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Pasqualoni S, Bai Y, Curl A, Rettew J, Kimball L, Devadanam V, Yousef H, Hudziak J, Copeland WE. The substance use behaviors change of first-year college students before and during COVID-19 pandemic. JOURNAL OF AMERICAN COLLEGE HEALTH : J OF ACH 2025; 73:1502-1509. [PMID: 38227917 DOI: 10.1080/07448481.2023.2299419] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/23/2022] [Revised: 09/04/2023] [Accepted: 12/10/2023] [Indexed: 01/18/2024]
Abstract
OBJECTIVE This article tests the substance use behaviors of college students before and during COVID-19 pandemic. METHODS In-depth assessment and nightly survey data was used from a longitudinal study (n = 675) which examined student substance use during the 2019-2020 academic year, both before and during the onset of the COVID-19 pandemic. Changes in beer/wine, tobacco, liquor, and marijuana use before versus during the pandemic, in addition to the interaction of COVID-19, were tested with gender and subjective social status. RESULTS Marijuana use significantly decreased from a weekly prevalence of 9.9% before COVID-19 to 6.4% during COVID-19 (p = 0.002). A similar decrease was seen in liquor use (10.6% before COVID to 6.4% during COVID, p = 0.01). There was no significant change observed for beer/wine use or for tobacco use. CONCLUSION In the wake of the COVID-19 pandemic, liquor, and marijuana use decreased for college students, while other substance use stayed the same.
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Affiliation(s)
| | - Yang Bai
- University of Utah, Salt Lake City, Utah, USA
| | - Azilee Curl
- University of Vermont, Burlington, Vermont, USA
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2
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Swannell M, Bradlow RCJ, Pham D, Gabriel J, Manahan Y, Arunogiri S. Pharmacological treatments for co-occurring PTSD and substance use disorders: A systematic review. JOURNAL OF SUBSTANCE USE AND ADDICTION TREATMENT 2025; 169:209601. [PMID: 39672336 DOI: 10.1016/j.josat.2024.209601] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/30/2024] [Revised: 11/11/2024] [Accepted: 11/29/2024] [Indexed: 12/15/2024]
Abstract
INTRODUCTION Post-traumatic stress disorder and substance use disorders commonly co-occur and are associated with worse health outcomes. Currently, only psychosocial therapies are specifically recommended for use in the co-occurring population, but these come with numerous barriers to access and engagement. This study aims to identify potential pharmacological treatments to enhance treatment options and outcomes for this population. METHODS This systematic review identified studies on pharmacological treatment of co-occurring PTSD and SUD in humans, using validated outcome measurements, with study design of RCT, observational study, case control study or cohort study. RESULTS 29 studies were identified for inclusion, looking at a range of 16 pharmacotherapies. A majority concentrated on alcohol use disorders and males, with many focused on the veteran population. CONCLUSIONS This is an area for further research, inclusive of more SUDs, genders and civilians. Future studies utilizing consistent dosing, populations and measurement outcomes will allow for future meta-analysis.
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Affiliation(s)
- Megan Swannell
- Eastern Health Mental Health Service, Victoria, Australia
| | | | - Daniel Pham
- Turning Point, Eastern Health, Victoria, Australia
| | | | - Yasmin Manahan
- Eastern Health Mental Health Service, Victoria, Australia
| | - Shalini Arunogiri
- Turning Point, Eastern Health, Victoria, Australia; Eastern Health Clinical School and Monash Addiction Research Centre, Faculty of Medicine, Nursing and Health Sciences, Monash University, Victoria, Australia.
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Link KM, Bryant BE, Boness CL. Reducing Stigma and Enhancing Care for People Who Use Alcohol. JOURNAL OF HEALTH SERVICE PSYCHOLOGY 2025; 51:31-41. [PMID: 40276597 PMCID: PMC12017455 DOI: 10.1007/s42843-025-00124-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 04/26/2025]
Abstract
Alcohol use is common and associated with varying degrees of harm. Heavy alcohol use can lead to the development of an alcohol use disorder (AUD). The stigma and discrimination that people with AUD often face can act as barriers to seeking clinical services and may negatively impact the quality of care they receive. This paper outlines best practices for working with people who use alcohol, emphasizing the importance of addressing stigma in caring for and communicating with clients. Written from a harm-reduction perspective, it highlights the significance of client-driven goal setting and autonomy, meeting clients where they are regarding their behavior change goals, and maintaining a non-judgmental, compassionate stance.
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Affiliation(s)
- Kara M. Link
- Department of Psychology, University of New Mexico, Albuquerque, NM, USA
| | - Brittany E. Bryant
- Department of Psychiatry and Behavioral Sciences, University of California, San Francisco, San Francisco, CA USA
| | - Cassandra L. Boness
- Department of Psychology, University of New Mexico, Albuquerque, NM, USA
- Center on Alcohol, Substance use, And Addictions, University of New Mexico, Albuquerque, NM, USA
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Medenblik AM, Garner AR, Basting EJ, Sullivan JA, Jensen MC, Shorey RC, Stuart GL. Examining trauma, anxiety, and depression as predictors of dropout from residential treatment for substance use disorders. J Clin Psychol 2024; 80:1767-1779. [PMID: 38662953 DOI: 10.1002/jclp.23692] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2023] [Revised: 02/27/2024] [Accepted: 04/01/2024] [Indexed: 07/05/2024]
Abstract
Substance use disorders (SUDs) are highly prevalent and have deleterious effects on one's health and well-being. Inpatient treatment for SUDs reduces patient relapse, which subsequently ameliorates these negative effects on the individual and society. Additionally, those who complete treatment are less likely to relapse compared to those who do not complete treatment. Thus, maintaining patient engagement in treatment and reducing the rates of those leaving against medical advice (AMA) is particularly important. Examining the factors and comorbidities that may contribute to treatment dropout has the potential to identify at-risk patients in need of additional individualized intervention. The current study aimed to examine comorbid anxiety, depression, and posttraumatic stress disorder (PTSD) symptoms as predictors of dropout AMA in a residential substance use treatment population. Results showed that patients with social anxiety were more likely to leave treatment AMA, while those with PTSD were more likely to complete treatment. Findings suggest that PTSD-specific treatment, as offered in this facility, may help with patient retention, while group focused therapy may be distressing to those with social anxiety. Clinical implications of this research may include incorporating evidence-based practice for social anxiety early during inpatient treatment to reduce anxiety such that patients may better engage with SUDs treatment.
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Affiliation(s)
- Alyssa M Medenblik
- Department of Psychology, University of Tennessee-Knoxville, Knoxville, Tennessee, USA
| | - Alisa R Garner
- Department of Psychology, University of Tennessee-Knoxville, Knoxville, Tennessee, USA
| | - Evan J Basting
- Department of Psychology, University of Tennessee-Knoxville, Knoxville, Tennessee, USA
| | - Jacqueline A Sullivan
- Department of Psychology, University of Tennessee-Knoxville, Knoxville, Tennessee, USA
| | - Mary C Jensen
- Department of Psychology, University of Tennessee-Knoxville, Knoxville, Tennessee, USA
| | - Ryan C Shorey
- Department of Psychology, University of Tennessee-Knoxville, Knoxville, Tennessee, USA
- Department of Psychology, University of Wisconsin-Milwaukee, Milwaukee, Wisconsin, USA
| | - Gregory L Stuart
- Department of Psychology, University of Tennessee-Knoxville, Knoxville, Tennessee, USA
- Residential Addiction Treatment Center, Cornerstone of Recovery, Alcoa, Tennessee, USA
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Burnett DP, Trikalinos TA, Kiluk BD, Ray L, Misquith C, Magill M. A Descriptive Review and Meta-Regression Study of Demographic and Study Context Factors in US Clinical Trials of Cognitive Behavioral Interventions for Alcohol or Other Drug Use. Subst Use Misuse 2024; 59:1711-1721. [PMID: 38946162 PMCID: PMC11421968 DOI: 10.1080/10826084.2024.2369167] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/02/2024]
Abstract
Objectives. Cognitive-Behaviorally Based Interventions (CBIs) are evidence-based treatments for alcohol and other drug (AOD) use with potential variable effectiveness by population sub-groups. This study used evidence synthesis to examine treatment effect by demographic and study context factors in clinical trials of CBI for AOD. Methods. Studies were systematically identified, and their characteristics and outcome data were extracted and summarized. Standardized mean differences were calculated for within- and between-condition effects on substance use outcomes. Demographic and study context moderators were identified during data acquisition and several sensitivity analyses were conducted. Results. The sample included K = 29 trials and a total of 15 study-level moderators were examined. Information on participants' age, biological sex, and race were reported in at least 26 trials, but information on gender identity, sexual orientation, and ethnicity were reported infrequently or in non-inclusive ways. The mean between-condition effect size was small and moderately heterogenous (d = 0.158, 95% CI = 0.079, 0.238, I2 = 46%) and the mean within-condition effect size was large and showed high heterogeneity (dz = 1.147, 95% CI = 0.811, 1.482, - I2 = 96%). The specific drug targeted in the study and whether biological assay-based outcomes were used moderated between-condition CBI efficacy and the inclusion of co-occurring mental health conditions and study publication date moderated within-condition CBI effects. Conclusions. Results provide preliminary data on study context factors associated with effect estimates in United States based clinical trials of CBI for AOD.
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Affiliation(s)
| | | | | | - Lara Ray
- University of California at Los Angeles CA
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6
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Hien DA, Papini S, Saavedra LM, Bauer AG, Ruglass LM, Ebrahimi CT, Fitzpatrick S, López-Castro T, Norman SB, Killeen TK, Back SE, Morgan-López AA. Project harmony: A systematic review and network meta-analysis of psychotherapy and pharmacologic trials for comorbid posttraumatic stress, alcohol, and other drug use disorders. Psychol Bull 2024; 150:319-353. [PMID: 37971855 PMCID: PMC10939977 DOI: 10.1037/bul0000409] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2023]
Abstract
We conducted a systematic review and network meta-analyses (NMA) of psychotherapy and pharmacologic treatments for individuals with co-occurring posttraumatic stress disorder (PTSD) and alcohol or other drug use disorder (AOD). A comprehensive search spanning 1995-2019 yielded a pool of 39 studies for systematic review, including 24 randomized controlled trials for the NMA. Study interventions were grouped by target of treatment (PTSD + AOD, PTSD-only, and AOD-only) and approach (psychotherapy or medication). Standardized mean differences (SMD) from the NMA yielded evidence that at the end of treatment, integrated, trauma-focused therapy for PTSD + AOD was more effective at reducing PTSD symptoms than integrated, non-trauma-focused therapy (SMD = -0.30), AOD-focused psychotherapy (SMD = -0.29), and other control psychotherapies (SMD = -0.43). End-of-treatment alcohol use severity was less for AOD medication compared to placebo medication (SMD = -0.36) and trauma-focused therapy for PTSD + placebo medication (SMD = -0.67), and less for trauma-focused psychotherapy + AOD medication compared to PTSD medication (SMD = -0.53), placebo medication (SMD = -0.50), and trauma-focused psychotherapy + placebo medication (SMD = -0.81). Key limitations include the small number of studies in the NMA for pharmacologic treatments and the lack of demographic diversity apparent in the existing literature. Findings suggest room for new studies that can address limitations in study sample composition, sample sizes, retention, and apply new techniques for conducting comparative effectiveness in PTSD + AOD treatment. (PsycInfo Database Record (c) 2024 APA, all rights reserved).
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Affiliation(s)
- Denise A Hien
- Department of Clinical Psychology, Center of Alcohol and Substance Use Studies, Graduate School of Applied and Professional Psychology, Rutgers University-New Brunswick
| | | | | | - Alexandria G Bauer
- Department of Clinical Psychology, Center of Alcohol and Substance Use Studies, Graduate School of Applied and Professional Psychology, Rutgers University-New Brunswick
| | | | - Chantel T Ebrahimi
- Department of Clinical Psychology, Center of Alcohol and Substance Use Studies, Graduate School of Applied and Professional Psychology, Rutgers University-New Brunswick
| | | | | | - Sonya B Norman
- Department of Psychiatry, University of California, San Diego
| | - Therese K Killeen
- Department of Psychiatry and Behavioral Sciences, Medical University of South Carolina
| | - Sudie E Back
- Department of Psychiatry and Behavioral Sciences, Medical University of South Carolina
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Morgan‐López AA, Saavedra LM, Hien DA, Norman SB, Fitzpatrick SS, Ye A, Killeen TK, Ruglass LM, Blakey SM, Back SE. Differential symptom weighting in estimating empirical thresholds for underlying PTSD severity: Toward a "platinum" standard for diagnosis? Int J Methods Psychiatr Res 2023; 32:e1963. [PMID: 36789653 PMCID: PMC10485310 DOI: 10.1002/mpr.1963] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2022] [Revised: 12/22/2022] [Accepted: 01/26/2023] [Indexed: 02/16/2023] Open
Abstract
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.
