Women in outpatient treatment for alcohol abuse: sociodemographic and clinical characteristics

Abstracts

Estudo quantitativo e descritivo, com o objetivo de identificar características sociodemográficas e clínicas de mulheres em tratamento ambulatorial por abuso de álcool. Os dados foram coletados em prontuários de mulheres com transtornos relacionados ao álcool, atendidas em serviço psiquiátrico ambulatorial. Foi realizado levantamento, leitura e análise descritiva. A amostra foi composta por 27 prontuários, a média de idade das mulheres foi 50 anos, maioria casada (59,6%), não trabalhava (70,4%), com ensino fundamental incompleto (70,4%), com familiar alcoolista (81,5%) e outros diagnósticos psiquiátricos (70,3%). Prejuízos físicos, sociais e emocionais mais frequentes foram: sintomas advindos da síndrome de abstinência alcoólica (66,7%), conflitos familiares (72%) e "tristeza" (79,2%). A violência familiar foi registrada em 11 prontuários (40,7%). Verificaram-se baixa escolaridade, desemprego, comorbidades psiquiátricas e presença de outro familiar com abuso de álcool como características comuns. Destaca-se a importância do conhecimento profissional sobre as peculiaridades do alcoolismo feminino para ações de saúde mais efetivas.

Mulheres; Saúde da mulher; Alcoolismo

El estudio cuantitativo y descriptivo tuvo como objetivo identificar las características sociodemográficas y clínicas de las mujeres sometidas a tratamiento ambulatorio por abuso de alcohol. Los datos fueron obtenidos de las historias clínicas de mujeres con trastornos relacionados con el alcohol que fueron tratadas en un servicio psiquiátrico ambulatorio. Se realizó un análisis descriptivo y lectura de estos datos. La muestra se compone de 27 historias clínicas, la edad promedio de las mujeres era de 50 años, casadas (59,6%), sin trabajar (70,4%), con educación primaria incompleta (70,4%), con una familia alcohólica (81,5%) y otros diagnósticos psiquiátricos (70,3%). Las pérdidas físicas, sociales y emocionales fueron los síntomas más comunes que resultan de síndrome de abstinencia de alcohol (66,7%), conflictos familiares (72%) y "tristeza" (79,2%). La violencia familiar se registró en 11 registros (40,7%). Hubo baja escolaridad, el desempleo, las comorbilidades psiquiátricas y la presencia de miembros de la familia con el abuso de alcohol como características comunes. Hacemos hincapié en la importancia del conocimiento profesional acerca de las peculiaridades del alcoholismo femenino para actividades de salud más eficaces.

Mujeres; Salud de la mujer; Alcoholismo

ORIGINAL ARTICLE

^IPhD student of the Graduate Mental Health Programme, School of Medicine of Ribeirão Preto - University of São Paulo (FMRP-USP), Ribeirão Preto, São Paulo (SP), Brazil

^IIProfessor, PhD Faculty of Philosophy, Sciences and Languages of Ribeirão Preto (USP), Department of Philosophy, Ribeirão Preto, SP, Brazil

^IIIProfessor, PhD Ribeirão Preto College of Nursing of the University of São Paulo, Department of Psychiatric Nursing and Human Sciences, Ribeirão Preto, SP, Brazil

^IVProfessor, PhD School of Medicine of Ribeirão Preto - University of São Paulo, (FMRP-USP), Department of Neuroscience and Behavioural Science, Ribeirão Preto, SP, Brazil

Author's address

ABSTRACT

Quantitative and descriptive study aimed to identify sociodemographic and clinical characteristics of women undergoing outpatient treatment for alcohol abuse. Data were collected from medical records of women with alcohol-related disorders who were treated at a psychiatric outpatient service. We performed a reading and descriptive analysis of such data. The sample was composed of 27 medical records, the average age of women was 50 years, mostly married (59.6%), not working (70.4%) with incomplete primary education (70.4%), with an alcoholic family (81.5%) and other psychiatric diagnoses (70.3%). Losses physical, social and emotional was the most common symptoms resulting from alcohol withdrawal syndrome (66.7%), family conflicts (72%) and "sadness" (79.2%). Family violence was recorded in 11 records (40.7%). There was low education, unemployment, psychiatric comorbidities and the presence of other family members with alcohol abuse as common characteristics. We emphasize the importance of professional knowledge about the peculiarities of female alcoholism for health activities more effective.

