controlling for socioeconomic resources.

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3. Demonstrate more symptom severity for substance abuse, trauma, and mental illness, even when controlling for socioeconomic resources. METHODS Sample We examine baseline interview data for 2,534 women enrolled in the Women, Co-occurring Disorders and Violence Study ~WCDVS!, which was sponsored by SAMHSA. The sample comprised Hispanics ~19.6%!, non-Hispanic Blacks0African Americans ~28.6%!, and non-Hispanic Whites ~51.7%! The study was conducted at nine sites within the United States using a quasi-experimental comparison group design to assess the impact of an integrated, trauma-informed service approach for women with histories of mental health and substance abuse disorders who have experienced interpersonal violence. Study participants who did not identify with one of the three racial0ethnic groups noted ~ N 195, 7%! were not included because this subsample was too small and heterogeneous for analyses. For a full description of the study, see Becker and colleagues ~this issue!, Giard and colleagues ~this issue!, and McHugo and colleagues ~2005!. Measures The articles noted above provide descriptions of the interview study and its measures ~Giard et al., this issue!, the specific approach to measuring trauma history and experiences ~McHugo et al., 2005!, and the general characteristics of all women in the study ~Becker et al., this issue!. The following discussion focuses on the use of terms specific to the analyses reported here. Race and Ethnicity. We used the following self-identified racial0ethnic categories: Hispanic0 Latina, including Hispanic0Latina groups mentioned under other race; non-Hispanic Black0African American; and non-Hispanic White. Hispanics in the sample identified as follows: 41.4% Puerto Rican, 37.6% Mexican American0Chicana, and 21% other or unspecified Hispanic. Social Vulnerability. To assess indicators of social vulnerability such as socioeconomic resources, family characteristics, criminal justice involvement, loss of parental rights, and exposure to community violence, respondents were asked closed-ended questions about demographic information including age, number of children, years of education, relationship status, employment status, living situation, and income in the past 30 days. Based on individual income, a variable was constructed that placed women above or below a predetermined level suggesting economic hardship ~$767.83 per month!, which was based on the U.S. Census Bureaus annual poverty threshold ~$9,214! for a single person under 65 years old with no children ~DeNavas-Walt, Proctor, & Mills, 2004!. Participants were also asked about court-ordered treatment, being in jail or having close family members in jail, child custody rights, foster care of children, and witnessing or being victims of exposure to violent crime. Substance Abuse, Mental Health, and Trauma Measures. All substance use questions were derived from the Addiction Severity Index ~ASI! interview ~McLellan, Luborsky, Woody,

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& OBrien, 1980!. Respondents were asked to identify their major problem substance, and lifetime use, age of first use, and use in the past 30 days of alcohol and all other drugs. For this analysis, the major self-identified problem substances were recategorized into six problem substance groups: alcohol to intoxication; alcohol and another substance; heroin; cocaine or crack; tobacco; and other ~including all other drugs and polydrug use!. Composite scores were arithmetically derived summary indices based on combinations of items in each area that describe problems during the past 30 days ~McLellan et al., 1992!. Respondents answered questions from the Brief Symptom Inventory ~BSI; Derogatis & Melisaratos, 1983!, a psychological self-report symptom scale with 53 items. Based on the BSI, the Global Severity Index ~GSI! provides a composite score that can measure change in severity of symptoms; using normative data, Derogatis ~1993! has suggested a value indicative of a probable case. Respondents were also asked about psychiatric hospitalizations, age at first mental health treatment, and use of prescribed psychotropic medications. Several trauma measures were derived from the trauma history interview used in the study ~McHugo et al., 2005!. The first, The Lifetime Exposure to Stressful Events ~LESE! scale, indicates how many of 31 stressful events respondents have experienced in their lifetimes. The second derived scale, Lifetime Frequency of Interpersonal Abuse ~LFIA!, assesses through 12 questions how often ~1 once, 2 a few times, 3 a lot ! respondents have experienced interpersonal abuse in their lifetimes. In addition, information from the interview was used to construct four dichotomous variables that measured childhood ~i.e., occurring before age 18! physical abuse ~CPA!, childhood sexual abuse ~CSA!, adult physical abuse ~APA!, and adult sexual abuse ~ASA!. The Posttraumatic Stress Symptom Scale ~PSS! assesses posttraumatic stress disorder ~PTSD! symptom severity. Respondents indicated how frequently they experienced 17 symptoms of PTSD related to current or past traumatic events ~McHugo et al., 2005!. Statistical Analysis Means and standard deviations are presented for continuous variables, and percents are given for categorical variables. Racial0ethnic differences were tested using analysis of variance ~ANOVA! for continuous variables and the chi-square test for categorical variables. If significant differences were found at the 0.05 level, three pairwise comparisons ~i.e., Hispanic vs. Black @HB#, Hispanic vs. White @HW#, and Black vs. White @BW#! were made to determine which pairs were significantly different. For the continuous variables, p-values were adjusted for multiple comparisons using the Bonferroni procedure. A Bonferroni-like method was used for the categorical variables. Specifically, a separate chi-square test was conducted for each pair of racial0ethnic groups. If the chi-square p-value was 0.017 ~alpha 0.05 divided by 3, the number of comparisons!, the difference was considered statistically significant. We first compared socioeconomic and demographic characteristics, mental health, substance abuse, mental health and trauma measures for the three racial0ethnic groups directly using t tests for comparison of means and chi-square tests for comparison of categorical variables. A second group of analyses was performed comparing criminal justice status, loss of parental rights, exposure to community violence, substance abuse, mental health, and trauma measures for the three racial0ethnic groups, controlling for age, education, and poverty level using Cochran-Mantel0Haenszel statistical analysis for categorical variables and the analysis of covariance ~ANCOVA! model for

