Estimating posttraumatic stress disorder severity in the presence of differential item functioning across populations, comorbidities, and interview measures: Introduction to Project Harmony

Cannabis use and trauma-focused treatment for co-occurring posttraumatic stress disorder and substance use disorders: A meta-analysis of individual patient data

High rates of cannabis use among people with posttraumatic stress disorder (PTSD) have raised questions about the efficacy of evidence-based PTSD treatments for individuals reporting cannabis use, particularly those with co-occurring alcohol or other substance use disorders (SUDs). Using a subset of four randomized clinical trials (RCTs) included in Project Harmony, an individual patient meta-analysis of 36 RCTs (total N = 4046) of treatments for co-occurring PTSD+SUD, we examined differences in trauma-focused (TF) and non-trauma-focused (non-TF) treatment outcomes for individuals who did and did not endorse baseline cannabis use (N = 410; 70% male; 33.2% endorsed cannabis use). Propensity score-weighted mixed effects modeling evaluated main and interactive effects of treatment assignment (TF versus non-TF) and baseline cannabis use (yes/no) on attendance rates and within-treatment changes in PTSD, alcohol, and non-cannabis drug use severity. Results revealed significant improvements across outcomes among participants in all conditions, with larger PTSD symptom reductions but lower attendance among individuals receiving TF versus non-TF treatment in both cannabis groups. Participants achieved similar reductions in alcohol and drug use across all conditions. TF outperformed non-TF treatments regardless of recent cannabis use, underscoring the importance of reducing barriers to accessing TF treatments for individuals reporting cannabis use.

Collateral effects of Coping Power on caregiver symptoms of depression and long-term changes in child behavior

A large body of research demonstrates positive impacts of the Coping Power Program as a preventive intervention for youth behavioral outcomes, but potential collateral effects for caregivers is less known. The current study examined whether the youth-focused Coping Power Program can have a secondary impact on caregiver self-reported symptoms of depression and in turn result in longer-term impacts on child disruptive behavior problems including aggression, conduct problems and hyperactivity. Data from 360 youth/caregiver pairs across 8 waves of data (grades 4 through 10) were analyzed. We used two methodological approaches to (a) assess indirect effects in the presence of potential bidirectionality using timepoint-to-timepoint dynamic effects under Autoregressive Latent Trajectory modeling and (b) estimate scale scores in the presence of measurement non-invariance. Results showed that individually delivered Coping Power (ICP) produced greater direct effects on conduct problems and indirect effects on general externalizing and hyperactivity (through reductions in caregiver self-reported symptoms of depression), compared to group Coping Power (GCP). In comparison to GCP, ICP produced similar direct effects on reductions in caregiver depression. Child-focused prevention interventions can have an indirect impact on caregiver depression, which later shows improvements in longer-term reductions for child disruptive problems.

Introduction to the Special Issue on Innovations and Applications of Integrative Data Analysis (IDA) and Related Data Harmonization Procedures in Prevention Science

This paper serves as an introduction to the special issue of Prevention Science entitled, "Innovations and Applications of Integrative Data Analysis (IDA) and Related Data Harmonization Procedures in Prevention Science." This special issue includes a collection of original papers from multiple disciplines that apply individual-level data synthesis methodologies, including IDA, individual participant meta-analysis, and other related methods to harmonize and integrate multiple datasets from intervention trials of the same or similar interventions. This work builds on a series of papers appearing in a prior Prevention Science special issue, entitled "Who Benefits from Programs to Prevent Adolescent Depression?" (Howe, Pantin, & Perrino, 2018). Since the publication of this prior work, the use of individual-level data synthesis has increased considerably in and outside of prevention. As such, there is a need for an update on current and future directions in IDA, with careful consideration of innovations and applications of these methods to fill important research gaps in prevention science. The papers in this issue are organized into two broad categories of (1) evidence synthesis papers that apply best practices in data harmonization and individual-level data synthesis and (2) new and emerging design, psychometric, and methodological issues and solutions. This collection of original papers is followed by two invited commentaries which provide insight and important reflections on the field and future directions for prevention science.

