Alcohol-dependent patients receiving specialised outpatient care : an overview of gender issues

Objective: The objective of the present study, with focus on gender, was aimed at evaluating alcohol-dependent individual in terms of socio-demographic variables related to alcohol consumption and therapeutic interventions. Methods: This is a retrospective cross-sectional study of 1,051 patients (833 men and 218 women), with diagnosis of alcohol dependence syndrome, according to ICD-10 criteria, who had sought treatment for the first time at a specialised health centre between 2000 and 2006. Results: The results showed that women, compared to men, are more likely to be unemployed and without partner, in addition to having higher educational level, latter age of alcohol initiation, needing less outpatient alcohol detoxification program, consuming more fermented beverage, presenting less psychiatric comorbidities, and using less coadjutant medications during treatment. Conclusion: We can state that some peculiarities exist permeating both gender and alcohol consumption. A further focus on the characteristics of each population is needed to facilitate the adequate use of therapeutic interventions according to gender specificities.


artigo original
Alcohol-dependent patients receiving specialised outpatient care introDUCtion Gender differences in alcohol use have been important ways in which societies have symbolized and regulated gender roles.There is evidence that the consumption of alcoholic beverages by women was a practice condemned within the ancient societies, whose punishment was more rigorous with them than with men 1 .
The practical result of this intense social stigma and embarrassment applied to alcoholic women kept them in hiding 1 and until the early 1990s the substance abuse treatment literature was based primarily on male samples, or mixed samples of men and women without any interesting on gender differences and, as a result, women remained subestimated and sub-represented in the research 2 .
Over the last decade researchers began to focus on the disparities between men and women and point out there are a number of target characteristics (socio-demographic, biological, clinical, cultural) can be seen as an important key to answering broader questions about gender-specific predictors of treatment outcomes 3 .
Due to the importance of this theme and scantiness of studies on this issue the objective of the present study was to evaluate the alcohol-dependent individual in terms of socio-demographic variables related to alcohol consumption and therapeutic interventions, on focus in the gender.

MEtHoDS
This is a cross-sectional study involving 1,051 alcoholic patients (833 men and 218 women), according to ICD-10 criteria, who had sought treatment for the first time at the Alcohol and Drugs Research Unit (Uniad), a service linked to the Federal University of São Paulo , between 2000 and 2006.
Outpatient screening for alcoholism was conducted by psychologists, physicians, and nurses in order to collect sociodemographic data, investigate patterns and frequency of alcohol consumption, evaluate previous and current therapeutic interventions, make differential diagnosis between alcohol abuse and alcoholism (according to ICD-10 criteria), elucidate physical, psychological, and social problems resulting from alcohol use, observe physical signs and symptoms of alcohol withdrawal syndrome (AWS), and finally, verify the need for alcoholic detoxification (DST) with specific medications.
The Short Alcohol Dependence Data Questionnaire (SADD) was used to evaluate the severity of dependence syndrome in those cases of diagnosed alcoholism.This instrument was validated for use in Brazil by Jorge and Masur  (1985)  4 and has been regularly applied to the patients attending this unit.It consists of 15 items with scores ranging from 0 to 3 (0 = never, 1 = a few times, 2 = many times, 3 = always) in which the following classification can be achieved: mild dependence (1 to 9 points), moderate (10 to 19), and severe (20 to 45).
Chi-square test was used to analyse the variables and Student-t test to compare the mean values between both groups, considering p < 0.05 for statistical association.
This study was approved by the Ethics Committee of the Federal University of São Paulo (Process number 1627/05).

rESUltS
Table 1 shows the distribution of socio-demographic data regarding the sample studied.With regard to marital status, we have found statistical association and also a greater proportion of women living alone.
The educational level among women was at the extremes, that is, illiterates and university graduates.Also, it was observed a great proportion of unemployed women.
Table 2 lists the distribution of alcohol consumptionrelated variables in the sample, with women using more fermented beverages.
Alcohol dependence was found to be severe in both groups, although no statistical association was observed.
Table 3 shows the distribution of treatment-related variables in the sample, with women using less coadjutant medications than men.Also, fewer women were found to have some form of psychiatric disorder and used less outpatient alcohol detoxification program.