Descriptors: Women. Women's health. Alcoholism.

INTRODUCTION

A recent report published by the World Health Organization (WHO) revealed data on alcohol consumption in more than 100 countries. Alcohol abuse is linked to approximately 4% of deaths and disabilities around the world. It is also one of the four most common risk factors for a wide range of non-communicable diseases, such as cardiovascular disease, chronic pulmonary disease, cancer and diabetes ⁽¹⁾.

Epidemiological studies show that there are gender differences in relation to alcohol consumption patterns in different societies. Women, in comparison to men, have a greater tendency for abstinence and lower levels of consumption of this substance. The prevalence of problematic alcohol use seems to be significantly greater in men, although alcohol consumption among women has increased ^(1,2). In Brazil, for example, a national survey shows that adolescents of both sexes are consuming alcohol with similar frequencies and only two thirds of these adolescents are abstinent ⁽³⁾.

Scientific evidence shows that after ingesting equivalent quantities of alcohol, the female body, given the particular characteristics of women, suffers a greater and more negative impact than the male body. One reason is that it is more difficult for the female body to metabolize alcohol due to lower water volumes and higher proportions of body fat. Consequently, women feel the effects of alcohol more rapidly than men, and require lower quantities to obtain the same effects. Women also tend to develop premature hepatic cirrhosis and cardiomyopathy due to greater tissue vulnerability ^(4,5) and they present alcohol dependency in a shorter period of time ⁽⁶⁾.

There are important differences between the way men and women relate to alcohol. Most frequently, women seem to consume alcohol to obtain emotional support for their anxieties and worries ⁽⁷⁾, while with men consumption seems to be related to leisure or interaction with friends at bars.

Studies suggest that women who consume alcohol in a manner that is considered problematic have a greater tendency to suffer from psychiatric disorders and emotional symptoms than men ^(7,8). Among pregnant women, disorders related to alcohol consumption were associated with increased psychiatric suffering and symptoms of depression or anxiety ⁽⁹⁾. Many pregnancies in Brazil are not planned or desired ⁽¹⁰⁾, so the fact that alcohol consumption is increasing among women, especially during the fertile period, exposes them to high consumptions risks at some point during pregnancy.

Studies conducted in the city of Ribeirão Preto showed that approximately 22% of pregnant women consumed alcohol at levels that were considered high-risk, considering that consumption can damage the organism and cause fetal development problems ^(9,10). Pre-natal complications related to alcohol consumption include an increased incidence of miscarriage during the second trimester of pregnancy and compromising factors during labour, such as the risk of infection, placental abruption, uterine hypertonus, premature labour and meconium in the amniotic fluid. Regarding fetal health risks, Fetal Alcohol Syndrome is considered to be the most serious damage that can be caused by maternal alcohol abuse. This syndrome comprises a pattern of defects (pre-natal and post-natal) in the development of the central nervous system of the infant and a series of characteristic facial abnormalities ⁽¹¹⁾.

In spite of the frequent physical and physiological problems resulting from the use of alcohol among women, the social stigma of consumption seems to prevent women from seeking treatment when they feel it is necessary ⁽¹²⁾. Women seem to conceal their consumption based on the fear of being judged, and are reluctant to seek treatment ⁽¹³⁾. Among the difficulties in treatment, there is a lack of identification of these women by healthcare professionals as, many times, the clinical dysfunctions they suffer are not recognized as being secondary symptoms of alcohol abuse. It is not uncommon for these women to seek medical services complaining of psychological or physical symptoms and omitting the problems they are having with alcohol ^(7-13).

Full acknowledgement of these women is extremely important because it provides the tools to improve assistance and adherence to treatment, and enables more effective healthcare actions ⁽¹³⁾.

In light of the information available in literature, the following guiding questions seemed pertinent: According to the medical records, who are the women that seek treatment for problems related to alcohol consumption? What are the main social and demographical characteristics identified? And, finally, what are their emotional and physical complaints?

Consequently, the aim of this study was to identify, by means of medical records, the key sociodemographic and clinical characteristics of the women who underwent treatment for disorders related to alcohol consumption in the psychiatric outpatient service of the university hospital.