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continuous variables. To provide the best estimates of the characteristics of women in treatment, we report the unadjusted means on the tables but indicate which were statistically significant in the multivariate models that controlled for age, education, and poverty level. All analyses were performed using SAS version 8.2. RESULTS Racial/Ethnic Comparisons on Social Vulnerability Socioeconomic Resources and Family Characteristics. Table 1 presents racial0ethnic comparisons of socioeconomic and family characteristics that reflect social vulnerability and
Table 1. Social Vulnerability: Socioeconomic Resources and Family Characteristics by Race/Ethnicity Race0Ethnicity Black White non-Hispanic non-Hispanic Overall (n 729! (n 1,317! p-value e
38.1 ~8.5! 7.4% 46.3% 28.4% 17.9% 8.1% 24.7% 27.4% 39.8% 2.0 ~1.9! 8.8% 23.8% 28.2% 39.3% $509 ~$772! 82.1% 93.4% 20.2% 10.3% 60.8% 8.7% 77.6% 35.4 ~8.8! 7.9% 30.9% 25.7% 35.5% .0001 13.2% 27.2% 34.4% 25.2% 1.9 ~1.4! 17.1% 15.1% 29.2% 38.6% $830 ~$1,305! 63.8% 95.7% 31.9% 14.8% 44.4% 8.8% 67.1% HB, BW .0001 .0001

Characteristic

Hispanic (n 498!

Betweengroup differences f
HB, HW, BW HB, HW, BW

Age in years, M ~ SD ! 33.5 ~8.4! Education 8 yrs 20.5% 8 yrs 44.9% High school diploma0GED 19.1% Beyond high school 15.5% Marital status Married 11.5% Significant other 28.7% Widowed, divorced, or separated 30.9% Never married 28.9% # of children 18 years, M ~ SD ! 2.4 ~1.8! Employment status Some employment 8.0% Unemployed 15.7% Disabled 24.3% 52.0% Other a Income in past 30 days b , M ~ SD ! $576 ~$1,165! 77.4% Income below poverty line c Current residence d Housed 97.6% Own house0apartment 18.6% Others house0apartment 7.4% Residential treatment 67.8% Other housed 6.2% Ever been homeless 72.1%

.0001 .0001

HB, HW HB, HW, BW

.0001 .0001 .0001

HW, BW HW, BW HW, BW

.0018

BW

a Other category includes student, homemaker, those in substance abuse or mental health treatment programs, or any fill-in response. b Total across all sources, legal and illegal. c Set as equivalent to the monthly income threshold calculated from the annual poverty threshold for a single person less than 65 years old with no children ~$767.83!. d Significance test does not include the Ever been homeless category. e Analysis of variance ~ANOVA! for continuous variables, chi-square test on group for categorical variables ~ p 0.05!. f H Hispanic, B Black, W White. Pairs of letters indicate which groups were significantly different. The Tukey procedure was used to adjust p -values for multiple comparisons for continuous variables ~ p 0.05!, while a Bonferroni-like adjustment was used to adjust p -values for multiple comparisons for categorical variables ~ p 0.017!.