DiSCUSSion
The present study shows the high proportion of women living alone as well as scientific evidence suggesting that marriage is a protective factor for men.On the other hand, marriage contributes for a shorter time to relapse among women and indicates that women using alcohol, compared to men, are more likely to marry partners who consume alcoholic beverage heavily 5,6 .
In Brazil, the rate of illiteracy for men and women aged 15 years old and above was estimated to be 11.3% and 10.8%, respectively 7 and the average of the study in Brazil is 7.4 years 8 .Although ethnicity wasn't addressed in this study, the rate of illiteracy and functional illiteracy among the black and mulatto population is about twice higher than that of white population.In turn, the proportion of white individuals aged 25 years old or more with at least 15 years of education is three times higher than that of black and mulatto 7 .The specialised literature points that women using psychoactive substances have lower educational level compared to men 9,10 .
The findings from this study not only indicate a great number of male and female patients with low educational level (incomplete elementary school), but also a greater proportion of illiterate women compared to men.On the other hand, more women have superior education compared to men, a fact that corroborates the findings reported by Zilberman et al. 11 .
The low educational level might lead to an unfavourable occupational situation, and the literature shows that women are less likely to be employed than men 12 , maybe because the former functions in certain societies, namely: wife, housekeeper, and mother.
The beginning age of regular consumption of alcoholic beverage was 19 years (SD = 6.7) for men and 24 years (SD = 11.9) for women, whereas the mean age of the patients was 42 years (SD = 10.6 and SD = 11.3,respectively for men and women).The telescopic effect, in which women begin drinking later than men but exhibit earlier negative consequences, is cited several times in the literature 13,14 .
In this study, distilled beverages were widely consumed by both men and women, and cachaça was the first option because its low cost.Laranjeira and Hinkly 15 analysed the density of alcoholic beverages selling points in low socioeconomic regions of São Paulo City and they observed 29 outlets per km or one outlet for every 12 owners.They concluded that this was the highest outlet density described in the medical literature, with 72% of the owners indicating cachaça as the most widely sold beverage.

artigo original
Alcohol-dependent patients receiving specialised outpatient care Despite women are more vulnerable to adverse effects of alcohol 16 , it is necessary to get additional information (last alcohol consumption, the level of dependence, type of beverage used, years of alcohol consumption) in order to increase understanding about the fewer needing care the outpatient alcohol detoxification program.
The literature ensures that depressive and anxiety disorders are among the most commonly psychiatric comorbidities found in alcoholic women, with rates higher than those for alcoholic men 17,18 , who in turn have more anti-social disorders 19 .The findings of this study, however, show a high proportion of men presenting depressive and anxiety disorders.As it is not uncommon to find a high rate of dropout during the first months of treatment, a great number of patients do not receive any psychiatric evaluation, thus reinforcing the idea that the rates of psychiatric disorders would be higher than those found elsewhere.
Stigma and social sanctions interfere with the early identification of alcoholism as women are less likely to seek specialised treatment compared to men 20 .Moreover, not only there is a lack of practitioners in other areas who are able to identify the real cause for help seeking and the problems involved 21 , but also the health mental professionals have difficulty in treating such patients 22 .
In Brazil, patients have opted for disulfiram as coadjutant medication because of its low price.In addition, there is a great concentration of severely alcoholic patients and a rapid-acting medication is of great value provided that the patient understands the treatment goal, becomes motivated to keep abstinence, and has responsibility on the medication being taken.A recent study has proved that despite being an old drug, disulfiram is effective in keeping alcoholic individuals under outpatient treatment regardless of their gender 23 .

table 1 .
Gender distribution of socio-demographic variables in the sample i: incomplete; c: complete.Elbreder MF, Silva RS, Laranjeira R artigo original

table 2 .
Gender distribution of alcohol consumption-related variables in the sample

table 3 .
Gender distribution of treatment-related variables in the sample