METHODOLOGY

This is a cross-sectional quantitative case study. Data were collected using the medical records of women who visited the substance dependence unit of the Clinical Hospital at the School of Medicine of Ribeirão Preto, University of São Paulo (HCFMRP-USP) between 2000 and 2005. This period was selected because this article is associated to a larger project that was presented to graduate students of the Nursing School of Ribeirão Preto for final course work ⁽¹⁴⁾ and, later, to the Faculty of Philosophy, Science and Letters of Ribeirão Preto as a doctoral thesis. The aim of this broader project was to identify clinical and life characteristics of all the women undergoing psychiatric treatment in this psychiatric unit.

Some of the women who received medical assistance at the outpatient unit in this study were referred by the gastroenterology clinic due to medical diagnoses performed at the Clinical Hospital. For this study, a standardized medical chart was used to record sociodemographic and clinical information related to alcoholic intake. Data were collected using records completed by physicians and residents of the gastroenterology and psychiatric clinics.

A list containing the record number of all patients who underwent treatment during the study period was prepared. This study included medical records which contained information about women who had sought assistance at the Substance Abuse Unit of the HCFMRP and had been diagnosed with a disorder related to alcohol use according to the International Classification of Disease (ICD-10). The records of women who underwent treatment for disorders with other substances (illegal drugs, pharmaceuticals) were excluded.

Data collection was only initiated after the analysis and approval of the Ethics Committee of the Clinical Hospital, School of Medicine of Ribeirão Preto (10/01/2007, process 13420/2006).

RESULTS

This exploratory study, which does not include hypothesis testing, was based on sample description. A total of 110 medical records of women who were outpatients of the psychiatric service between 2000 and 2005 were identified for this study. All selected records were read and only 27 complied with the inclusion criteria. The key factor for exclusion was additional treatment for other psychoactive substances. For this study, only women who were being monitored for alcohol-related disorders were selected.

The mean age of the women in treatment for alcohol abuse was 50 years, with a minimum age of 27 and a maximum of 66 (sd = 10). The majority of the women were married (n = 16; 59.3%), mothers (n = 25; 92.6%), Catholic (n = 14; 51.9%) and were unemployed at the time of the last consultation (n = 19; 70.4%).

Regarding schooling, only one of the women in the records had not attended school (3.7%), 13 had not completed elementary education (48.1%), four had completed elementary education (14.8%), four had not completed high school education (14.8%), one had completed a higher education course (3,7%) and four records did not specific the schooling levels (14.8%).

The presence of another alcoholic family member was identified in 22 records (81.5%), of which 12 were the husbands of these patients, (31.6%), nine were parents (23.7%), seven were siblings (18.4%), four were mothers (10.5%), two were the children of patients (5.3%) and four were other family members (10.5%).

The ICD-10 was used to classify diagnoses related to alcohol abuse. Consequently, a total of 26 (96.3%) women were diagnosed with Alcohol Dependence Syndrome and only one woman received a diagnosis of Harmful Alcohol Use (3.7%).

Other psychiatric complaints were identified in the records of 19 women (70.3%), including more frequent depressive episodes (n = 11; 57.8%), followed by personality disorders (n = 04; 21%), anxiety disorders (n = 03; 15.9%) and psychotic disorders (n = 01; 5.3%).

The mean age at the start of the alcohol abuse was 33.4 years (min = 10; max = 59; sd = 12.9), with the ages ranging from 30 to 39 years (25.9%) in seven records. Situations considered as being triggers of alcohol consumption were identified in 21 records (Table 1), namely: change of social role (death of family member, death of spouse, pregnancy, child birth, children leaving home and sickness of family members); emotional relationship difficulties (unfaithfulness, fights with spouse or companion and domestic violence); stimulus of spouse and a gradual increase, in some cases the motive was unknown.

Table 01. Frequency and percentage of situations considered as triggers of alcohol consumption, Ribeirão Preto, 2010.

In the records evaluated for this study, physical, social and emotional impairments were identified by the patients during the consultations or by the residents as being the result of alcohol abuse. Records of physical impairments (Table 2) were found in 21 files (77.8%), of which Abstinence Syndrome symptoms (hallucinations, headaches, tremors, convulsion) appeared with greater frequency (n = 14; 66.7%), followed by liver problems (n = 10; 47.6%), gastrointestinal problems (n = 7; 33.3%), cognitive impairments (n = 7; 33.3%) and sleep disorders (n = 7; 33.3%).