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are relevant to womens treatment needs. The socioeconomic and family profiles of participants show significant racial0ethnic differences, indicating fewer resources among Hispanic ~H! and Black ~B! respondents than among White ~W! respondents. Hispanic women made up the youngest group ~mean age 33.5 H; 38.1 B; 35.4 W; p .0001!, and they were the least likely to have education beyond high school ~15.5% compared with 17.9% for Blacks and 35.5% for Whites; p .0001!. Black women, the oldest of all groups, had a lower educational status than White women did. Consistent with lower levels of education, Hispanic ~8%! and Black ~8.8%! women were less likely than Whites ~17.1%, p .0001! to have a job status of some employment. Black women were the most likely to be unemployed in the prior 30 days ~23.8%! compared with 15.7% for Hispanic women and 15.1% for White women ~ p .0001!. A greater proportion of Hispanic women identified their employment status as other, which included roles such as housewife ~52%! compared with 39.3% for Blacks and 38.6% for Whites ~ p .0001!. Also consistent with lower education and employment, Hispanic ~ M $576! and Black ~ M $509! women had significantly ~ p .0001! lower average monthly incomes than Whites ~ M $830!. In addition, they were more likely than White women to be living in poverty ~B: 82.1%; H: 77.4%; W: 63.8%; p .0001!. Although the majority of women in all groups had been married or were currently in a relationship, Blacks ~39.8%! were more likely than either Hispanics ~28.9%! or Whites ~25.2%! to have never been married ~ p .0001!. Despite their younger age, Hispanic women ~ M 2.4! had ~on average! more children under the age of 18 years than Black women ~ M 2.0! or White women ~ M 1.9; p .0001!. Based on these responses, the youngest, least-educated, and less frequently married women had the greatest burden of child rearing. As shown in Table 1, the vast majority of women had housing at the time of the interview. Of these women, 67.8% of Hispanics, 60.8% of Blacks, but only 44.4% of Whites were living in a residential treatment setting ~ p .0001, distribution on residential status!. White women ~31.9%! were significantly more likely to live on their own in a house or apartment than Black or Hispanic women ~20.2% for Blacks and 18.6% for Hispanics, p .0001!. White women were also more likely to live in someone elses apartment ~14.8%! than their Black ~10.3%! and Hispanic ~7.4%! counterparts. Black ~77.6%! and Hispanic ~72.1%! women were significantly more likely than Whites ~67.1%, p .0018! to have been homeless at some point in their lives.

Criminal Justice Involvement, Loss of Parental Rights, and Exposure to Community Violence. Table 2 shows that, after controlling for age, education and income, there were statistically significant racial0ethnic differences in involvement with the criminal justice, as predicted in hypothesis 2. The rate for current court-ordered treatment was 45.2% for Hispanics compared with 33.9% for Whites and 31.8% for Blacks ~ p .001, adjusted!. Multivariate analysis revealed that being court-ordered to treatment was partially mediated by the womans having a greater number of children in her custody ~ p .0001! and younger womens age ~ p .0001!. However, these factors did not fully explain the higher rates of mandated treatment among Hispanic women. Hispanics ~28.0%! compared to Blacks ~21.5%! and Whites ~17.8%! were more likely ~ p .01, adjusted! to have been in jail in the prior 3 months and to have had a close friend or family member in jail ~W: 61.3%; H: 73.6%; B: 72.2%, p .0001, adjusted!. While unadjusted analysis found that White women ~22.3%! were less likely to have lost parental rights for at least one child than Hispanic ~29.3%! and Black

