Substance Use and Mental Illness among Women Admitted in a Rehabilitation Center in Jos, Nigeria: A 5-Year Profile

Substance use disorder are among the most common public health problems caused by using legal and/or illegal substances. Therefore, this study is aimed at reviewing a five-year profile of women admitted at a rehabilitation center in Jos, Nigeria for substance use and mental illness. This is a retrospective cross-sectional study carried out on 183 females admitted between 2012 and 2017 at a rehabilitation center in Jos, Nigeria. Data collection was carried out from documents note of these female participants. Data were analyzed using SPSS version 22. The mean age of the participants was 38.515.3 years. Almost half of the participants were within the age bracket of 20 – 29 years and married (45.9%). Depressive disorder (36.1%) was the commonest mental disorder in the studied participants. Among those abusing substances, multiple substance use (12.6%) was the most prevalent with alcohol use disorder (9.3%) the main diagnosis among those with substance use disorder. According to the result almost half of the studied participants were young, married and educated females. Depression and multiple substance abuse with alcohol the main drug of abuse was a cause for concern in this population. This portrays significant health and economic consequences and the need for urgent action.


INTRODUCTION
ubstance dependence in women is becoming increasingly prevalent. Generally, it is assumed that S substance use in women often start in adolescence years 1,2 like in the male counterparts. The number of drug users in Nigeria is estimated at 14.4 per cent or 14.3 million people aged between 15 and 64 years according to the 3 results of the National Drug Use Survey. The data suggested that the 2018 prevalence of past year drug use \20 in Nigeria was more than twice the global average of 5.6 per cent. According to the survey, one in four of every drug user in Nigeria was a woman while one of five of high-risk drug users inject drugs. The report showed a gap in meeting the needs for treatment and care for people with drug use disorders even as close to 3 million Nigerians were living with some level of drug dependence. It highlighted extremely limited availability of drug counselling and treatment services in 3 Nigeria. Globally, UNODC estimates that between 155 and 250 million people, or 3.5% to 5.7% of the population aged 15-64, had used illicit substances at least once in the previous year. Cannabis users comprises the largest number of illicit drug users (129-190 million people). Amphetamine-type stimulants are the second most commonly used illicit drugs, followed by opiates and cocaine. However, in terms of harm associated with 4 use, opiates would be ranked at the top. A study in the United States of America has shown that 7.7% of males in comparison with 5% of females were drug abusers (the sex difference was lower than 3% documented 5 previously). Also, almost 4.5 million women drink alcohol, 3.5 million abuse prescription drugs, and more 5 than 3 million abused illicit drugs. The pattern of substance use varies according to culture 2 of people, psychosocial factors, hence gender specific 6 treatment are increasingly advocated. Over 2.5 million women are currently addicted to drugs in the United 7 States. Worldwide, alcohol use in women has received the widest attention and problems related to illicit substance use and their treatment mirror the issues related to alcohol use in many ways, not minding that important 8 differences may exist. Studies have also shown that while males consume alcohol to enhance happiness, females consume the same to reduce stress and 9,10 negativity. Women naturally are more sensitive to pain and are likely to experience chronic pain and anxiety, making them more susceptible to abuse of prescribed 11 drugs. While drug abuse significantly decreased as boys grew older (year-over-year reduction), the same was not 12 seen in girls. Several reasons exist why women abuse drugs and develop addictions and these are not exclusive to women per se, but are much more prevalent in women than in men. They include self-image issues, sexual abuse 7 and physical abuse. Gender differences in substance use have been consistently observed in the west, among general population as well as in the treatment-seeking samples, with men exhibiting significantly higher rates of 13,14 substance use, abuse, and dependence. Women are less 7 likely to seek treatment for drug addictions than men. For many drugs, women are almost twice as likely to become addicted as men and 2 of 3 women's Acquired Immune Deficiency Syndrome (AIDS) cases in the United States 7 involve drugs in some way. According to National 15 Institute on Drug Abuse (NIDA) women often use substances differently than men, such as using smaller amounts of certain drugs for less time before they become addicted. Women can respond to substances differently. They may have more drug cravings and may be more likely to relapse after treatment. Also, sex hormones can make women more sensitive than men to the effects of some drugs. However, this gender differences tend to 16 disappear after the age of 50 years. In a study among female university students aged 18-25 years in India, 17 Kaur et al reported that participants used substances out of curiosity, for having fun, personal problems, easy availability, familial use, and health problems. According to an Indian national epidemiologic survey in 2001,7.9% of women across cities used at least one type of 18 substance. In the study, heroin, alcohol, cannabis, and painkillers were the dominant substances of abuse. Another part of the survey focusing on women used snowballing sampling technique and reported high rates of opioid and alcohol use in female substance users with an alarming 40% women reporting lifetime history of 18 Injection drug use. Though it is hard for anyone to acknowledge the issues with their substance addiction, the stigma of substance addiction, being in denial and the false assumption that if they can still hold a job and take care of house chores, the addiction is under control tends 7 to make women seek intervention late. The gap in in prevalence rate of substance use is gradually closing worldwide. According to USA surveys, in the 1980s they reported 5:1 male/female ratio of alcohol-use 20 disorders, the ratio dropped to approximately 3:1 in a 21 2007 survey. In a 2012 study amongst 41.5 million illicit drug users, more than 42% were women, suggesting a 22 male/female ratio of 1.4:1. In 2013, the rate of substance dependence among adolescent males was 5.3 percent and 23 their female counterparts was 5.2 percent. Data from the National Household Survey on Drug Abuse (NHSDA) in 2000 from USA showed that rates of substance use were almost similar between girls and boys in the age groups of 12-17 years (9.5% vs. 9.8%) and tobacco use was higher in these adolescent girls (14.1% vs. 12.8%, 12 respectively). A study on substance use in a Nigerian community found a similar incidence rates among males 24 and females(49.1% and 49.2%) respectively. Comorbid psychological factors have been strongly implicated in women with substance use disorders 25 irrespective of the type of substance used. Having a comorbid psychiatric diagnosis also increases the chances of women developing a substance use disorder with substance serving as a coping strategy for the mental 26 illness. Indian studies on treatment-seeking women users have found comorbid depressive disorders in 12%, adjustment disorder in 5%, somatoform disorder in 3%, anxiety disorder in 2%, schizophrenia in 2%, obsessive compulsive disorder in 1% and bipolar affective disorder 8,27 in 1%. Similarly, from the Indian national Rapid Assessment Survey (RAS study), respondents reported several psychological problems like insomnia, depression, anxiety, suicidal attempts and guilt 8,18 feelings. The World Health Organization cites that women are two times more likely than men to develop certain mental health conditions like depression, eating 28,29 disorders, and panic disorders.
These disorders, in which women predominate, affect approximately 1 in 3 people in the community and constitute a serious public 29 health problem. There are no marked gender differences in the rates of severe mental disorders like schizophrenia and bipolar disorder that affect less than 2% of the 29 population. Women have lower serotonin levels than men and also process the chemical at slower rates, which 28 can contribute to fluctuations in mood. Gender differences exist in patterns of help seeking for psychological disorder. Women are more likely to seek help from and disclose mental health problems to their primary health care physician while men are more likely to seek specialist mental health care and are the principal 29 users of inpatient care. The research has given us a rather detailed overview of psychopathology among women from a generic lens. Also there seems to be a focus on the American and Indian populations. While this is a good first start to using the "funnel approach", the article would read better if the literature was further streamlined to the Nigerian context. The research might uncover patterns and gaps in the literature which would provide better justification and significance to the study. Quintessential healthcare center, Jos has been attending to clients with general mental illness and substance use disorder both on in-patient and out-patient basis since its inception in 2012. In this retrospective study, we report a five-year profile, drug use and mental illness of women who were admitted into rehabilitation between 2012 and 2017. The review attempts to highlight issues unique to women attending a rehabilitation center. Such knowledge is necessary for developing appropriate services and 30 designing effective treatment.
The study was conducted at Quintessential Healthcare Center (QHC), Jos South Local government area of Plateau state, Nigeria. The center was established in 2012 with a vision of providing mental health promotion, treatment and rehabilitation for general mental illnesses and substance abuse as well as training and research. QHC offers residential treatment based on therapeutic community model as well as out-patient treatment. Ethical clearance was obtained from the management of Plateau Specialist Hospital for the study and permission by the QHC Management to access data from records of  A retrospective cross-sectional data was collected from the clients' information documented in their case notes.