Social impairments (Table 3) were registered in the records of 25 women (92.6%), with family conflicts appearing with the highest frequency (n = 25; 92.6%), followed by social isolation (n = 11; 44%) and losses in the role of mother and housewife (n = 8; 32%).

In relation to emotional complaints (Table 4), 24 records (88.9%) showed the occurrence of these problems, with sadness presenting the highest frequency (n = 19; 79.2%), followed by discouragement (n = 08; 33.3%), guilt and aggressivity (n = 06; 25%).

Family violence was registered in 11 records (40.7%) and the aggressors were identified as the parents (n = 03; 11.1%) and, more frequently, the husbands (n = 08; 29.6%). Other relevant reports, found in 14 (51.9%) records, were thoughts of suicide or suicide attempts.

The records were also used to identify situations that contributed to behavioural changes. Of these situations, the most common were concerns with health and medical guidance (68.2%) and the desire to perform the social gender roles expected by society (mother, wife, housewife) (68.2%). Other situations included motivation for new projects (the desire to feel more willingness to work, go back to school, develop potentials, save money, feel self-proud) (36.4%) and family support (13.6%).

DISCUSSION

The higher occurrence of patients with dependence in comparison to harmful use of alcohol is due to the fact that this psychiatric outpatient service is provided at a tertiary reference hospital in the region of Ribeirão Preto-SP, and receives cases that are considered serious and difficult to handle by other services.

Among the samples evaluated in this study, 48.1% had not completed elementary education and most were not working at the time of the last consultation (76.2%). Another study presented results that corroborate these data. Research conducted at a specialized substance abuse outpatient unit showed that the majority of the women attended at the service had not completed elementary education, were single and unemployed. Low schooling levels and minimal professional qualifications can hinder the insertion of these women in the labour market ⁽¹⁵⁾.

The majority of the women who presented increased alcohol abuse were over 30 years of age (n = 13; 48.2%) and the mean age of the patients was 50 years. These findings are consistent with another study, in which regular alcohol consumption was more frequent in older women treated for alcohol dependence, in comparison to men. In alcohol abuse situations, women were usually accompanied by their husbands or companions ⁽¹⁶⁾.

Although this abuse occurs later and is less frequent in women, from the biological standpoint, studies support the hypothesis that the female metabolism is less tolerant to alcohol^(4,5). Once it is ingested in equivalent quantities, alcohol has a greater negative impact on the female body than in the male body ⁽⁵⁾. The "telescope effect" is the term cited to refer to problems caused by alcohol use or abuse that appears prematurely for women ⁽⁶⁾.

In this study, in relation to the physical impairments caused by the harmful use of alcohol, 81% of the women in treatment suffered some form of physical loss, especially liver damage followed by abstinence syndrome symptoms. In relation to social impairments, the most frequent reports were family conflicts (66.7%) and difficulties in complying with the social roles expected of women, such as being a mother and housewife (33.3%). After analysing these data together with emotional impairments, sadness and discouragement were the most frequent complaints in 76.2% of the records, followed by irritation, guilt, aggressivity and shame. Studies show that the difficulty in performing their activities due to substance abuse triggers feelings of guilt and shame among women ^(12,13).

In addition, a qualitative study with women undergoing treatment for chemical dependency showed that the representations regarding alcohol use carry some particularities for women. The authors state that the consequences of female alcoholism identified by the patients were frequently related to their families and the differences in gender relationships within the family. The representation of "women suffering from alcohol abuse", for example, was identified as pertaining to women who find it difficult to adequately perform the social role of "mother", "care-giver" and "wife", that is, the woman who consumes alcohol in an abusive manner was described by this sample as being someone who does not perform her social role ⁽¹⁷⁾.

The medical records also included statements of other family members with alcohol abuse (n = 22; 81.5%), namely, husbands (n = 12; 31.6%), parents (n = 09; 23.7%) and siblings (n = 07; 18.4%). Family abuse of alcohol may be related to alcohol consumption of these women. One of the difficulties that women find when they try to stop is that their companion is also a consumer of alcohol. In this case, the companion can discourage her from adhering to treatment and she, fearful of altering relationships at home, continues consuming alcohol or often relapses ⁽¹⁸⁾.