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Table 2. Social Vulnerability: Criminal Justice Involvement, Parental Rights, and Exposure to Community Violence by Race/Ethnicity Race0Ethnicity BetweenBlack White group Hispanic non-Hispanic non-Hispanic Overall (n 498! (n 729! (n 1,317! p-value a differences b
45.2% 28.0% 74.9% 73.6% 29.3% 59.8% 20.9% 54.0% 48.2% 31.8% 21.5% 71.7% 72.9% 30.2% 55.0% 16.9% 59.0% 54.6% 33.9% 17.8% 66.4% 61.3% 22.3% 61.0% 21.8% 44.8% 43.4% .001 .01 NS c .0001 NS c NS NS c .0001 .001 HB, HW HB, HW HW, BW HW, BW BW

Characteristic
Currently court-ordered substance abuse or mental health treatment Jail in last 3 months Ever been in jail or juvenile detention Ever had a close friend or family member in jail Ever had parental rights terminated Has custody of at least one child 18 years of age Ever been in foster care or been put up for adoption Ever witnessed a robbery, mugging, or attack Ever been robbed, mugged, or physically attacked

a Analysis of covariance ~ANCOVA! for continuous variables controlling for age, education, and poverty level; CochranMantel-Haenszel x 2 test for all categorical variables ~ p 0.05! adjusting for age, education, and poverty level. b H Hispanic, B Black, W White. Pairs of letters indicate which groups were significantly different. The Tukey procedure of ANCOVA was used to adjust p -values for multiple comparisons for continuous variables ~ p 0.05!, while a Bonferronilike adjustment of Cochran-Mantel-Haenszel x 2 was used to adjust p-values for multiple comparisons for categorical variables ~ p 0.017!. c The difference in these rates was statistically significant before controlling for age, education level, and income level.

~30.2%! women, contrary to hypothesis 2, racial0ethnic differences were not significant after we controlled for age, education, and income. As per hypothesis 2, compared to White women, Black and Hispanic women reported higher exposure to violent crime such as witnessing a robbery, mugging, or attack ~W: 44.8%; H: 54%; B: 59%, p .0001, adjusted! and Black women were more likely to have been a victim of a robbery, mugging, or physical attack ~B: 54.6%; H: 48.2%; W: 43.4%, p .001, adjusted!. Racial0Ethnic Comparisons on Substance Abuse, Mental Health, and Trauma. As shown in the substance abuse section of Table 3, analyses controlling for age, education, and income revealed significant racial and ethnic differences in history and severity of drug and alcohol use. With respect to the major problem substance identified by participants, significant differences ~ p .0001, adjusted! emerged, indicating varying patterns of drug use. Hispanics reported heroin ~21.5%! as the major problem more often than did Whites ~17.3%! or Blacks ~12.4%!. Whites reported that use of alcohol to the point of intoxication ~23.3%! was the major problem more often than did Blacks ~15%! or Hispanics ~13.7%!. Blacks ~47.9%! reported that cocaine0crack was a major problem more often than Hispanics ~24.7%! or Whites ~13.5%!. Reports of illicit drug use in the last 30 days varied significantly across the three groups, with Blacks reporting the lowest rates of use ~B: 53.5%; W: 63.1%; H: 63.2%,

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Table 3. Substance Abuse and Mental Health by Race/Ethnicity Race0Ethnicity Black White Hispanic non-Hispanic non-Hispanic Overall (n 498! (n 729! (n 1,317! p-value d
.0001 13.7% 6.6% 21.5% 24.7% 0.8% 32.7% 47.2% 63.2% 14.7 ~5.2! 13.9 ~4.6! 15.1 ~4.8! 0.19 ~0.29! 0.19 ~0.17! 15.0% 6.6% 12.4% 47.9% 1.8% 16.4% 47.0% 53.5% 15.1 ~5.0! 14.4 ~4.2! 16.2 ~4.9! 0.20 ~0.30! 0.15 ~0.14! 23.3% 6.5% 17.3% 13.5% 1.3% 38.3% 44.0% 63.1% 13.8 ~4.5! 13.1 ~4.4! 14.3 ~4.1! 0.20 ~0.30! 0.17 ~0.16! NS .001 .0001 .0001 .0001 NS .0001 .0001 .0001 NS NS .0001 HB, BW HB, BW HW, BW HW, BW HW, BW