DISCUSSION
A good number of female clients were admitted into the center within the study period. The number admitted per year was relatively stable implying that the turn-up was not subject to variables such as political environment and socioeconomic factors. The center operates a therapeutic community based on Christian doctrine and this can explain the fewer number of Muslim clients compared to the Christian clients. Most of the clients were educated and would likely have given reliable information. Also, all information gotten were corroborated with the family members at admission making the data gathered reliable. From the reported data, a vast majority of the clients were less than thirty years. These represent the productive age range of the society implying a high rate of economic loss due to mental health conditions. More subjects were admitted for other mental disorders than for substance use disorder. Depression was the leading diagnosis followed closely by schizophrenia and bipolar disorders in that order. This is similar with other 28,32 studies that recorded depression as the commonest diagnosable mental disorder among females and as a silent cause of mortality and morbidity among women. Few women actually presented with comorbid mental illness and substance use disorder 27(14.8%) suggesting that primary mental illness may not be a significant cause of substance use among females. Alcohol was the most used substance among the participants. This is in agreement with other hospital- 33 based studies but differed from results of surveys that 3,4 reported cannabis as the most abused substance. Within Nigeria, alcohol is legal and it is culturally accepted and readily available within the environment of the study in various forms. This could explain the higher rate of alcohol abuse relative to other substances in the study. Pentazocine use was equally high among the studied participants. However, tramadol and codeine which are illicit substances were not highly abused among the participants. Difficulty in accessing these substances could be responsible for the low prevalence.
This enquiry into the issues unique to women attending a rehabilitation center in Nigeria found that among females, substance use is a younger age affair. More females enter rehabilitation for severe mental illness than for substance \25 use disorder. The study also found that females abuse multiple substances and this portrays significant health and economic consequences to the female gender.

CONCLUSION
We recommend a prospective study to evaluate factors associated with use of substances among females entering rehabilitation.