Mitigating Multiple Sources of Bias in a Quasi-Experimental Integrative Data Analysis: Does Treating Childhood Anxiety Prevent Substance Use Disorders in Late Adolescence/Young Adulthood?

Psychiatric epidemiologists, developmental psychopathologists, prevention scientists, and treatment researchers have long speculated that treating child anxiety disorders could prevent alcohol and other drug use disorders in young adulthood. A primary challenge in examining long-term effects of anxiety disorder treatment from randomized controlled trials is that all participants receive an immediate or delayed study-related treatment prior to long-term follow-up assessment. Thus, if a long-term follow-up is conducted, a comparison condition no longer exists within the trial. Quasi-experimental designs (QEDs) pairing such clinical samples with comparable untreated epidemiological samples offer a method of addressing this challenge. Selection bias, often a concern in QEDs, can be mitigated by propensity score weighting. A second challenge may arise because the clinical and epidemiological studies may not have used identical measures, necessitating Integrative Data Analysis (IDA) for measure harmonization and scale score estimation. The present study uses a combination of propensity score weighting, zero-inflated mixture moderated nonlinear factor analysis (ZIM-MNLFA), and potential outcomes mediation in a child anxiety treatment QED/IDA (n = 396). Under propensity score-weighted potential outcomes mediation, CBT led to reductions in substance use disorder severity, the effects of which were mediated by reductions in anxiety severity in young adulthood. Sensitivity analyses highlighted the importance of attending to multiple types of bias. This study illustrates how hybrid QED/IDAs can be used in secondary prevention contexts for improved measurement and causal inference, particularly when control participants in clinical trials receive study-related treatment prior to long-term assessment.

Integrative data analysis of clinical trials network studies to examine the impact of psychosocial treatments for black people who use cocaine: Study protocol

BACKGROUND

Cocaine overdose death rates among Black people are higher than that of any other racial/ethnic group, attributable to synthetic opioids in the cocaine supply. Understanding the most effective psychostimulant use treatment interventions for Black people is a high priority. While some interventions have proven effective for the general population, their comparative effectiveness among Black people remains unknown. To address this gap, our NIDA-funded Clinical Trials Network (CTN) study (0125), will use Integrative Data Analysis (IDA) to examine treatment effectiveness across 9 CTN studies. This manuscript describes the study protocol for CTN-0125.

METHODS

Of the 59 completed randomized clinical trials in the CTN with available datasets, nine met our inclusion criteria: 1) behavioral intervention, 2) targeted cocaine use or use disorder, 3) included sub-samples of participants who self-identified as Black and 4) included outcome measures of cocaine and psychostimulant use and consequences. We aim to 1) estimate scale scores of cocaine use severity while considering study-level measurement non-invariance, 2) compare the effectiveness of psychosocial treatments for psychostimulant use, and 3) explore individual (e.g., concomitant opioid use, age, sex, employment, pre-treatment psychiatric status) and study-level moderators (e.g., attendance/retention) to evaluate subgroup differences in treatment effectiveness.

CONCLUSION

The NIDA CTN provides a unique collection of studies that can offer insight into what interventions are most efficacious for Black people. Findings from our CTN-0125 study have the potential to substantially inform treatment approaches specifically designed for Black people who use psychostimulants.

Differential symptom weighting in estimating empirical thresholds for underlying PTSD severity: Toward a "platinum" standard for diagnosis?

OBJECTIVE

Symptom counts as the basis for Post-Traumatic Stress Disorder (PTSD) diagnoses in the DSM presume each symptom is equally reflective of underlying disorder severity. However, the "equal weight" assumption fails to fit PTSD symptom data when tested. The present study developed an enhanced PTSD diagnosis based on (a) a conventional PTSD diagnosis from a clinical interview and (b) an empirical classification of full PTSD that reflected the relative clinical weights of each symptom.

METHOD

Baseline structured interview data from Project Harmony (N = 2658) was used. An enhanced diagnosis for full PTSD was estimated using an empirical threshold from moderated nonlinear factor analysis (MNLFA) latent PTSD scale scores, in combination with a full conventional PTSD diagnosis based on interview data.