Characteristic
Substance abuse Major problem substance Alcohol to intoxication Alcohol and another substance Heroin Cocaine0crack Tobacco a Other b Recent alcohol abuse c ~in past 30 days! Recent illicit drug abuse c ~in past 30 days! Age at first tobacco use, M ~ SD ! Age at first alcohol use, M ~ SD ! Age at first illicit drug use, M ~ SD ! Addiction Severity Index score alcohol, M ~ SD ! Addiction Severity Index score drug, M ~ SD ! Mental health Global Severity Index ~GSI! probable case Global Severity Index ~GSI! score, M ~ SD ! Number of psychiatric hospitalization, M ~ SD ! Age at first mental health treatment, M ~ SD ! Taking psychiatric medication

Betweengroup difference e
HB, HW, BW

73.5% 1.42 ~0.85! 3.6 ~6.1! 23.4 ~9.7! 47.5%

66.3% 1.21 ~0.78! 4.4 ~5.7! 24.2 ~9.7! 52.5%

77.2% 1.39 ~0.74! 4.5 ~6.7! 24.0 ~9.7! 62.4%

HB, BW HB, BW

HW, BW

a Significance testing does not include tobacco. b Other category includes marijuana, methadone, other opiates0 analgesics, barbiturates, sedatives0benzodiazepines0tranquilizers0hypnotics, methamphetamines0amphetamines0stimulants, hallucinogens, inhalants, other illegal drugs, and polydrug use. c If respondent was in a controlled environment, the question refers to the 30 days prior to being in this controlled environment. d Analysis of covariance ~ANCOVA! for continuous variables controlling for age, education, and poverty level; Cochran-Mantel-Haenszel x 2 test for all categorical variables ~ p .05! adjusting for age, education and poverty level. e H Hispanic, B Black, W White. Pairs of letters indicate which groups are significantly different. The Tukey procedure of ANCOVA was used to adjust p-values for multiple comparisons for continuous variables ~ p 0.05! while a Bonferroni-like adjustment of Cochran-Mantel-Haenszel x 2 was used to adjust p-values for multiple comparisons for categorical variables ~ p .017!.

p .001, adjusted!. The mean Addiction Severity Index-Drug Composite Score varied significantly ~ p .0001, adjusted! between groups, with Hispanics ~0.19! and Whites ~0.17! scoring statistically higher ~meaning that their addiction was more severe! than Blacks ~0.15!. No significant differences in alcohol use in the past 30 days or on the Addiction Severity Index-Alcohol Composite Score were found. Age at onset of substance use varied significantly by racial0ethnic group, with White women reporting earlier age at onset of tobacco use ~means W: 13.8; H: 14.7; B: 15.1, p .0001, adjusted!,

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alcohol use ~means W: 13.1; H: 13.9; B: 14.4; p .0001, adjusted!, and illicit drug use ~means W: 14.3; H: 15.1; B: 16.2, p .0001, adjusted!. Contrary to hypothesis 3, Black and Hispanic women did not have higher scores in substance abuse symptomatology. As seen in the mental health section of Table 3, after controlling for age, education, and income, White and Hispanic women were most likely to meet criteria for probable case ~diagnosis of mental health disorder! as determined by the Global Symptom Inventory ~GSI! ~W: 77.2%; H: 73.5%; B: 66.3%, p .0001, adjusted!. Similarly, Whites ~ M 1.39! had GSI mean scores comparable with those of Hispanics ~ M 1.42! but higher scores ~indicating more severe symptoms! than those of Blacks ~ M 1.21, p .0001, adjusted!. Consistent with the difference between White and Black women in the rate of reported global symptoms, Whites were more likely to report use of psychiatric medication than Blacks ~62.4% and 52.5%, respectively, p .0001, adjusted!. However, White women were also more likely than Hispanics ~62.4% and 47.5%, respectively! to be receiving medication for treatment of psychiatric illness, even though these two groups had similar mean GSI scores. There were no racial0ethnic differences in age at first mental health treatment or number of psychiatric hospitalizations. Findings do not support the racial0ethnic differences in mental health symptomatology predicted by hypothesis 3. Table 4 shows significant racial0ethnic differences in measures of trauma after controlling for age, education, and income, although counter to the hypothesized direction. Compared to White women, Black women had significantly lower scores on the Posttraumatic Stress Disorder Symptoms Scale ~W: 24.4; H: 24.2; B: 22.6, p .001, adjusted! and the Lifetime Exposure to Stressful Events Scale ~W: 16.4; H: 16.1; B: 15.9, p .01, adjusted!, while scores for Hispanic women were similar to those for White women. On the Lifetime Frequency of Interpersonal Abuse Scale, both
Table 4. Trauma Characteristics by Race/Ethnicity Race0Ethnicity Black non-Hispanic ~ n 729!
22.6 ~12.2! 14.3 ~7.2! 15.9 ~4.6! 55.1% 54.1% 81.3% 57.2%