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Affiliation(s)
| | - Lissette M. Saavedra
- Community Health Research DivisionRTI InternationalResearch Triangle ParkNorth CarolinaUSA
| | - Denise A. Hien
- Center of Alcohol & Substance Use StudiesRutgers University–New BrunswickPiscatawayNew JerseyUSA
| | - Sonya B. Norman
- Department of PsychiatryUniversity of CaliforniaSan DiegoVirginiaUSA
| | | | - Ai Ye
- Department of Psychology & NeuroscienceL.L. Thurstone Psychometric LaboratoryUNC‐Chapel HillChapel HillNorth CarolinaUSA
- Department PsychologieLudwig‐Maximilians‐UniversitätMunichGermany
| | - Therese K. Killeen
- Department of Psychiatry and Behavioral SciencesMedical University of South CarolinaCharlestonSouth CarolinaUSA
- Ralph H. Johnson VA Medical CenterCharlestonSouth CarolinaUSA
| | - Lesia M. Ruglass
- Department of PsychologyCity College of New YorkNew YorkNew YorkUSA
| | - Shannon M. Blakey
- Community Health Research DivisionRTI InternationalResearch Triangle ParkNorth CarolinaUSA
| | - Sudie E. Back
- Department of Psychiatry and Behavioral SciencesMedical University of South CarolinaCharlestonSouth CarolinaUSA
- Ralph H. Johnson VA Medical CenterCharlestonSouth CarolinaUSA
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Ellis JD, Rabinowitz JA, Ware OD, Wells J, Dunn KE, Huhn AS. Patterns of polysubstance use and clinical comorbidity among persons seeking substance use treatment: An observational study. JOURNAL OF SUBSTANCE USE AND ADDICTION TREATMENT 2023; 146:208932. [PMID: 36880895 PMCID: PMC10035066 DOI: 10.1016/j.josat.2022.208932] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/31/2022] [Revised: 09/08/2022] [Accepted: 10/31/2022] [Indexed: 01/09/2023]
Abstract
INTRODUCTION Polysubstance use is common among individuals seeking treatment for substance use disorders (SUD). However, we know less about patterns and correlates of polysubstance use among treatment-seeking populations. The current study aimed to identify latent patterns of polysubstance use and associated risk factors in persons entering SUD treatment. METHODS Patients (N = 28,526) being admitted for substance use treatment reported on their use of thirteen substances (e.g., alcohol, cannabis, cocaine, amphetamines, methamphetamines, other stimulants, heroin, other opioids, benzodiazepines, inhalants, synthetics, hallucinogens, and club drugs) in the month before treatment and prior to the month before treatment. Latent class analysis (LCA) determined the relationship between class membership and gender, age, employment status, unstable housing, self-harm, overdose, past treatment, depression, generalized anxiety disorder, and/or post-traumatic stress disorder (PTSD). RESULTS Identified classes included: 1) Alcohol primary, 2) Moderate probability of past-month alcohol, cannabis, and/or opioid use; 3) Alcohol primary, Lifetime cannabis and cocaine use; 4) Opioid primary, Lifetime use of alcohol, cannabis, hallucinogens, club drugs, amphetamines, and cocaine; 5) Moderate probability of past-month alcohol, cannabis, and/or opioid use, Lifetime use of various substances; 6) Alcohol and cannabis primary, Lifetime use of various substances; and 7) High past-month polysubstance use. Individuals who engaged in past-month polysubstance use attended to face elevated risk of screening positive for recent unstable housing, unemployment, depression, anxiety, PTSD, self-harm, and overdose. CONCLUSIONS Current polysubstance use is associated with significant clinical complexity. Tailored treatments that reduce harms resulting from polysubstance use and related psychiatric comorbidity may improve treatment outcomes in this population.
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Affiliation(s)
- Jennifer D Ellis
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, MD, United States of America.
| | - Jill A Rabinowitz
- Department of Mental Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, United States of America
| | - Orrin D Ware
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, MD, United States of America; University of North Carolina at Chapel Hill School of Social Work, Chapel Hill, NC, United States of America
| | - Jonathan Wells
- Division of Epidemiology, Department of Family Medicine and Population Health, Virginia Commonwealth University, Richmond, VA, United States of America
| | - Kelly E Dunn
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, MD, United States of America
| | - Andrew S Huhn
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, MD, United States of America.
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9
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Coffman DL, Ayer L, Schuler MS, Godley MD, Griffin BA. The Role of Pre-Treatment Traumatic Stress Symptoms in Adolescent Substance Use Treatment Outcomes. Subst Use Misuse 2023; 58:551-559. [PMID: 36762441 PMCID: PMC11311142 DOI: 10.1080/10826084.2023.2177960] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/11/2023]
Abstract
Background: Prominent theories suggest that individuals with co-occurring traumatic stress symptoms (TSS) and substance use (SU) may be less responsive to SU treatment compared to those with SU only. However, empirical findings in adult samples are mixed, and there has been limited work among adolescents. This study assesses the association between TSS and SU treatment outcomes among trauma-exposed adolescents, using statistical methods to reduce potential confounding from important factors such as baseline SU severity. Method: 2,963 adolescents with lifetime history of victimization received evidence-based SU treatment in outpatient community settings. At baseline, 3- and 6-months, youth were assessed using the Global Appraisal of Individual Needs Traumatic Stress Scale and the Substance Frequency Scale. Propensity score weighting was used to mitigate potential confounding due to baseline differences in sociodemographic characteristics and SU across youth with varying levels of TSS. Results: Propensity score weighting successfully balanced baseline differences in sociodemographic factors and baseline SU across youth. Among all youth, mean SU was lower at both 3- and 6- month follow-up relative to baseline, indicating declining use. After adjusting for potential confounders, we observed no statistically significant relationship between TSS and SU at either 3- or 6-month follow-up. Conclusions: Based on this investigation, conducted among a large sample of trauma-exposed youth receiving evidence-based outpatient SU treatment, baseline TSS do not appear to be negatively associated with SU treatment outcomes. However, future research should examine whether youth with TSS achieve better outcomes through integrative treatment for both SU and TSS.
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Hien DA, Morgan-López AA, Saavedra LM, Ruglass LM, Ye A, López-Castro T, Fitzpatrick S, Killeen TK, Norman SB, Ebrahimi CT, Back SE. Project Harmony: A Meta-Analysis With Individual Patient Data on Behavioral and Pharmacologic Trials for Comorbid Posttraumatic Stress and Alcohol or Other Drug Use Disorders. Am J Psychiatry 2023; 180:155-166. [PMID: 36475373 PMCID: PMC10016363 DOI: 10.1176/appi.ajp.22010071] [Citation(s) in RCA: 27] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
OBJECTIVE Treatment efficacy for co-occurring posttraumatic stress disorder (PTSD) and substance use disorders is well established, yet direct evidence for comparative effectiveness across treatments is lacking. The present study compared the effectiveness of several behavioral and pharmacological therapies for adults with co-occurring PTSD and alcohol or other drug use disorders. METHODS A systematic search of PsycINFO, MEDLINE, and ClinicalTrials.gov was conducted through December 2020 for trials targeting PTSD, alcohol or other drug use disorders, or both disorders (36 studies, N=4,046). Primary outcomes were severity scores for PTSD, alcohol use, and drug use, estimated via moderated nonlinear factor analysis. Propensity score weight-adjusted multilevel models were used. Model-predicted effect sizes were estimated for each treatment, and comparative effect sizes for each active arm against treatment as usual, at end of treatment and at 12-month follow-up. RESULTS Compared with treatment as usual, combining trauma-focused therapy and pharmacotherapy for substance use disorders showed the largest comparative effect sizes for PTSD severity (d=-0.92, 95% CI=-1.57, -0.30) and alcohol use severity (d=-1.10, 95% CI=-1.54, -0.68) at end of treatment. Other treatments with large comparative effect sizes included pharmacotherapies for alcohol or other drug use disorders, trauma-focused integrated therapies, and trauma-focused nonintegrated therapies. Reductions in outcomes for PTSD symptoms and alcohol use were observed for nearly all treatments. CONCLUSIONS The findings provide support for treating comorbid PTSD and substance use disorders using a variety of approaches, with alcohol-targeted pharmacotherapies and trauma-focused behavioral therapies as a combination of treatments that lead to early and sustained improvements in PTSD and alcohol use severity. Further treatment development is indicated for combining behavioral and pharmacological treatments for synergized impact and understanding the mechanisms of action and conditions under which each treatment type is optimized.