Family violence was also frequently reported in this sample. In this study, 11 records (40.7%) stated the occurrence of violence, and in eight of these cases the husband was reported as being the aggressor. Domestic violence, betrayal and fights with the companion were identified as being the main triggers for the abusive consumption of alcohol in 24% of the records.

Marital problems, high conjugal aggression rates and disagreements with companions have been targeted as stressors in women with alcohol consumption problems. The use of this substance seems to be a strategy to deal with bad memories or present situations of pain and passiveness. A study indicates that the start of consumption is related to situations of violence toward the women and .also indicated that women who abuse alcohol have a higher incidence of physical or sexual abuse during their childhood or adolescence in comparison with women who do not use alcohol ⁽¹⁹⁾.

In addition to physical violence, other stressors such as death in the family or death of the spouse, the departure of children from the family home and sickness were identified as triggers of abusive consumption. The exposure to stress caused by these experiences can increase the potential for the initiation of and increase in the frequency of substance consumption, and can contribute to a higher number of relapses of alcohol use after a period of abstinence ⁽¹⁹⁾.

In this study, 76.2% of the women recorded an additional psychiatric diagnosis, followed by personality disorders, anxiety and psychotic disorders. Women who resort to the harmful use of alcohol show a higher prevalence of psychiatric disorders and emotional symptoms in comparison to men with the same diagnosis, they also present a greater incidence of depression, anxiety and eating disorders ⁽⁷⁾.

A systematic review showed that around one third of patients with more serious depressive episodes also suffered from a disorder related to the abusive use of psychoactive substances and this comorbidity increased the risk of suicide and other social impairments ⁽²⁰⁾. Data on suicidal thoughts or suicide attempts were found in 57.1% of the records and symptoms of depression and anxiety were found in 52.4%. Some hypotheses are presented in the literature for this comorbidity, including the hypothesis that there is a common factor for both diagnoses; the hypothesis that disorders caused by substance use are secondary to the psychiatric disorder; the hypothesis of a secondary mental disorder to the disorder of substance abuse; the two-directional hypothesis - each disorder increases the chance that the other will appear ^(14-20).

In this study, it was not possible to identify whether comorbidity is the result of consumption or not, considering that a patient could have had another psychiatric disorder and not received treatment, or received treatment in another unit. However, the physicians that accompanied these women during their care for alcohol dependency noted that this is an important evaluation that should be considered and deserves to be registered in the records.

CONCLUSIONS

This study allowed the identification of specific characteristics of women with harmful use or alcohol dependency, who were outpatients at a psychiatric unit. Key findings and common characteristics of this sample include low schooling level, unemployment and the presence of another family member that abused alcohol.

Research on this subject indicated important differences between men and women in relation to psychoactive substance abuse, and that women are the target of increasing investigation due to their greater vulnerability to the negative effect of alcohol and the psychological and social particularities of consumption among women.

Clinical characteristics mainly comprised physical, emotional and social impairments, especially the social consequences of alcohol consumption. Changes in social roles and difficulties in emotional relationships were identified as triggers for abusive consumption. These data emphasize the importance of more careful consideration of the emotional factors when considering women's health.

The strengthening of social support and services, such as primary care that allows closer contact with the population and a more sensitive approach to the needs of women, is therefore suggested. These services can help women find the strategies to deal with their difficulties, such as sickness, death in the family and domestic violence, within the family environment and subsequently help to prevent problems such as those related to alcohol consumption.

During treatment in specialized services for alcohol and drug abuse, it is also important that the professional approach the different aspects in the lives of the women who abuse alcohol and consider their complexities in order to help them reconstruct their lives.

The fact that this study was based on a small sample group and secondary sources of information creates some limitations in terms of asserting the results. Although a standardized chart was used to facilitate data collection, there were certain difficulties in reading some notes and information in the records. However, the results obtained emphasize the importance of evaluating the characteristics and specificities related to alcohol consumption in the female population.

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Women in outpatient treatment for alcohol abuse: sociodemographic and clinical characteristics

Larissa Horta Esper^I; Clarissa Mendonça Corradi-Webster^II; Ana Maria Pimenta Carvalho^III; Erikson Felipe Furtado^IV

Publication Dates

• Publication in this collection
  26 July 2013
• Date of issue
  June 2013

History

• Received
  25 Oct 2011
• Accepted
  06 Dec 2012