Scales and selected scale components

Posttraumatic Stress Disorder Symptom Scale ~PSS!, M ~ SD ! Lifetime Frequency Interpersonal Abuse ~LFIA! score, M ~ SD ! Lifetime Exposure to Stressful Events ~LESE! score, M ~ SD ! Childhood physical abuse ~CPA! Child sexual abuse ~CSA! Adult physical abuse ~APA! Adult sexual abuse ~ASA!

Hispanic ~ n 498!
24.2 ~12.1! 14.8 ~7.4! 16.1 ~4.8! 62.5% 57.1% 85.0% 50.5%

White non-Hispanic ~ n 1,317!

24.4 ~11.5! 16.9 ~7.3! 16.4 ~4.4! 64.8% 67.4% 87.7% 64.2%

Overall p-value a
0.001 .0001 .01 .001 .0001 .001 .0001

Betweengroup differences b
BW HW, BW BW BW HW, BW BW HW, BW

a Analysis of covariance ~ANCOVA! for continuous variables controlling for age, education, and poverty level; CochranMantel-Haenszel x 2 test for all categorical variables ~ p .05! adjusting for age, education, and poverty level. b H Hispanic, B Black, W White. Pairs of letters indicate which groups were significantly different. The Tukey procedure of ANCOVA was used to adjust p -values for multiple comparisons for continuous variables ~ p .05! while a Bonferroni-like adjustment of Cochran-Mantel-Haenszel x 2 was used to adjust p -values for multiple comparisons for categorical variables ~ p .017!.

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Hispanic and Black women had lower mean scores compared to Whites ~W: 16.9; H: 14.8; B: 14.3, p .0001, adjusted!. Racial0ethnic differences were also found in history of physical and sexual abuse but in the opposite direction from that hypothesized. The prevalence of childhood physical abuse was significantly higher in White ~64.8%! and Hispanic ~62.5%! women than in Black women ~55.1%, p .001, adjusted!. Sexual abuse during childhood was most prevalent among White women ~W: 67.4%; H: 57.1%; B: 54.1%, p .0001, adjusted! while more than 8 in 10 women in each group had been exposed to adult physical abuse, the prevalence was significantly higher among White women than Black women ~87.7% and 81.3%, respectively, p .001, adjusted!. Adult sexual abuse was significantly higher in White women than in Black or Hispanic women ~W: 64.2%; B: 57.2%; H: 50.5%, p .0001, adjusted!. DISCUSSION Overall, the findings indicated that nearly all women seeking care in this sample were economically and socially marginalized. However, when the three racial profiles were compared, Black and Hispanic women demonstrated heightened social vulnerability as reflected in more severely disadvantaged economic and social life conditions than White women, and each group presented with different clinical patterns. Our findings lend support to our first hypothesis: that compared to White women, Hispanic and Black women in treatment who have co-occurring disorders and trauma histories have significantly lower socioeconomic resources. Socioeconomic, racial, and ethnic disparities documented in the general population ~U.S. Bureau of the Census, 2000! are also evident among this sample of largely poor women in treatment. These findings are consistent with other studies of Black and Hispanic women receiving mental health and substance abuse treatment ~Amaro et al., 1999, 1987; Grella, Annon, & Anglin, 1995! and studies of women at risk for HIV ~Wyatt et al., 2002!. Differences in life conditions among women with co-occurring disorders are of critical clinical significance. Comfort, Sockloff, Loverro, and Kaltenbach ~2003! examined an array of personal and family characteristics and multifaceted life outcomes among women in substance abuse treatment and found that life circumstances and historical profiles of personal risk were important predictors of treatment outcomes, concluding: What the client brings to the treatment process strongly determines her life outcomes ~pp. 221222!. Their findings underscore the importance of providing treatment that is tailored to individual needs and environmental context. Although Comfort and colleagues did not investigate racial or ethnic differences in life circumstances and personal risk profiles, their findingstogether with the documented impact of race and ethnicity on life circumstances and personal risk profiles ~Smedley et al., 2003; Williams, 2002! underscores the need to consider these in any study of comorbidity among women. While all women in treatment may benefit from ancillary services, our findings suggest that Black and Hispanic women with co-occurring disorders would particularly benefit from treatment programs that have educational, job-training, and jobplacement components. Previous research has reported improved outcomes in substance abuse treatment for women when ancillary comprehensive services such as vocational training, child care, and parenting classes are offered ~Howell, Heiser, & Harrington, 1999; Stranz & Welch, 1995!. Current and forthcoming treatment guidelines for gender-specific services ~Ashley, Marsden, & Brady, 2003; US DHHS, in press!