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Affiliation(s)
- Denise A Hien
- Center of Alcohol and Substance Use Studies, Rutgers University-New Brunswick, Piscataway, N.J. (Hien, Ruglass, Ebrahimi); Department of Psychology, City College of New York, New York (Ruglass, López-Castro); L.L. Thurstone Psychometric Laboratory, Department of Psychology and Neuroscience, University of North Carolina-Chapel Hill (Ye); Department of Psychology, York University, Toronto (Fitzpatrick); Department of Psychiatry and Behavioral Sciences, Medical University of South Carolina, Charleston, and Ralph H. Johnson VA Medical Center, Charleston (Killeen, Back); Department of Psychiatry, University of California, San Diego, and VA San Diego Healthcare System (Norman);Department of Psychology, New School, New York (Ebrahimi)
| | - Antonio A Morgan-López
- Center of Alcohol and Substance Use Studies, Rutgers University-New Brunswick, Piscataway, N.J. (Hien, Ruglass, Ebrahimi); Department of Psychology, City College of New York, New York (Ruglass, López-Castro); L.L. Thurstone Psychometric Laboratory, Department of Psychology and Neuroscience, University of North Carolina-Chapel Hill (Ye); Department of Psychology, York University, Toronto (Fitzpatrick); Department of Psychiatry and Behavioral Sciences, Medical University of South Carolina, Charleston, and Ralph H. Johnson VA Medical Center, Charleston (Killeen, Back); Department of Psychiatry, University of California, San Diego, and VA San Diego Healthcare System (Norman);Department of Psychology, New School, New York (Ebrahimi)
| | - Lissette M Saavedra
- Center of Alcohol and Substance Use Studies, Rutgers University-New Brunswick, Piscataway, N.J. (Hien, Ruglass, Ebrahimi); Department of Psychology, City College of New York, New York (Ruglass, López-Castro); L.L. Thurstone Psychometric Laboratory, Department of Psychology and Neuroscience, University of North Carolina-Chapel Hill (Ye); Department of Psychology, York University, Toronto (Fitzpatrick); Department of Psychiatry and Behavioral Sciences, Medical University of South Carolina, Charleston, and Ralph H. Johnson VA Medical Center, Charleston (Killeen, Back); Department of Psychiatry, University of California, San Diego, and VA San Diego Healthcare System (Norman);Department of Psychology, New School, New York (Ebrahimi)
| | - Lesia M Ruglass
- Center of Alcohol and Substance Use Studies, Rutgers University-New Brunswick, Piscataway, N.J. (Hien, Ruglass, Ebrahimi); Department of Psychology, City College of New York, New York (Ruglass, López-Castro); L.L. Thurstone Psychometric Laboratory, Department of Psychology and Neuroscience, University of North Carolina-Chapel Hill (Ye); Department of Psychology, York University, Toronto (Fitzpatrick); Department of Psychiatry and Behavioral Sciences, Medical University of South Carolina, Charleston, and Ralph H. Johnson VA Medical Center, Charleston (Killeen, Back); Department of Psychiatry, University of California, San Diego, and VA San Diego Healthcare System (Norman);Department of Psychology, New School, New York (Ebrahimi)
| | - Ai Ye
- Center of Alcohol and Substance Use Studies, Rutgers University-New Brunswick, Piscataway, N.J. (Hien, Ruglass, Ebrahimi); Department of Psychology, City College of New York, New York (Ruglass, López-Castro); L.L. Thurstone Psychometric Laboratory, Department of Psychology and Neuroscience, University of North Carolina-Chapel Hill (Ye); Department of Psychology, York University, Toronto (Fitzpatrick); Department of Psychiatry and Behavioral Sciences, Medical University of South Carolina, Charleston, and Ralph H. Johnson VA Medical Center, Charleston (Killeen, Back); Department of Psychiatry, University of California, San Diego, and VA San Diego Healthcare System (Norman);Department of Psychology, New School, New York (Ebrahimi)
| | - Teresa López-Castro
- Center of Alcohol and Substance Use Studies, Rutgers University-New Brunswick, Piscataway, N.J. (Hien, Ruglass, Ebrahimi); Department of Psychology, City College of New York, New York (Ruglass, López-Castro); L.L. Thurstone Psychometric Laboratory, Department of Psychology and Neuroscience, University of North Carolina-Chapel Hill (Ye); Department of Psychology, York University, Toronto (Fitzpatrick); Department of Psychiatry and Behavioral Sciences, Medical University of South Carolina, Charleston, and Ralph H. Johnson VA Medical Center, Charleston (Killeen, Back); Department of Psychiatry, University of California, San Diego, and VA San Diego Healthcare System (Norman);Department of Psychology, New School, New York (Ebrahimi)
| | - Skye Fitzpatrick
- Center of Alcohol and Substance Use Studies, Rutgers University-New Brunswick, Piscataway, N.J. (Hien, Ruglass, Ebrahimi); Department of Psychology, City College of New York, New York (Ruglass, López-Castro); L.L. Thurstone Psychometric Laboratory, Department of Psychology and Neuroscience, University of North Carolina-Chapel Hill (Ye); Department of Psychology, York University, Toronto (Fitzpatrick); Department of Psychiatry and Behavioral Sciences, Medical University of South Carolina, Charleston, and Ralph H. Johnson VA Medical Center, Charleston (Killeen, Back); Department of Psychiatry, University of California, San Diego, and VA San Diego Healthcare System (Norman);Department of Psychology, New School, New York (Ebrahimi)
| | - Therese K Killeen
- Center of Alcohol and Substance Use Studies, Rutgers University-New Brunswick, Piscataway, N.J. (Hien, Ruglass, Ebrahimi); Department of Psychology, City College of New York, New York (Ruglass, López-Castro); L.L. Thurstone Psychometric Laboratory, Department of Psychology and Neuroscience, University of North Carolina-Chapel Hill (Ye); Department of Psychology, York University, Toronto (Fitzpatrick); Department of Psychiatry and Behavioral Sciences, Medical University of South Carolina, Charleston, and Ralph H. Johnson VA Medical Center, Charleston (Killeen, Back); Department of Psychiatry, University of California, San Diego, and VA San Diego Healthcare System (Norman);Department of Psychology, New School, New York (Ebrahimi)
| | - Sonya B Norman
- Center of Alcohol and Substance Use Studies, Rutgers University-New Brunswick, Piscataway, N.J. (Hien, Ruglass, Ebrahimi); Department of Psychology, City College of New York, New York (Ruglass, López-Castro); L.L. Thurstone Psychometric Laboratory, Department of Psychology and Neuroscience, University of North Carolina-Chapel Hill (Ye); Department of Psychology, York University, Toronto (Fitzpatrick); Department of Psychiatry and Behavioral Sciences, Medical University of South Carolina, Charleston, and Ralph H. Johnson VA Medical Center, Charleston (Killeen, Back); Department of Psychiatry, University of California, San Diego, and VA San Diego Healthcare System (Norman);Department of Psychology, New School, New York (Ebrahimi)
| | - Chantel T Ebrahimi
- Center of Alcohol and Substance Use Studies, Rutgers University-New Brunswick, Piscataway, N.J. (Hien, Ruglass, Ebrahimi); Department of Psychology, City College of New York, New York (Ruglass, López-Castro); L.L. Thurstone Psychometric Laboratory, Department of Psychology and Neuroscience, University of North Carolina-Chapel Hill (Ye); Department of Psychology, York University, Toronto (Fitzpatrick); Department of Psychiatry and Behavioral Sciences, Medical University of South Carolina, Charleston, and Ralph H. Johnson VA Medical Center, Charleston (Killeen, Back); Department of Psychiatry, University of California, San Diego, and VA San Diego Healthcare System (Norman);Department of Psychology, New School, New York (Ebrahimi)
| | - Sudie E Back
- Center of Alcohol and Substance Use Studies, Rutgers University-New Brunswick, Piscataway, N.J. (Hien, Ruglass, Ebrahimi); Department of Psychology, City College of New York, New York (Ruglass, López-Castro); L.L. Thurstone Psychometric Laboratory, Department of Psychology and Neuroscience, University of North Carolina-Chapel Hill (Ye); Department of Psychology, York University, Toronto (Fitzpatrick); Department of Psychiatry and Behavioral Sciences, Medical University of South Carolina, Charleston, and Ralph H. Johnson VA Medical Center, Charleston (Killeen, Back); Department of Psychiatry, University of California, San Diego, and VA San Diego Healthcare System (Norman);Department of Psychology, New School, New York (Ebrahimi)
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11
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Chetty A, Guse T, Malema M. Integrated vs non-integrated treatment outcomes in dual diagnosis disorders: A systematic review. Health SA 2023; 28:2094. [PMID: 37151615 PMCID: PMC10157410 DOI: 10.4102/hsag.v28i0.2094] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2022] [Accepted: 02/08/2023] [Indexed: 05/09/2023] Open
Abstract
Background The incidence of dual diagnosis (DD) (i.e. substance use disorders [SUD] and co-occurring mental disorders) is widespread; however, they vary widely in permutation and combination. As a result, establishing effective and empirically supported interventions for this clinical population remains challenging. Aim This study aimed to examine current literature on the treatment outcomes for patients with DD. Method A systematic review of randomised controlled trials (RCTs) published between 2009 and 2018 was conducted for two broad intervention categories identified by the literature: non-integrated and integrated treatment. Multiple electronic databases were searched using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines (PRISMA). Results The search generated a total of 743 studies, of which 11 satisfied the inclusion criteria. These studies were thematically synthesised into two main analytical themes: 'treatment outcomes' and 'reported strengths and limitations of DD treatment'. Specifically, integrated treatment held an advantage over non-integrated treatment in significantly improving psychiatric symptomatology. However, no significant benefits were found between integrated and non-integrated treatment regarding substance misuse and treatment retention. Conclusion Overall, the results provided insufficient evidence to support the enhanced efficacy of integrated or non-integrated treatment over the other in treating patients with DD. Contribution The study's findings were used to provide recommendations to inform the clinical psychological service delivery of dual diagnosis treatment in South Africa and also to identify gaps in the literature and highlight areas for future research.
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Affiliation(s)
- Ashley Chetty
- Department of Psychology, Faculty of Humanities, University of Pretoria, Pretoria, South Africa
| | - Tharina Guse
- Department of Psychology, Faculty of Humanities, University of Pretoria, Pretoria, South Africa
| | - Mosa Malema
- Department of Psychology, Faculty of Humanities, University of Pretoria, Pretoria, South Africa
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12
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Simpson TL, Kaysen DL, Fleming CB, Rhew IC, Jaffe AE, Desai S, Hien DA, Berliner L, Donovan D, Resick PA. Cognitive Processing Therapy or Relapse Prevention for comorbid Posttraumatic Stress Disorder and Alcohol Use Disorder: A randomized clinical trial. PLoS One 2022; 17:e0276111. [PMID: 36445895 PMCID: PMC9707793 DOI: 10.1371/journal.pone.0276111] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2022] [Accepted: 08/12/2022] [Indexed: 12/03/2022] Open
Abstract
OBJECTIVE To compare a Posttraumatic Stress Disorder (PTSD) treatment (Cognitive Processing Therapy; CPT), an Alcohol Use Disorder (AUD) treatment (Relapse Prevention; RP), and assessment-only (AO) for those meeting diagnostic criteria for both PTSD and AUD. METHOD Participants with current PTSD/AUD (N = 101; mean age = 42.10; 56% female) were initially randomized to CPT, RP, or AO and assessed post-treatment or 6-weeks post-randomization (AO). AO participants were then re-randomized to CPT or RP. Follow-ups were at immediate post-treatment, 3-, and 12-months. Mixed effects intent-to-treat models compared conditions on changes in PTSD symptom severity, drinking days, and heavy drinking days. RESULTS At post-treatment, participants assigned to CPT showed significantly greater improvement than those in AO on PTSD symptom severity (b = -9.72, 95% CI [-16.20, -3.23], d = 1.22); the RP and AO groups did not differ significantly on PTSD. Both active treatment conditions significantly decreased heavy drinking days relative to AO (CPT vs. AO: Count Ratio [CR] = 0.51, 95% CI [0.30, 0.88]; RP vs. AO: CR = 0.34, 95% CI [0.19, 0.59]). After re-randomization both treatment conditions showed substantial improvements in PTSD symptoms and drinking between pre-treatment and post-treatment over the 12-month follow-up period, with RP showing an advantage on heavy drinking days. CONCLUSION Treatments targeting one or the other aspects of the PTSD/AUD comorbidity may have salutary effects on both PTSD and drinking outcomes. These preliminary results suggest that people with this comorbidity may have viable treatment options whether they present for mental health or addiction care. TRIAL REGISTRATION The trial is registered at clinicaltrials.gov (NCT01663337).
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Affiliation(s)
- Tracy L. Simpson
- Center of Excellence in Substance Addiction Treatment and Education, VA Puget Sound Health Care, Seattle, WA, United States of America
- Department of Psychiatry and Behavioral Sciences, School of Medicine, University of Washington, Seattle, WA, United States of America
| | - Debra L. Kaysen
- Department of Psychiatry and Behavioral Sciences, School of Medicine, University of Washington, Seattle, WA, United States of America
- Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford, CA, United States of America
| | - Charles B. Fleming
- Center for the Study of Health and Risk Behaviors, Department of Psychiatry and Behavioral Sciences, School of Medicine, University of Washington, Seattle, WA, United States of America
| | - Isaac C. Rhew
- Center for the Study of Health and Risk Behaviors, Department of Psychiatry and Behavioral Sciences, School of Medicine, University of Washington, Seattle, WA, United States of America
| | - Anna E. Jaffe
- Department of Psychology, University of Nebraska-Lincoln, Lincoln, NE, United States of America
| | - Sruti Desai
- Center for the Study of Health and Risk Behaviors, Department of Psychiatry and Behavioral Sciences, School of Medicine, University of Washington, Seattle, WA, United States of America
| | - Denise A. Hien
- Department of Clinical Psychology, Graduate School of Applied and Professional Psychology, Rutgers University, Center of Alcohol & Substance Use Studies, Piscataway, NJ, United States of America
| | - Lucy Berliner
- Harborview Center for Sexual Assault and Traumatic Stress, University of Washington, Seattle, WA, United States of America
| | - Dennis Donovan
- Alcohol and Drug Abuse Institute, Department of Psychiatry and Behavioral Sciences, School of Medicine, University of Washington, Seattle, WA, United States of America
| | - Patricia A. Resick
- Department of Psychiatry and Behavioral Sciences, Duke Health, Durham, NC, United States of America
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13
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Morgan-López AA, Hien DA, Saraiya TC, Saavedra LM, Norman SB, Killeen TK, Simpson TL, Fitzpatrick S, Mills KL, Ruglass LM, Back SE, López-Castro T, Consortium on Addiction, Stress and Trauma (CAST). Estimating posttraumatic stress disorder severity in the presence of differential item functioning across populations, comorbidities, and interview measures: Introduction to Project Harmony. J Trauma Stress 2022; 35:926-940. [PMID: 35124864 PMCID: PMC9844237 DOI: 10.1002/jts.22800] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2021] [Revised: 12/03/2021] [Accepted: 12/04/2021] [Indexed: 01/19/2023]
Abstract
Multiple factor analytic and item response theory studies have shown that items/symptoms vary in their relative clinical weights in structured interview measures for posttraumatic stress disorder (PTSD). Despite these findings, the use of total scores, which treat symptoms as though they are equally weighted, predominates in practice, with the consequence of undermining the precision of clinical decision-making. We conducted an integrative data analysis (IDA) study to harmonize PTSD structured interview data (i.e., recoding of items to a common symptom metric) from 25 studies (total N = 2,568). We aimed to identify (a) measurement noninvariance/differential item functioning (MNI/DIF) across multiple populations, psychiatric comorbidities, and interview measures simultaneously and (b) differences in inferences regarding underlying PTSD severity between scale scores estimated using moderated nonlinear factor analysis (MNLFA) and a total score analog model (TSA). Several predictors of MNI/DIF impacted effect size differences in underlying severity across scale scoring methods. Notably, we observed MNI/DIF substantial enough to bias inferences on underlying PTSD severity for two groups: African Americans and incarcerated women. The findings highlight two issues raised elsewhere in the PTSD psychometrics literature: (a) bias in characterizing underlying PTSD severity and individual-level treatment outcomes when the psychometric model underlying total scores fails to fit the data and (b) higher latent severity scores, on average, when using DSM-5 (net of MNI/DIF) criteria, by which multiple factors (e.g., Criterion A discordance across DSM editions, changes to the number/type of symptom clusters, changes to the symptoms themselves) may have impacted severity scoring for some patients.