RESULTS

One in 4 patients in the sample had a PTSD diagnosis that was inconsistent with their empirical PTSD grouping, such that the enhanced diagnostic standard reduced the diagnostic discrepancy rate by 20%. Veterans, and in particular female Veterans, were at greatest odds for discrepancy between their underlying PTSD severity and DSM diagnosis.

CONCLUSION

Psychometric methodologies that differentially weight symptoms can complement DSM criteria and may serve as a platform for symptom prioritization for diagnoses in future editions of DSM.

Cumulative exposure to traumatic events and craving among women in residential treatment for substance use disorder: The role of emotion dysregulation and mindfulness disposition

Objective

Strong evidence links exposure to traumatic life events with subsequent substance use disorders (SUD). Compared to men, women in SUD treatment are more likely to have a history of trauma, characterized in part by emotion dysregulation known to negatively influence treatment outcomes. Existing research has been conducted with predominantly male and non-Hispanic White samples, with an emphasis on adverse childhood experiences. Little is known about how exposure to cumulative traumatic events across the lifespan affects emotion dysregulation and how this may influence craving, particularly among racial and ethnic minoritized women with SUD. Mindfulness disposition may serve as a protective factor that could buffer the impact of trauma exposure and emotion dysregulation on substance use craving among underrepresented minoritized women with SUD. This study examined the association between cumulative exposure to traumatic events, emotion dysregulation, and mindfulness disposition on substance use craving in a sample of predominantly Hispanic and non-Hispanic Black women in residential treatment for SUD.

Method

Cross-sectional data were analyzed for a baseline sample of 241 women (56.96% Hispanic, 20.7% non-Hispanic White, 20.7% non-Hispanic Black; age: M = 32.11) entering a SUD residential treatment facility who agreed to participate in a parent randomized controlled trial.

Results

Findings indicated that greater cumulative exposure to traumatic events and emotion dysregulation were associated with higher levels of craving. Cumulative traumatic event exposure was indirectly associated with higher craving via lower levels in the mindfulness dimension of acting with awareness. Interaction effects also revealed greater exposure to traumatic events was associated with higher levels of craving among women with low and average (but not high) levels of mindfulness disposition.

Conclusion

These findings provide insight into the potential benefits of targeting emotion regulation and mindfulness-building strategies such as acting with awareness in interventions among racial-ethnically diverse women with SUD. These strategies may be particularly beneficial among those that have experienced extensive histories of trauma exposure. Overall, knowledge gained from the present study can be particularly valuable towards informing treatment models in minoritized groups that currently experience disparities in treatment utilization and outcomes.

Measurement Error-Corrected Estimation of Clinically Significant Change Trajectories for Interventions Targeting Comorbid PTSD and Substance Use Disorders in OEF/OIF Veterans

In randomized control trials (RCTs), a focus on average differences between treatment arms often limits our understanding of whether individuals show clinically significant improvement or deterioration. The present study examined differences in individual-level clinical significance trajectories between Concurrent Treatment of PTSD and Substance Use Disorders Using Prolonged Exposure (COPE) and Relapse Prevention (RP). Eighty-one treatment-seeking veterans with a comorbid PTSD/SUD diagnosis were randomized to COPE or RP; data from an additional n = 48 patients who did not meet criteria for both disorders was used to establish a normative threshold. A newly developed, modernized approach to the Jacobson and Truax (1991) clinically significant change framework, using (a) moderated nonlinear factor analysis (MNLFA) scale scoring and (b) measurement error-corrected multilevel modeling (MEC-MLM) was used; this approach was compared to other approaches using conventional total scores and/or assuming no measurement error. Using a conventional approach to estimating the Reliable Change Index (RCI) yielded no differences between COPE and RP in the percentage of patients achieving statistically significant improvement (SSI; 88.9% for both groups). However, under MNLFA/MEC-MLM, higher percentages of patients receiving COPE (75.0%) achieved SSI compared to RP (40.7%). Findings suggest that, even though COPE and RP appear to reduce the same number of PTSD symptoms, MNLFA scoring of outcome measures gives greater weight to interventions that target and reduce "hallmark" PTSD symptoms.