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recommend integration of educational and job training components and other ancillary life-skills building services with womens treatment. Our findings further suggest that tailoring approaches to the specific economic conditions of each group are appropriate. A tailored approach to meet the needs of Black and Hispanic women in this sample would focus on services that assist them to achieve high school equivalency, and a tailored approach for Hispanic women would include a focus on acquiring language skills. Considering the lower educational attainment of Black and Hispanic women in the sample, educational and job training programs should be started early in treatment and extend through the aftercare period, include high school equivalency programs in Spanish, and employ culturally and linguistically appropriate staff. To gain sufficient skills to achieve economic self-sufficiency, Hispanic and African American women with low educational attainment, minimal work skills, and co-occurring disorders may need training programs longer in duration than those designed for other groups. For example, a staged developmental approach that builds basic job skills in a progressive manner through onsite vocational training options while women are in treatment may better prepare them to then participate in other standard job training programs. Based on a review conducted by Ashley and colleagues ~2003!, no randomized controlled studies have been conducted on the efficacy of job-training treatment components in gender-tailored programs for women in general or for Black and Hispanic women specifically. Services directed at helping women obtain safe housing, job training, and education are especially important for treatment of women with trauma because economic dependence can place women at risk of reliance on abusive partners and further victimization ~Browne & Bassuk, 1997; Cunradi, Caetano, & Schafer, 2002; Kantor & Asdigian, 1997; Straus & Gelles, 1990; Salomon, Bassuk, & Huntington, 2002; Wolfner & Gelles, 1993!. We found some support for our second hypothesis that compared to White women, Hispanic and Black women are at greater risk for other social vulnerabilities, including criminal justice involvement, termination of parental rights, and greater exposure to community violence, even when controlling for differences in socioeconomic resources. Racial0ethnic group differences were significant for criminal justice involvement and vulnerability to community-based interpersonal violence. And while race0 ethnic differences in termination of parental rights were not found once confounding factors were controlled, increased scrutiny from the child welfare system expressed in termination of parental rights appears to be explained by socioeconomic factors closely associated with race0ethnicity. Substantial involvement with the criminal justice system may contribute to womens social vulnerability by diminishing opportunities for employment and housing. Access to legal services and advocacy is a recommended component of gender-specific treatment ~US DHHS, in press!. Our findings indicate that vulnerability because of previous jail time is particularly common among Hispanic women. Although this study was not able to assess the factors that explain racial and ethnic differences in involvement with the criminal justice system, socioeconomic differences appear to play a mediating role. Other studies have documented systemic biases that lead to greater rates of mandated treatment and incarceration among minority women and men ~Mosher & Yanagisake, 1991; Reed & Reed, 1997!. Given the higher level of involvement with the criminal justice system and the recency of incarceration among Hispanic women, as well as the possibility of re-incarceration that these findings imply, treatment programs need to have strong collaborative linkages with the criminal justice system to enhance service continuity both within and outside of jail0prison and reduce recidivism