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Affiliation(s)
| | - Denise A. Hien
- Center for Alcohol Studies, Rutgers University–Piscataway, Piscataway, New Jersey, USA
| | - Tanya C. Saraiya
- Department of Psychiatry and Behavioral Sciences, Medical University of South Carolina, Charleston, South Carolina, USA
| | | | - Sonya B. Norman
- Veterans Affairs San Diego Healthcare System, San Diego, California, USA
- Department of Psychiatry, University of California–San Diego, San Diego, California, USA
| | - Therese K. Killeen
- Department of Psychiatry and Behavioral Sciences, Medical University of South Carolina, Charleston, South Carolina, USA
- Ralph H. Johnson VA Medical Center, Charleston, South Carolina, USA
| | - Tracy L. Simpson
- Veterans Affairs Puget Sound Healthcare System, Seattle, Washington, USA
| | | | | | - Lesia M. Ruglass
- Department of Psychology, City College of New York, New York, New York, USA
| | - Sudie E. Back
- Department of Psychiatry and Behavioral Sciences, Medical University of South Carolina, Charleston, South Carolina, USA
- Ralph H. Johnson VA Medical Center, Charleston, South Carolina, USA
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14
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Leconte C, Mongeau R, Noble F. Traumatic Stress-Induced Vulnerability to Addiction: Critical Role of the Dynorphin/Kappa Opioid Receptor System. Front Pharmacol 2022; 13:856672. [PMID: 35571111 PMCID: PMC9091501 DOI: 10.3389/fphar.2022.856672] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2022] [Accepted: 04/07/2022] [Indexed: 11/13/2022] Open
Abstract
Substance use disorders (SUD) may emerge from an individual’s attempt to limit negative affective states and symptoms linked to stress. Indeed, SUD is highly comorbid with chronic stress, traumatic stress, or post-traumatic stress disorder (PTSD), and treatments approved for each pathology individually often failed to have a therapeutic efficiency in such comorbid patients. The kappa-opioid receptor (KOR) and its endogenous ligand dynorphin (DYN), seem to play a key role in the occurrence of this comorbidity. The DYN/KOR function is increased either in traumatic stress or during drug use, dependence acquisition and DYN is released during stress. The behavioural effects of stress related to the DYN/KOR system include anxiety, dissociative and depressive symptoms, as well as increased conditioned fear response. Furthermore, the DYN/KOR system is implicated in negative reinforcement after the euphoric effects of a drug of abuse ends. During chronic drug consumption DYN/KOR functions increase and facilitate tolerance and dependence. The drug-seeking behaviour induced by KOR activation can be retrieved either during the development of an addictive behaviour, or during relapse after withdrawal. DYN is known to be one of the most powerful negative modulators of dopamine signalling, notably in brain structures implicated in both reward and fear circuitries. KOR are also acting as inhibitory heteroreceptors on serotonin neurons. Moreover, the DYN/KOR system cross-regulate with corticotropin-releasing factor in the brain. The sexual dimorphism of the DYN/KOR system could be the cause of the gender differences observed in patients with SUD or/and traumatic stress-related pathologies. This review underlies experimental and clinical results emphasizing the DYN/KOR system as common mechanisms shared by SUD or/and traumatic stress-related pathologies, and suggests KOR antagonist as a new pharmacological strategy to treat this comorbidity.
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15
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Roberts NP, Lotzin A, Schäfer I. A systematic review and meta-analysis of psychological interventions for comorbid post-traumatic stress disorder and substance use disorder. Eur J Psychotraumatol 2022; 13:2041831. [PMID: 35558682 PMCID: PMC9090345 DOI: 10.1080/20008198.2022.2041831] [Citation(s) in RCA: 43] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2021] [Revised: 01/13/2022] [Accepted: 01/29/2022] [Indexed: 12/14/2022] Open
Abstract
Background The psychological treatment of comorbid post-traumatic stress disorder (PTSD) and substance use disorder (SUD) is clinically challenging, and outcomes are often poor. Objective This paper describes a systematic review and meta-analysis which sought to establish the current efficacy for a number of established psychological approaches for adults and adolescents, in comparison to interventions for SUD alone, or other active approaches, following a pre-registered protocol. Method This review followed PRISMA and Cochrane Collaboration guidelines. Data extraction and risk of bias judgements using Cochrane criteria were undertaken by all authors. Primary outcomes were PTSD severity and substance use post-treatment. The quality of findings was assessed using GRADE. Following a comprehensive search, conducted to 13 September 2021, 27 studies were included. Results We found a relatively high level of dropout across studies. In our main comparisons, we found no benefits for present-focused treatment approaches aimed at improving coping skills beyond those for SUD-only interventions. We found modest benefits for trauma-focused intervention plus SUD intervention post-treatment for PTSD (standardized mean difference (SMD) = -0.36, 95% confidence interval (CI) -0.64, -0.08), and at 6-13 months for PTSD (SMD = -0.48, 95% CI -0.81, -0.15) and alcohol use (SMD = -0.23, 95% CI -0.44, -0.02). There were no benefits for cognitive restructuring interventions as a group, but we found a modest effect for integrated cognitive behavioural therapy (ICBT) for PTSD post-treatment (SMD = -0.33, 95% CI -0.62, -0.04). There was evidence of some benefit for trauma-focused intervention over present-focused intervention for PTSD from a single study and for reduction in dropout for incentivized attendance for trauma-focused intervention from another single study. Most findings were of very low quality. Conclusion There is evidence that trauma-focused therapy and ICBT can improve PTSD for some individuals, but many patients do not fully engage with treatment and average treatment effects are modest. HIGHLIGHTS For PTSD, evidence was strongest for trauma-focused CBT-based approaches, but effects were modest.There was little evidence of any added benefit on substance use, beyond that of standard addiction treatments, for any included intervention.Dropout from treatment was high.
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Affiliation(s)
- Neil P. Roberts
- Cardiff & Vale University Health Board, Cardiff, UK
- Division of Psychological Medicine and Clinical Neurosciences, Cardiff University, Cardiff, UK
| | - Annett Lotzin
- Department of Psychiatry and Psychotherapy, Center for Interdisciplinary Addiction Research, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Ingo Schäfer
- Department of Psychiatry and Psychotherapy, Center for Interdisciplinary Addiction Research, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
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16
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Simpson TL, Goldberg SB, Louden DKN, Blakey SM, Hawn SE, Lott A, Browne KC, Lehavot K, Kaysen D. Efficacy and acceptability of interventions for co-occurring PTSD and SUD: A meta-analysis. J Anxiety Disord 2021; 84:102490. [PMID: 34763220 PMCID: PMC8819868 DOI: 10.1016/j.janxdis.2021.102490] [Citation(s) in RCA: 42] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2021] [Revised: 09/30/2021] [Accepted: 10/20/2021] [Indexed: 12/17/2022]
Abstract
Over the past 20 years, numerous treatments addressing comorbid Posttraumatic Stress Disorder (PTSD) and Substance Use Disorder (SUD) have been developed and tested. The current meta-analysis examined the efficacy and acceptability of the two central treatment types- trauma-focused and non-trauma-focused - compared with all comparators and with cognitive-behavioral manualized SUD treatments immediately post-treatment and at longest follow-up. Twenty-eight randomized clinical trials (N = 3247) were included. There were small to large within-group effects for all forms of active treatment (gs = 0.30-1.11). Trauma-focused but not non-trauma-focused treatments outperformed all comparators on PTSD outcomes at post-treatment. Neither trauma-focused nor non-trauma-focused treatment outperformed all comparators on SUD outcomes at post-treatment. Neither trauma- nor non-trauma-focused treatment outperformed manualized SUD treatments on PTSD outcomes at either time point. Manualized SUD treatments outperformed trauma-focused treatments on SUD outcomes at post-treatment and non-trauma-focused treatments on PTSD outcomes at follow-up. Regarding treatment retention, neither trauma-focused nor non-trauma-focused treatments significantly differed from all comparators or from manualized SUD treatments. Between-group results were largely unchanged in trim-and-fill analyses, but were not robust to fail-safe N. Few moderators were detected. Taken together, results suggest that trauma-focused, non-trauma-focused, and manualized SUD interventions are sound options for individuals with comorbid PTSD/SUD.
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Affiliation(s)
- Tracy L Simpson
- VA Puget Sound Center of Excellence in Substance Addiction Treatment and Education, 1660 South Columbian Way, Seattle, WA 98108, USA; University of Washington, Department of Psychiatry, 1959 NE Pacific St, Seattle, WA 98195, USA.
| | - Simon B Goldberg
- Department of Counseling Psychology, University of Wisconsin - Madison, 1000 Bascom Mall, Madison, WI 53706, USA.
| | - Diana K N Louden
- University of Washington, Health Sciences Libraries, 1959 NE Pacific St, Seattle, WA 98195, USA.
| | - Shannon M Blakey
- Durham VA Medical Center, 508 Fulton St, Durham, NC 27705, USA; VA Mid-Atlantic Mental Illness Research, Education and Clinical Center, 3022 Croasdaile Dr, Durham, NC 27705, USA.
| | - Sage E Hawn
- Boston VA Medical Center, 150S Huntington Ave, Boston, MA 02130, USA.
| | - Aline Lott
- VA Puget Sound Center of Excellence in Substance Addiction Treatment and Education, 1660 South Columbian Way, Seattle, WA 98108, USA.
| | - Kendall C Browne
- VA Puget Sound Center of Excellence in Substance Addiction Treatment and Education, 1660 South Columbian Way, Seattle, WA 98108, USA; University of Washington, Department of Psychiatry, 1959 NE Pacific St, Seattle, WA 98195, USA.
| | - Keren Lehavot
- University of Washington, Department of Psychiatry, 1959 NE Pacific St, Seattle, WA 98195, USA; VA Puget Sound Seattle/Denver HSR&D COIN, 1660 South Columbian Way, Seattle, WA 98108, USA.
| | - Debra Kaysen
- Stanford University, Department of Psychiatry, 401 Quarry Road, Stanford, CA 94305, USA.
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17
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Mehta K, Hoadley A, Ray LA, Kiluk BD, Carroll KM, Magill M. Cognitive-Behavioral Interventions Targeting Alcohol or Other Drug Use and Co-Occurring Mental Health Disorders: A Meta-Analysis. Alcohol Alcohol 2021; 56:535-544. [PMID: 33778869 PMCID: PMC8406071 DOI: 10.1093/alcalc/agab016] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2020] [Revised: 02/19/2021] [Accepted: 02/20/2021] [Indexed: 01/10/2023] Open
Abstract
AIMS This meta-analysis reviewed 15 clinical trials (18 study sites/arms), examining the efficacy of an integrated cognitive-behavioral intervention (CBI) delivered to individuals with an alcohol or other drug use disorder and a co-occurring mental health disorder (AOD/MHD). Outcomes were alcohol or other drug use and mental health symptoms at post-treatment through follow-up. METHODS The inverse-variance weighted effect size was calculated for each study and pooled under random effects assumptions. RESULTS Integrated CBI showed a small effect size for AOD (g = 0.188, P = 0.061; I2 = 86%, τ2 = 0.126, k = 18) and MHD (g = 0.169, P = 0.024; I2 = 58%, τ2 = 0.052, k = 18) outcomes, although only MHD outcomes were statistically significant. Analysis by subgroup suggested that effect magnitude varied by type of contrast condition (integrated CBI + usual care vs. usual care only; integrated CBI vs. a single-disorder intervention), follow-up time point (post-treatment vs. 3-6 months) and primary AOD/MHD diagnosis, although these sub-groups often contained significant residual heterogeneity. In a series of mixed effects, meta-regression models, demographic factors were non-significant predictors of between-study heterogeneity. For AOD outcomes, greater effects were observed in higher quality studies, but study quality was not related to effect size variability for MHD outcomes. CONCLUSIONS The current meta-analysis shows a small and variable effect for integrated CBI with the most promising effect sizes observed for integrated CBI compared with a single disorder intervention (typically an AOD-only intervention) for follow-up outcomes, and for interventions targeting alcohol use and/or post-traumatic stress disorder. Given the clinical and methodological variability within the sample, results should be considered a preliminary, but important step forward in our understanding of treatment for co-occurring AOD/MHD.