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over time. Future analyses of data from this study should investigate race0ethnic differences in pathways to treatment and whether different routes of entry into treatment lead to different treatment outcomes. With regard to our third hypothesis, we found either no racial and ethnic differences on substance abuse, trauma, and mental health, or ones in the opposite direction than predicted. First, in our comparison of mental health and trauma histories, indicators of mental health disorders generally revealed more severity among White and Hispanic women than among Black women, with White women having the most severe profile of mental health problems. This finding is consistent with findings from a community-based study using the National Comorbidity Study ~Alegria et al., 2002!. Among men and women screened for psychiatric problems, Black0African Americans were less likely to have a mental health disability, to have a current mental health diagnosis, or to have a lifetime diagnosis ~Alegria et al., 2002!. Similarly, in our study Black women showed the lowest levels of exposure to physical abuse in childhood when compared with White women. White women also had significantly higher levels of exposure to sexual abuse compared to Black and Hispanic women. Second, Hispanic women were the least likely to report use of psychiatric medications, despite the presence of a mental health pattern similar to that of White women ~who reported the highest usage of such medications!. This disparity indicates that this important area of service need should be explored. A randomized trial of depression treatment found that guideline-based care for impoverished Black and Hispanic women, particularly care that included medication, improved depressive symptoms and duration of treatment substantially compared with care given to women referred to community mental health services ~Miranda et al., 2003!. One contributing factor to Hispanic womens underutilization of psychiatric medication may be the additional barriers to mental health services they face, such as the lack of bilingual mental health providers that have been documented in other studies ~US DHHS, 1999!. Third, race0ethnic differences emerged among patterns of substance use in this sample of women who were seeking treatment similar to those reported in previous studies ~SAMHSA, 1998!. White women initiated use of all substances at the earliest age compared to Black and Hispanic women and also had more severe drug addiction severity scores compared to Black women, suggesting a more compromised clinical profile among White women, consistent with their greater mental health and trauma severity. Findings from other studies ~Kilpatrick, Acierno, Resnick, Saunders, & Best, 1997; Najavits et al., 1997! suggest that the earlier age of substance use initiation and greater clinical vulnerability among White women may be related to their earlier exposure to sexual and physical abuse and more frequent exposure to interpersonal abuse. These findings indicate that while White women may benefit from greater access to economic resources, their clinical needs are more severe, and treatment for addiction and mental health disorders and trauma should be especially sensitive to these needs. Future analyses of data from this study should explore racial and ethnic differences in the relative role that economic and social vulnerability compared to clinical severity play in treatment outcomes, and in the intensity and length of intervention required to achieve positive outcomes. It is not clear, for example, why White women seem to be entering treatment at higher levels of symptom severity and Black women at lower levels. Similarly, the study findings raise questions about why Hispanic women, who initiate substance use later and have lower rates of sexual abuse than Whites, have levels of addiction, trauma, and mental health symptomatology similar to

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Whites. Further, the findings point to the importance of exploring the protective factors or buffers that may mediate the effects of economic and social vulnerability among Black women. Research is also needed to better understand the role of immigration, acculturative stress, and English language proficiency in this group of Hispanic womens social and economic vulnerabilities and underutilization of psychiatric medications. The limits of our data prevented exploration of cultural identity, including identification with particular cultural values or practices, social support, or social network characteristics as possible protective factors. These are important areas for further research. Although this is the largest sample of women with co-occurring mental health and substance abuse disorders studied to date, there are a number of study limitations that warrant consideration. The sample was not randomly drawn and thus, results may not necessarily be applicable to the larger population. Women in publicly funded treatment programs may represent those with the most severe co-occurring disorders that interfere with social function and the ability to have adequate private insurance coverage. Further, because the psychometric properties of the scales we used have not been established in Hispanic and Black women, measurement error may account, in part, for differences or lack of differences reported. There may also be bias introduced with self-reported drug and alcohol use because underreporting is common. Also, racial0ethnic differences, while statistically significant, may not always be clinically significant. Finally, the sample did not allow for separate analysis of data for Asian American and Native American women. In summary, our findings indicate significant differences among Black, Hispanic, and White women with co-occurring disorders receiving treatment services and provide additional evidence that tailoring programs to target groups of women may help to improve treatment outcomes. Future analyses of data from the current study and others can explore the clinical relevance of these differences and their impact on treatment outcomes with more representative samples. REFERENCES
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