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Affiliation(s)
- Kahini Mehta
- Center for Alcohol and Addiction Studies, Brown University, Providence, RI 02912, USA
| | - Ariel Hoadley
- College of Public Health, Temple University, Philadelphia, PA 19122, USA
| | - Lara A Ray
- Department of Clinical Psychology, University of California at Los Angeles, Los Angeles, CA 90095, USA
| | - Brian D Kiluk
- Department of Psychiatry, Yale School of Medicine, New Haven, CT 06520, USA
| | - Kathleen M Carroll
- Department of Psychiatry, Yale School of Medicine, New Haven, CT 06520, USA
| | - Molly Magill
- Center for Alcohol and Addiction Studies, Brown University, Providence, RI 02912, USA
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18
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Repeated cocaine exposure prior to fear conditioning induces persistency of PTSD-like symptoms and enhancement of hippocampal and amygdala cell density in male rats. Brain Struct Funct 2021; 226:2219-2241. [PMID: 34195855 DOI: 10.1007/s00429-021-02320-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2021] [Accepted: 06/11/2021] [Indexed: 12/29/2022]
Abstract
Pre- and post-trauma drug use can interfere with recovery from post-traumatic stress disorder (PTSD). However, the biological underpinnings of this interference are poorly understood. Here we examined the effect of pre-fear conditioning cocaine self-administration on PTSD-like symptoms in male rats, and defined impairment of fear extinction as difficulty to recover from PTSD. We also examined cell density changes in brain regions suspected of being involved in resistance to PTSD recovery. Before footshock stress testing, rats were trained to self-administer cocaine during 20 consecutive days, after which they were exposed to footshocks, while other rats continued to self-administer cocaine until the end of the experiment. Upon assessment of three PTSD-like symptoms (fear during situational reminders, anxiety-like behavior, and impairment of recognition memory) and fear extinction learning and memory, changes in cell density were measured in the medial prefrontal cortex, hippocampus, and amygdala. Results show that pre-footshock cocaine exposure did not affect fear during situational reminders. Fear conditioning did not lead to an increase in cocaine consumption. However, in footshock stressed rats, cocaine induced a reduction of anxiety-like behavior, an aggravation of recognition memory decline, and an impairment of extinction memory. These behavioral alterations were associated with increased cell density in the hippocampal CA1, CA2, and CA3 regions and basolateral amygdala, but not in the medial prefrontal cortex. Our findings suggest that enhancement of cell density in the hippocampus and amygdala may be changes associated with drug use, interfering with PTSD recovery.
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19
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Saavedra LM, Morgan-López AA, Hien DA, Killeen TK, Back SE, Ruglass LM, Fitzpatrick S, Lopez-Castro T. Putting the Patient Back in Clinical Significance: Moderated Nonlinear Factor Analysis for Estimating Clinically Significant Change in Treatment for Posttraumatic Stress Disorder. J Trauma Stress 2021; 34:454-466. [PMID: 33175470 DOI: 10.1002/jts.22624] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2020] [Revised: 08/25/2020] [Accepted: 09/09/2020] [Indexed: 12/21/2022]
Abstract
The present study introduced a modernized approach to Jacobson and Truax's (1991) methods of estimating treatment effects on individual-level (a) movement from the clinical to the normative range and (b) reliable change on posttraumatic stress disorder (PTSD) severity. Participants were 450 trauma-exposed women (M age = 39.2 years, SD = 8.9, range: 18-65 years) who presented to seven geographically diverse community mental health and substance use treatment centers. Data from 53 of these women, none of whom met the criteria for full or subthreshold PTSD, were used to establish the normative range. Using moderated nonlinear factor analysis (MNLFA) scale scoring, which weights symptoms by their clinical relevance, a significantly larger proportion of participants moved into the normative range for PTSD severity scores and/or exhibited reliable changes after treatment compared to the same individuals' movement when using symptom counts. Further, approximately 24% of the participants showed discrepant judgments on reliable change indices (RCI) between MNLFA scores and symptom counts, likely due to the false assumption that the standard error of measurement is equal for all levels of underlying PTSD severity when estimating RCIs with symptom counts. An MNLFA approach to estimating underlying PTSD severity can provide clinically meaningful information about individual-level change without the de facto assumption that PTSD symptoms have equivalent weight. Study implications are discussed with regard to a joint emphasis on (a) measurement models that highlight differential symptom weighting and (b) treatment-arm differences in individual-level outcomes rather than the current overemphasis of treatment-arm differences on group-averaged trajectories.
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Affiliation(s)
| | | | - Denise A Hien
- Center of Alcohol Studies, Rutgers University-New Brunswick, New Brunswick, New Jersey, USA
| | - Therese K Killeen
- Department of Psychiatry and Behavioral Sciences, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Sudie E Back
- Department of Psychiatry and Behavioral Sciences, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Lesia M Ruglass
- Department of Psychology, The City College of New York, New York, New York, USA.,Center of Alcohol and Substance Use Studies, Rutgers University-New Brunswick, New Jersey, USA
| | | | - Teresa Lopez-Castro
- Department of Psychology, The City College of New York, New York, New York, USA
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Ford JH, Kaur A, Rao D, Gilson A, Bolt DM, Garneau HC, Saldana L, McGovern MP. Improving Medication Access within Integrated Treatment for Individuals with Co-Occurring Disorders in Substance Use Treatment Agencies. IMPLEMENTATION RESEARCH AND PRACTICE 2021; 2:26334895211033659. [PMID: 34988462 PMCID: PMC8726008 DOI: 10.1177/26334895211033659] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND The best approach to provide comprehensive care for individuals with co-occurring disorders (CODs) related to substance use and mental health is to address both disorders through an integrated treatment approach. However, only 25% of behavioral health agencies offer integrated care and less than 7% of individuals who need integrated treatment receive it. A project used a cluster-randomized waitlist control group design to evaluate the effectiveness of Network for the Improvement of Addiction Treatment (NIATx) implementation strategies to improve access to addiction and psychotropic medications. METHODS This study represents a secondary analysis of data from the NIATx project. Forty-nine agencies were randomized to Cohort1 (active implementation group, receiving the NIATx strategy [n=25]) or Cohort2 (waitlist control group [n=24]). Data were collected at three time points (Baseline, Year1 and Year2). A two-level (patient within agency) multinomial logistic regression model investigated the effects of implementation strategy condition on one of four medication outcomes: both medication types, only psychotropic medication, only addiction medication, or neither medication type. A per-protocol analysis included time, NIATx fidelity, and agency focus as predictors. RESULTS The intent-to-treat analysis found a statistically significant change in access to addiction versus neither medication, but Cohort1 compared to Cohort2 at Year1 showed no differences. Changes were associated with the experimental intervention and occurred in the transition from Year 1 to Year 2, where greater increases were seen for agencies in Cohort2 versus Cohort1. The per-protocol analysis showed increased access to both medications and addiction medications from pre- to post-intervention for agencies in both cohorts; however, differences in change between high- and low-implementation agencies were not significant. CONCLUSIONS Access to integrated services for people with CODs is a long-standing problem. NIATx implementation strategies had limited effectiveness in improving medication access for individuals with CODs. Implementation strategy adherence is associated with increased medication access.
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Affiliation(s)
- James H Ford
- School of Pharmacy, Social and Administrative Sciences Division, University of
Wisconsin–Madison, USA
| | - Arveen Kaur
- School of Pharmacy, Social and Administrative Sciences Division, University of
Wisconsin–Madison, USA
| | - Deepika Rao
- School of Pharmacy, Social and Administrative Sciences Division, University of
Wisconsin–Madison, USA
| | - Aaron Gilson
- School of Pharmacy, Social and Administrative Sciences Division, University of
Wisconsin–Madison, USA
| | - Daniel M Bolt
- School of Education, Educational Psychology Division, University of
Wisconsin–Madison, USA
| | - Helene Chokron Garneau
- Center for Behavioral Health Services and Implementation Research,
Division of Public Health & Population Sciences, Department of Psychiatry and
Behavioral Sciences, Stanford University School of
Medicine, USA
| | | | - Mark P McGovern
- Center for Behavioral Health Services and Implementation Research,
Division of Public Health & Population Sciences, Department of Psychiatry and
Behavioral Sciences, Stanford University School of
Medicine, USA
- Division of Primary Care and Population Health, Department of
Medicine, Stanford University School of
Medicine, USA
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21
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Dansiger S, Chabra R, Emmel L, Kovacs J. The MET(T)A Protocol: Mindfulness and EMDR Treatment Template for Agencies. SUBSTANCE ABUSE-RESEARCH AND TREATMENT 2020; 14:1178221820977483. [PMID: 33311983 PMCID: PMC7716072 DOI: 10.1177/1178221820977483] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/21/2020] [Accepted: 10/31/2020] [Indexed: 12/05/2022]
Abstract
Evidence indicating the relationship between trauma and substance use disorders (SUDs), in addition to relapse and treatment retention rates for this population, suggests there is a need for a trauma-focused solution to treat SUDs. Eye movement desensitization and reprocessing (EMDR) therapy has been studied extensively as an effective approach for treating trauma and Posttraumatic Stress Disorder (PTSD). The research evaluating its treatment for other mental health disorders such as SUDs is promising. Merging mindfulness and ethical mindfulness practices with EMDR therapy lends additional evidence-based elements to make the case for this integrative system of treatment to be studied as a trauma-focused primary psychotherapy to treat SUDs. The resulting treatment, the MET(T)A Protocol (Mindfulness and EMDR Treatment Template for Agencies), has been created to address the need for a trauma-focused solution to treat SUDs. Procedures of the MET(T)A Protocol as applied in each of the 8 phases of EMDR therapy are described in detail. Clinical examples are provided to explain the application of the MET(T)A Protocol.
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22
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Najavits LM, Clark HW, DiClemente CC, Potenza MN, Shaffer HJ, Sorensen JL, Tull MT, Zweben A, Zweben JE. PTSD / substance use disorder comorbidity: Treatment options and public health needs. CURRENT TREATMENT OPTIONS IN PSYCHIATRY 2020; 7:544-558. [PMID: 35444925 PMCID: PMC9017717 DOI: 10.1007/s40501-020-00234-8] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
Purpose of Review Posttraumatic stress disorder (PTSD) commonly co-occurs with substance use disorder (SUD) and is challenging to treat. We review all behavioral therapy models with at least one randomized controlled trial in a current PTSD/SUD population. We identify factors in selecting a model for clinical use, emphasizing a public health framework that balances the need for evidence with the need for feasibility in frontline settings. Recent Findings Seven published models and 6 unpublished models are reviewed. Public health considerations for choosing a model include: whether it's been studied across a broad range of SUDs and in complex SUD patients; whether it can be conducted in group modality; its appeal to patients and providers; its cost; workforce requirements; and its ability to reduce substance use in addition to PTSD. Summary There are two broad types of models: those that originated in the PTSD field versus the SUD field. Overall, the latter are stronger on public health factors and more feasible in SUD settings. Published models in this category include Relapse Prevention, BRENDA, and Seeking Safety. PTSD/SUD research is at an early stage and there is a need for methodology that quantifies "level of burden" (patients' socioeconomic disadvantages) across trials.
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Affiliation(s)
| | | | | | - Marc N Potenza
- Departments of Psychiatry, Child Study and Neuroscience, Yale University School of Medicine
| | | | - James L Sorensen
- Department of Psychiatry and Behavioral Sciences, University of California at San Francisco, Zuckerberg San Francisco General Hospital and Trauma Center
| | | | | | - Joan E Zweben
- University of California, San Francisco, Veterans Affairs Medical Center, San Francisco
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23
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María-Ríos CE, Morrow JD. Mechanisms of Shared Vulnerability to Post-traumatic Stress Disorder and Substance Use Disorders. Front Behav Neurosci 2020; 14:6. [PMID: 32082127 PMCID: PMC7006033 DOI: 10.3389/fnbeh.2020.00006] [Citation(s) in RCA: 54] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2019] [Accepted: 01/13/2020] [Indexed: 12/11/2022] Open
Abstract
Psychoactive substance use is a nearly universal human behavior, but a significant minority of people who use addictive substances will go on to develop an addictive disorder. Similarly, though ~90% of people experience traumatic events in their lifetime, only ~10% ever develop post-traumatic stress disorder (PTSD). Substance use disorders (SUD) and PTSD are highly comorbid, occurring in the same individual far more often than would be predicted by chance given the respective prevalence of each disorder. Some possible reasons that have been proposed for the relationship between PTSD and SUD are self-medication of anxiety with drugs or alcohol, increased exposure to traumatic events due to activities involved in acquiring illegal substances, or addictive substances altering the brain's stress response systems to make users more vulnerable to PTSD. Yet another possibility is that some people have an intrinsic vulnerability that predisposes them to both PTSD and SUD. In this review, we integrate clinical and animal data to explore these possible etiological links between SUD and PTSD, with an emphasis on interactions between dopaminergic, adrenocorticotropic, GABAergic, and glutamatergic neurobehavioral mechanisms that underlie different emotional learning styles.
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Affiliation(s)
| | - Jonathan D. Morrow
- Neuroscience Graduate Program, University of Michigan, Ann Arbor, MI, United States
- Department of Psychiatry, University of Michigan, Ann Arbor, MI, United States
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24
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Bailey K, Trevillion K, Gilchrist G. What works for whom and why: A narrative systematic review of interventions for reducing post-traumatic stress disorder and problematic substance use among women with experiences of interpersonal violence. J Subst Abuse Treat 2019; 99:88-103. [DOI: 10.1016/j.jsat.2018.12.007] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2018] [Revised: 12/20/2018] [Accepted: 12/20/2018] [Indexed: 12/13/2022]
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Abstract
Given the high co-occurrence between alcohol use disorder (AUD) and mental health conditions (MHCs), and the increased morbidity associated with the presence of co-occurring disorders, it is important that co-occurring disorders be identified and both disorders addressed in integrated treatment. Tremendous heterogeneity exists among individuals with co-occurring conditions, and factors related to both AUD and MHCs, including symptom type and acuity, illness severity, the chronicity of symptoms, and recovery capital, should be considered when recommending treatment interventions. This article reviews the prevalence of co-occurring AUD and MHCs, screening tools to identify individuals with symptoms of AUD and MHCs, and subsequent assessment of co-occurring disorders. Types of integrated treatment and current challenges to integrate treatment for co-occurring disorders effectively are reviewed. Innovative uses of technology to improve education on co-occurring disorders and treatment delivery are also discussed. Systemic challenges exist to providing integrated treatment in all treatment settings, and continued research is needed to determine ways to improve access to treatment.
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Affiliation(s)
- Amy M Yule
- ., is a psychiatrist at Massachusetts General Hospital and an assistant professor of psychiatry at Harvard Medical School, Boston, Massachusetts. ., is a psychologist at Massachusetts General Hospital and a professor of psychiatry at Harvard Medical School, Boston, Massachusetts
| | - John F Kelly
- ., is a psychiatrist at Massachusetts General Hospital and an assistant professor of psychiatry at Harvard Medical School, Boston, Massachusetts. ., is a psychologist at Massachusetts General Hospital and a professor of psychiatry at Harvard Medical School, Boston, Massachusetts
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26
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Is Integrated CBT Effective in Reducing PTSD Symptoms and Substance Use in Iraq and Afghanistan Veterans? Results from a Randomized Clinical Trial. COGNITIVE THERAPY AND RESEARCH 2018. [DOI: 10.1007/s10608-018-9931-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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27
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McGovern M, Dent K, Kessler R. A Unified Model of Behavioral Health Integration in Primary Care. ACADEMIC PSYCHIATRY : THE JOURNAL OF THE AMERICAN ASSOCIATION OF DIRECTORS OF PSYCHIATRIC RESIDENCY TRAINING AND THE ASSOCIATION FOR ACADEMIC PSYCHIATRY 2018; 42:265-268. [PMID: 29488173 DOI: 10.1007/s40596-018-0887-5] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/12/2018] [Accepted: 01/19/2018] [Indexed: 06/08/2023]
Affiliation(s)
- Mark McGovern
- School of Medicine, Stanford University, Stanford, CA, USA.
| | - Kaitlin Dent
- School of Medicine, Stanford University, Stanford, CA, USA
| | - Rodger Kessler
- School of the Science of Health Care Delivery, Arizona State University, Phoenix, AZ, USA
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28
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Emotion Dysregulation in Comorbid Posttraumatic Stress Disorder and Substance Use Disorders: A Narrative Review. MILITARY PSYCHOLOGY 2017. [DOI: 10.1037/mil0000157] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
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Wieferink CE, de Haan HA, Dijkstra BA, Fledderus M, Kok T. Treatment of substance use disorders: Effects on patients with higher or lower levels of PTSD symptoms. Addict Behav 2017. [PMID: 28622616 DOI: 10.1016/j.addbeh.2017.06.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
While guidelines advise integrated treatment of patients with substance use disorder (SUD) and posttraumatic stress disorder (PTSD), recent studies and reviews find no convincing evidence of different outcomes following treatment between non-trauma focused integrated programs and SUD treatment alone. In this study, we analyzed whether SUD patients with higher levels of PTSD symptoms receiving standard, non-integrated SUD treatment (N=145) differed in outcomes compared to patients with lower levels of PTSD symptoms (N=152). Patients with higher levels of PTSD symptoms showed no difference in days of substance use, but significantly more craving and psychiatric symptoms (depression, anxiety and stress) were measured at baseline. After 3 and 6months of SUD treatment, there was no difference between the groups in decreased days of substance use. After 6months of SUD treatment, depression, anxiety and stress were significantly diminished in both groups. However, those with higher levels of PTSD symptoms at the start of the SUD treatment still reported significantly higher scores on depression, anxiety and stress after 6months of SUD treatment. These findings corroborate earlier studies that SUD patients with PTSD symptoms do not necessarily have poorer addiction treatment outcomes. However, as anxiety and PTSD symptoms predict relapse, future research should note the effect of higher symptom levels on long-term SUD treatment results. Additionally, more research is needed to determine which patients need additional treatment in conjunction with or following SUD treatment.
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30
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Szafranski DD, Snead A, Allan NP, Gros DF, Killeen T, Flanagan J, Pericot-Valverde I, Back SE. Integrated, exposure-based treatment for PTSD and comorbid substance use disorders: Predictors of treatment dropout. Addict Behav 2017; 73:30-35. [PMID: 28460246 DOI: 10.1016/j.addbeh.2017.04.005] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2016] [Revised: 03/23/2017] [Accepted: 04/03/2017] [Indexed: 01/09/2023]
Abstract
High rates of comorbid posttraumatic stress disorder (PTSD) and substance use disorders (SUD) have been noted in veteran populations. Fortunately, there are a number of evidence-based psychotherapies designed to address comorbid PTSD and SUD. However, treatments targeting PTSD and SUD simultaneously often report high dropout rates. To date, only one study has examined predictors of dropout from PTSD/SUD treatment. To address this gap in the literature, this study aimed to 1) examine when in the course of treatment dropout occurred, and 2) identify predictors of dropout from a concurrent treatment for PTSD and SUD. Participants were 51 male and female veterans diagnosed with current PTSD and SUD. All participants completed at least one session of a cognitive-behavioral treatment (COPE) designed to simultaneously address PTSD and SUD symptoms. Of the 51 participants, 22 (43.1%) dropped out of treatment prior to completing the full 12 session COPE protocol. Results indicated that the majority of dropout (55%) occurred after session 6, with the largest amount of dropout occurring between sessions 9 and 10. Results also indicated a marginally significant relationship between greater baseline PTSD symptom severity and premature dropout. These findings highlight inconsistencies related to timing and predictors of dropout, as well as the dearth of information noted about treatment dropout within PTSD and SUD literature. Suggestions for procedural changes, such as implementing continual symptom assessments during treatment and increasing dialog between provider and patient about dropout were made with the hopes of increasing consistency of findings and eventually reducing treatment dropout.
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The role of anxiety sensitivity in reactivity to trauma cues in treatment-seeking adults with substance use disorders. Compr Psychiatry 2017; 78:107-114. [PMID: 28822277 PMCID: PMC5600861 DOI: 10.1016/j.comppsych.2017.07.011] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2017] [Revised: 07/05/2017] [Accepted: 07/25/2017] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Exposure to traumatic events and posttraumatic stress disorder (PTSD) are common among individuals with substance use disorders (SUDs). Although the presence of trauma exposure and/or PTSD among those with SUDs is associated with a range of negative outcomes, much remains to be understood about the factors contributing to these outcomes. Anxiety sensitivity (the tendency to respond fearfully to the signs and symptoms of anxiety) has been linked to greater PTSD symptoms and the use of substances to cope with PTSD symptoms, and is a promising factor for understanding the negative outcomes associated with co-occurring PTSD and SUDs. METHODS This study examined the association between anxiety sensitivity and trauma cue reactivity among 194 trauma-exposed patients with SUDs (27.3% met criteria for current PTSD). Participants completed ratings of negative affect and substance cravings prior to and after exposure to a personally-relevant trauma cue. RESULTS Results indicated that anxiety sensitivity was associated with greater emotional reactivity (but not craving reactivity) to the trauma cue; neither PTSD symptom severity nor PTSD diagnosis moderated these associations. PTSD symptom severity was associated with greater emotional and craving reactivity to the trauma cue. CONCLUSIONS Results highlight the potential utility of targeting anxiety sensitivity in treatments for trauma-exposed patients with SUDs with and without PTSD.
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32
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Hardy R, Fani N, Jovanovic T, Michopoulos V. Food addiction and substance addiction in women: Common clinical characteristics. Appetite 2017; 120:367-373. [PMID: 28958901 DOI: 10.1016/j.appet.2017.09.026] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2017] [Revised: 09/08/2017] [Accepted: 09/23/2017] [Indexed: 10/18/2022]
Abstract
Food addiction is characterized by poorly controlled intake of highly-palatable, calorically-dense, foods. While previous studies indicate that risk factors for food addiction are similar to substance use disorders (SUD), these studies have looked at food addiction and SUD in independent samples, limiting the ability to directly compare food addiction to SUD. The present study was conducted to assess rates of posttraumatic stress disorder (PTSD), depression, childhood and adult trauma exposure, as well as presence and severity of emotion dysregulation, in a sample of women (N = 229) who either meet criteria for no addiction, food addiction only or SUD only. The prevalence of food addiction was 18.3% and the prevalence of SUD was 30.6% in this sample. Women with food addiction and women with SUD endorsed more depression and PTSD symptoms when compared with individuals with no addiction. Individuals with food addiction and SUD had higher total emotion dysregulation scores, specifically with difficulties in goal directed behaviors, non-acceptance of emotional responses, impulse control, limited access to emotion regulation strategies, and lack of emotional clarity, when compared to individuals with no addiction (all p's < 0.05). There were no differences in PTSD and depression symptoms and emotion dysregulation scores between food addiction and SUD groups (all p > 0.05). However, women with SUD endorsed higher levels of total childhood (p < 0.01) and adulthood trauma (p < 0.01) as compared with women with no addiction or food addiction. These results suggest that women with food addiction and those with SUD share similar psychological characteristics and risk factors, with the exception of trauma histories. These findings have implications for the detection of risk for and treatment of these disorders.
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Affiliation(s)
- Raven Hardy
- Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine, Atlanta, GA, USA
| | - Negar Fani
- Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine, Atlanta, GA, USA
| | - Tanja Jovanovic
- Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine, Atlanta, GA, USA
| | - Vasiliki Michopoulos
- Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine, Atlanta, GA, USA; Yerkes National Primate Research Center, Atlanta, GA, USA.
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Abstract
Dual diagnosis is a prevalent and serious health problem. These disorders challenge psychiatric mental health and addiction nurses to treat 2 distinct disorders. Despite advances in the treatment of these disorders, there remains a void in the ideal approach. This article offers psychiatric nurses opportunities to improve their expertise in the identification of vulnerable or high-risk populations by using integrated screening and brief interventions to discern treatment options. Patients who require comprehensive treatment to stabilize 1 or both disorders further challenge nurses to have a basic understanding of the powerful effects of substance use on psychiatric conditions and vice versa.
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34
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Schacht RL, Brooner RK, King VL, Kidorf MS, Peirce JM. Incentivizing attendance to prolonged exposure for PTSD with opioid use disorder patients: A randomized controlled trial. J Consult Clin Psychol 2017; 85:689-701. [PMID: 28414485 DOI: 10.1037/ccp0000208] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
OBJECTIVE To determine whether contingent monetary incentives increase opioid use disorder patients' attendance to Prolonged Exposure (PE) therapy and whether attendance is associated with improvement in posttraumatic stress disorder (PTSD) and substance use disorder (SUD) outcomes. METHOD Patients (N = 58) with PTSD were offered PE or PE with incentives (PE + I; max $480) to attend PE sessions. Participants were assessed at baseline and weeks 6, 12, and 24 postrandomization. RESULTS Participants were mostly women (79%) and Caucasian (71%); mean age 37.43 years (SD = 11.33). PE + I participants attended a median of 9 (of 12) sessions compared to 1 session for PE participants (p < .001), which included more exposure sessions (PE + I mdn = 6; PE mdn = 0; p < .001). A Time × treatment condition interaction indicated that PE + I participants exhibited a greater decrease in PTSD severity over time than PE participants (OR = 3.1; 95% CI = 0.4-5.7; p = .024). PE + I participants remained in substance use treatment longer than PE participants (mdn days = 262 vs. 192; p = .039). There were no group differences in drug use. CONCLUSIONS Monetary incentives increased SUD patients' attendance to an otherwise poorly attended treatment for PTSD. Better attendance in the incentivized group was associated with greater PTSD improvement, better SUD treatment retention, and no increased drug use. Incentives are well supported for improving adherence to substance use treatment goals and promising as a means to improve therapy attendance, which may improve the effectiveness of existing psychotherapies in difficult-to-treat populations. (PsycINFO Database Record
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Affiliation(s)
| | - Robert K Brooner
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine
| | - Van L King
- Department of Psychiatry, University of Texas Health Science Center at San Antonio
| | - Michael S Kidorf
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine
| | - Jessica M Peirce
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine
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35
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Schäfer I, Chuey-Ferrer L, Hofmann A, Lieberman P, Mainusch G, Lotzin A. Effectiveness of EMDR in patients with substance use disorder and comorbid PTSD: study protocol for a randomized controlled trial. BMC Psychiatry 2017; 17:95. [PMID: 28302084 PMCID: PMC5356401 DOI: 10.1186/s12888-017-1255-9] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2017] [Accepted: 03/04/2017] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Eye Movement Desensitization and Reprocessing (EMDR) is an evidence-based treatment for PTSD. However, it is unclear whether EMDR shows the same effectiveness in patients with substance use disorders (SUD) and comorbid PTSD. In this trial, we examine the effectiveness of EMDR in reducing PTSD symptoms in patients with SUD and PTSD. METHODS/DESIGN We conduct a single-blinded RCT among 158 patients with SUD and comorbid PTSD admitted to a German addiction rehabilitation center specialized for the treatment of patients with SUD and comorbid PTSD. Patients are randomized to receive either EMDR, added to SUD rehabilitation and non-trauma-focused PTSD treatment (TAU), or TAU alone. The primary outcome is change from baseline in PTSD symptom severity as measured by the Clinician-Administered PTSD Scale at 6-month follow-up. Secondary outcomes are change from baseline in substance use, addiction-related problems, depressive symptoms, dissociative symptoms, emotion dysregulation and quality of life. Assessments are carried out by blinded raters at admission, at end of treatment, and at 3- and 6-month follow-up. We expect that EMDR plus TAU will be more effective in reducing PTSD symptoms than TAU alone. Mixed models will be conducted using an intention-to-treat and per-protocol approach. DISCUSSION This study aims to expand the knowledge about the effectiveness of EMDR in patients with SUD and comorbid PTSD. The expected finding of the superiority of EMDR in reducing PTSD symptoms compared to non-trauma-focused PTSD treatment may enhance the use of trauma-focused treatment approaches for patients with SUD and co-morbid PTSD. TRIAL REGISTRATION German Clinical Trials Register: DRKS00009007 ; U1111-1172-9213. Retrospectively registered 01 Juni 2016.
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Affiliation(s)
- Ingo Schäfer
- 0000 0001 2180 3484grid.13648.38Department of Psychiatry and Psychotherapy, University Medical Center Hamburg-Eppendorf, Hamburg, Germany ,Center for Interdisciplinary Addiction Research, Department of Psychiatry and Psychotherapy, University Medical Center Hamburg-Eppendorf, University of Hamburg, Martinistr. 52, Hamburg, D-20246 Germany
| | | | - Arne Hofmann
- EMDR-Institute Germany, Bergisch Gladbach, Germany
| | | | | | - Annett Lotzin
- Department of Psychiatry and Psychotherapy, University Medical Center Hamburg-Eppendorf, Hamburg, Germany. .,Center for Interdisciplinary Addiction Research, Department of Psychiatry and Psychotherapy, University Medical Center Hamburg-Eppendorf, University of Hamburg, Martinistr. 52, Hamburg, D-20246, Germany.
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Nam E, Matejkowski J, Lee S. Racial/Ethnic Differences in Contemporaneous Use of Mental Health and Substance Use Treatment Among Individuals Experiencing Both Mental Illness and Substance Use Disorders. Psychiatr Q 2017; 88:185-198. [PMID: 27271529 DOI: 10.1007/s11126-016-9444-0] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
This study examined whether the well-established racial/ethnic differences in mental health service utilization among individuals with mental illness are reflected in the treatment utilization patterns of individuals experiencing both mental illness and substance use disorders, particularly in regards to the use of contemporaneous mental health and substance abuse treatment. Using pooled data from the National Survey on Drug Use and Health (2009-2013), the patterns of mental health and substance use treatment utilization of 8748 White, Black, or Latino individuals experiencing both mental illness and substance use disorders were analyzed. Multinomial logistic regression was conducted to test the relationships among racial/ethnic groups and the receipt of contemporaneous treatment, mental health treatment alone, and substance use treatment alone as compared with no treatment utilization. Results indicated that Black and Latino respondents were less likely to receive contemporaneous treatment than Whites respondents. Also, significantly associated with outcomes were several interactions between race/ethnicity and predisposing, need and enabling factors known to be associated with service utilization. The findings suggest that an underlying mechanism of racial/ethnic differences among individuals with co-occurring mental illness and substance use disorders in the treatment utilization may differ by the specific types of treatment and between Blacks and Latinos. Therefore, efforts to reduce these disparities should consider specialty in each treatment settings and heterogeneity within diverse racial/ethnic groups.
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Affiliation(s)
- Eunji Nam
- School of Social Welfare, University of Kansas, Twente Hall, 1545 Lilac Lane, Lawrence, KS, 66045, USA.
| | - Jason Matejkowski
- School of Social Welfare, University of Kansas, Twente Hall, 1545 Lilac Lane, Lawrence, KS, 66045, USA
| | - Sungkyu Lee
- School of Social Welfare, Soongsil University, 369 Sangdo-ro, Dongjak-gu, Seoul, South Korea
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Simpson TL, Lehavot K, Petrakis IL. No Wrong Doors: Findings from a Critical Review of Behavioral Randomized Clinical Trials for Individuals with Co-Occurring Alcohol/Drug Problems and Posttraumatic Stress Disorder. Alcohol Clin Exp Res 2017; 41:681-702. [PMID: 28055143 DOI: 10.1111/acer.13325] [Citation(s) in RCA: 70] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2016] [Accepted: 01/03/2017] [Indexed: 12/20/2022]
Abstract
Prior reviews of behavioral treatments for individuals with comorbid alcohol and drug use disorders (substance use disorder SUD) and posttraumatic stress disorder (PTSD) have not systematically considered whether comparison conditions are matched to target treatments on time and attention. A systematic literature search using PubMed MESH terms for alcohol and substance use disorders, PTSD, and treatment identified relevant behavioral randomized clinical trials (RCTs) that evaluated PTSD-oriented exposure-based treatments, addiction-focused treatments, and coping-based treatments that do not involve exposure to trauma memories. Information pertaining to within-subject changes over time and between-subject differences, quality of control condition, recruitment efficiency, and assessment and treatment retention was synthesized. Alcohol and drug outcomes were described separately when possible. Twenty-four behavioral RCTs were identified: 7 exposure based, 6 addiction focused, and 11 coping based. Seven studies included SUD intervention comparison conditions matched to the target intervention on time and attention. Most of the 24 studies found that participants in both the experimental and control conditions improved significantly over time on SUD and PTSD outcomes. No study found significant between-group differences in both SUD and PTSD outcomes favoring the experimental treatment. Despite greater treatment dropout, there was greater improvement in some PTSD outcomes for exposure-based interventions than the control conditions, including when the control conditions were matched for time and attention. Addiction-focused and coping-based interventions did not generally show an advantage over comparably robust controls, although some coping-based interventions yielded better drug use outcomes than control conditions. When available, interventions that integrate exposure-based PTSD treatment and behavioral SUD treatment are recommended as they are associated with better PTSD outcomes than SUD care matched for time and attention. However, the results of this critical review also suggest that people with SUD/PTSD can benefit from a variety of treatment options, including standard SUD care.
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Affiliation(s)
- Tracy L Simpson
- Center of Excellence in Substance Abuse Treatment and Education (CESATE), VA Puget Sound Health Care, Seattle, Washington.,Department of Psychiatry & Behavioral Sciences, University of Washington, Seattle, Washington
| | - Keren Lehavot
- Department of Psychiatry & Behavioral Sciences, University of Washington, Seattle, Washington.,Health Services Research & Development (HSR&D), Center of Innovation for Veteran-Centered and Value-Driven Care, VA Puget Sound Health Care, Seattle, Washington.,Department of Health Services, University of Washington, Seattle, Washington
| | - Ismene L Petrakis
- Mental Illness Research, Education and Clinical Centers (MIRECC) VA Connecticut Health Care System, West Haven, Connecticut.,Department of Psychiatry, Yale University, New Haven, Connecticut
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Bergman BG, Kelly JF, Nargiso JE, McKowen JW. "The Age of Feeling in-Between": Addressing Challenges in the Treatment of Emerging Adults With Substance Use Disorders. COGNITIVE AND BEHAVIORAL PRACTICE 2016. [DOI: 10.1016/j.cbpra.2015.09.008] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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Prior K, Mills K, Ross J, Teesson M. Substance use disorders comorbid with mood and anxiety disorders in the Australian general population. Drug Alcohol Rev 2016; 36:317-324. [PMID: 27324816 DOI: 10.1111/dar.12419] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2015] [Revised: 02/25/2016] [Accepted: 02/29/2016] [Indexed: 10/21/2022]
Abstract
INTRODUCTION AND AIMS Substance use disorders (SUDs) are common and frequently co-occur with mood and anxiety disorders. This paper provides a detailed analysis of patterns, prevalence and correlates of mood and anxiety disorders among those with a (i) pure SUD; (ii) SUD plus a mood or anxiety disorder (SUDs + 1); and (iii) SUD plus a mood and anxiety disorder (SUDs + 2). DESIGN AND METHODS Data came from the 2007 National Survey of Mental Health and Wellbeing; a nationally representative household survey of 8841 Australians aged 16-85 years. RESULTS The 12-month prevalence of SUDs was 5.1%. Of those with a 12-month SUD, 65% met the criteria for pure SUDs, 19% for SUDs + 1 and 16% for SUDs + 2. Major depression was the most common mood disorder in both comorbid groups. One-third of SUDs + 1 experienced social phobia, while over half of SUDs + 2 experienced generalised anxiety disorder. Compared with pure SUDs, SUDs + 1 experienced two times more and SUDs + 2 experienced over four times more days out of role in the preceding 30 days. Both comorbid groups were more likely to experience severe levels of impairment. SUDs + 2 were over 18 times more likely to experience suicidal thoughts in the same year. SUDs + 1 were over three times and SUDs + 2 were over 10 times more likely to have had one or more consultations with a health professional in the previous year. DISCUSSIONS AND CONCLUSIONS These findings highlight the complexities inherent with responding to and treating multiple comorbidities among substance users and emphasise the need for coordinated, cohesive responses from drug and alcohol treatment services.[Prior K, Mills K, Ross J, Teesson M. Substance use disorders comorbid with mood and anxiety disorders in the Australian general population. Drug Alcohol Rev 2017;36:317-324].
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Affiliation(s)
- Katrina Prior
- National Health and Medical Research Council Centre of Research Excellence in Mental Health and Substance Use, Sydney, Australia.,National Drug and Alcohol Research Centre, University of New South Wales, Sydney, Australia
| | - Katherine Mills
- National Health and Medical Research Council Centre of Research Excellence in Mental Health and Substance Use, Sydney, Australia.,National Drug and Alcohol Research Centre, University of New South Wales, Sydney, Australia
| | - Joanne Ross
- National Health and Medical Research Council Centre of Research Excellence in Mental Health and Substance Use, Sydney, Australia.,National Drug and Alcohol Research Centre, University of New South Wales, Sydney, Australia
| | - Maree Teesson
- National Health and Medical Research Council Centre of Research Excellence in Mental Health and Substance Use, Sydney, Australia.,National Drug and Alcohol Research Centre, University of New South Wales, Sydney, Australia
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Saunders EC, McLeman BM, McGovern MP, Xie H, Lambert-Harris C, Meier A. The influence of family and social problems on treatment outcomes of persons with co-occurring substance use disorders and PTSD. JOURNAL OF SUBSTANCE USE 2016; 21:237-243. [PMID: 27182200 DOI: 10.3109/14659891.2015.1005184] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
OBJECTIVE Family and social problems may contribute to negative recovery outcomes in patients with co-occurring substance use and psychiatric disorders, yet few studies have empirically examined this relationship. This study investigates the impact of family and social problems on treatment outcomes among patients with co-occurring substance use and posttraumatic stress disorder (PTSD). METHOD A secondary analysis was conducted using data collected from a randomized controlled trial of an integrated therapy for patients with co-occurring substance use and PTSD. Substance use, psychiatric symptoms, and social problems were assessed. Longitudinal outcomes were analyzed using generalized estimating equations (GEE) and multiple linear regression. RESULTS At baseline, increased family and social problems were associated with more severe substance use and psychiatric symptoms. Over time, all participants had comparable decreases in substance use and psychiatric problem severity. However, changes in family and social problem severity were predictive of PTSD symptom severity, alcohol use, and psychiatric severity at follow-up. CONCLUSIONS For patients with co-occurring substance use and PTSD, family and social problem severity is associated with substance use and psychiatric problem severity at baseline and over time. Targeted treatment for social and family problems may be optimal.
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Affiliation(s)
- Elizabeth C Saunders
- Dartmouth Psychiatric Research Center, Geisel School of Medicine at Dartmouth, 85 Mechanic Street, Suite B4-1, Lebanon, NH, USA
| | - Bethany M McLeman
- Dartmouth Psychiatric Research Center, Geisel School of Medicine at Dartmouth, 85 Mechanic Street, Suite B4-1, Lebanon, NH, USA
| | - Mark P McGovern
- Department of Psychiatry and of Community and Family Medicine, Geisel School of Medicine at Dartmouth, Lebanon, NH, USA
| | - Haiyi Xie
- Department of Community & Family Medicine, Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire, USA
| | - Chantal Lambert-Harris
- Department of Psychiatry, Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire, USA
| | - Andrea Meier
- Department of Psychiatry, Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire, USA
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Roberts NP, Roberts PA, Jones N, Bisson JI, Cochrane Common Mental Disorders Group. Psychological therapies for post-traumatic stress disorder and comorbid substance use disorder. Cochrane Database Syst Rev 2016; 4:CD010204. [PMID: 27040448 PMCID: PMC8782594 DOI: 10.1002/14651858.cd010204.pub2] [Citation(s) in RCA: 54] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
BACKGROUND Post-traumatic stress disorder (PTSD) is a debilitating mental health disorder that may develop after exposure to traumatic events. Substance use disorder (SUD) is a behavioural disorder in which the use of one or more substances is associated with heightened levels of distress, clinically significant impairment of functioning, or both. PTSD and SUD frequently occur together. The comorbidity is widely recognised as being difficult to treat and is associated with poorer treatment completion and poorer outcomes than for either condition alone. Several psychological therapies have been developed to treat the comorbidity, however there is no consensus about which therapies are most effective. OBJECTIVES To determine the efficacy of psychological therapies aimed at treating traumatic stress symptoms, substance misuse symptoms, or both in people with comorbid PTSD and SUD in comparison with control conditions (usual care, waiting-list conditions, and no treatment) and other psychological therapies. SEARCH METHODS We searched the Cochrane Depression, Anxiety and Neurosis Group's Specialised Register (CCDANCTR) all years to 11 March 2015. This register contains relevant randomised controlled trials from the Cochrane Library (all years), MEDLINE (1950 to date), EMBASE (1974 to date), and PsycINFO (1967 to date). We also searched the World Health Organization International Clinical Trials Registry Platform and ClinicalTrials.gov, contacted experts, searched bibliographies of included studies, and performed citation searches of identified articles. SELECTION CRITERIA Randomised controlled trials of individual or group psychological therapies delivered to individuals with PTSD and comorbid substance use, compared with waiting-list conditions, usual care, or minimal intervention or to other psychological therapies. DATA COLLECTION AND ANALYSIS We used standard methodological procedures expected by Cochrane. MAIN RESULTS We included 14 studies with 1506 participants, of which 13 studies were included in the quantitative synthesis. Most studies involved adult populations. Studies were conducted in a variety of settings. We performed four comparisons investigating the effects of psychological therapies with a trauma-focused component and non-trauma-focused interventions against treatment as usual/minimal intervention and other active psychological therapies. Comparisons were stratified for individual- or group-based therapies. All active interventions were based on cognitive behavioural therapy. Our main findings were as follows.Individual-based psychological therapies with a trauma-focused component plus adjunctive SUD intervention was more effective than treatment as usual (TAU)/minimal intervention for PTSD severity post-treatment (standardised mean difference (SMD) -0.41; 95% confidence interval (CI) -0.72 to -0.10; 4 studies; n = 405; very low-quality evidence) and at 3 to 4 and 5 to 7 months' follow-up. There was no evidence of an effect for level of drug/alcohol use post-treatment (SMD -0.13; 95% CI -0.41 to 0.15; 3 studies; n = 388; very low-quality evidence), but there was a small effect in favour of individual psychological therapy at 5 to 7 months (SMD -0.28; 95% CI -0.48 to -0.07; 3 studies; n = 388) when compared against TAU. Fewer participants completed trauma-focused therapy than TAU (risk ratio (RR) 0.78; 95% CI 0.64 to 0.96; 3 studies; n = 316; low-quality evidence).Individual-based psychological therapy with a trauma-focused component did not perform better than psychological therapy for SUD only for PTSD severity (mean difference (MD) -3.91; 95% CI -19.16 to 11.34; 1 study; n = 46; low-quality evidence) or drug/alcohol use (MD -1.27; 95% CI -5.76 to 3.22; 1 study; n = 46; low-quality evidence). Findings were based on one small study. No effects were observed for rates of therapy completion (RR 1.00; 95% CI 0.74 to 1.36; 1 study; n = 62; low-quality evidence).Non-trauma-focused psychological therapies did not perform better than TAU/minimal intervention for PTSD severity when delivered on an individual (SMD -0.22; 95% CI -0.83 to 0.39; 1 study; n = 44; low-quality evidence) or group basis (SMD -0.02; 95% CI -0.19 to 0.16; 4 studies; n = 513; low-quality evidence). There were no data on the effects on drug/alcohol use for individual therapy. There was no evidence of an effect on the level of drug/alcohol use for group-based therapy (SMD -0.03; 95% CI -0.37 to 0.31; 4 studies; n = 414; very low-quality evidence). A post-hoc analysis for full dose of a widely established group therapy called Seeking Safety showed reduced drug/alcohol use post-treatment (SMD -0.67; 95% CI -1.14 to -0.19; 2 studies; n = 111), but not at subsequent follow-ups. Data on the number of participants completing therapy were not for individual-based therapy. No effects were observed for rates of therapy completion for group-based therapy (RR 1.13; 95% CI 0.88 to 1.45; 2 studies; n = 217; low-quality evidence).Non-trauma-focused psychological therapy did not perform better than psychological therapy for SUD only for PTSD severity (SMD -0.26; 95% CI -1.29 to 0.77; 2 studies; n = 128; very low-quality evidence) or drug/alcohol use (SMD 0.22; 95% CI -0.13 to 0.57; 2 studies; n = 128; low-quality evidence). No effects were observed for rates of therapy completion (RR 0.91; 95% CI 0.68 to 1.20; 2 studies; n = 128; very low-quality evidence).Several studies reported on adverse events. There were no differences between rates of such events in any comparison. We rated several studies as being at 'high' or 'unclear' risk of bias in multiple domains, including for detection bias and attrition bias. AUTHORS' CONCLUSIONS We assessed the evidence in this review as mostly low to very low quality. Evidence showed that individual trauma-focused psychological therapy delivered alongside SUD therapy did better than TAU/minimal intervention in reducing PTSD severity post-treatment and at long-term follow-up, but only reduced SUD at long-term follow-up. All effects were small, and follow-up periods were generally quite short. There was evidence that fewer participants receiving trauma-focused therapy completed treatment. There was very little evidence to support use of non-trauma-focused individual- or group-based integrated therapies. Individuals with more severe and complex presentations (e.g. serious mental illness, individuals with cognitive impairment, and suicidal individuals) were excluded from most studies in this review, and so the findings from this review are not generalisable to such individuals. Some studies suffered from significant methodological problems and some were underpowered, limiting the conclusions that can be drawn. Further research is needed in this area.
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Affiliation(s)
- Neil P Roberts
- Cardiff University School of MedicineInstitute of Psychological Medicine and Clinical NeurosciencesHadyn Ellis BuildingMaindy RoadCardiffUKCF24 4HQ
- Cardiff and Vale University Health BoardPsychology and Counselling DirecorateCardiffUK
| | - Pamela A Roberts
- Cardiff and Vale University Health BoardPsychology and Counselling DirecorateCardiffUK
- Cardiff and Vale University Health BoardCommunity Addiction ServiceCardiffUK
| | - Neil Jones
- Cardiff and Vale University Health BoardCommunity Addiction ServiceCardiffUK
| | - Jonathan I Bisson
- Cardiff University School of MedicineInstitute of Psychological Medicine and Clinical NeurosciencesHadyn Ellis BuildingMaindy RoadCardiffUKCF24 4HQ
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Ruglass LM, Pedersen A, Cheref S, Hu MC, Hien DA. Racial differences in adherence and response to combined treatment for full and subthreshold post-traumatic stress disorder and alcohol use disorders: A secondary analysis. J Ethn Subst Abuse 2015; 15:434-448. [PMID: 26422415 DOI: 10.1080/15332640.2015.1056927] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
We conducted a secondary data analysis to examine whether there were racial differences in adherence and treatment outcomes for participants with co-occurring full and subthreshold post-traumatic stress disorder (PTSD) and alcohol/substance use disorders (A/SUD) who were treated with Seeking Safety (a cognitive-behavioral therapy) and sertraline or Seeking Safety and placebo as part of a clinical trial. Bivarate analyses examined the association between race and adherence, and generalized estimating equations assessed whether race moderated the effect of combination treatment on PTSD and alcohol use outcomes. Except for education, there were no statistically significant racial differences in baseline demographic and psychiatric characteristics. African Americans and Caucasians were equally adherent in number of psychotherapy and medication sessions attended and medication compliance. After controlling for baseline demographics and psychiatric symptoms, however, a race by treatment condition interaction emerged suggesting that African Americans who received the Seeking Safety and sertraline treatment had significantly lower PTSD symptom severity posttreatment and at six months follow-up compared to their counterparts who received Seeking Safety and placebo. No differential effect of treatment condition was found for Caucasians. Moreover, results indicated that a diagnosis of major depressive disorder negatively impacted PTSD symptom recovery for African American participants but not for Caucasians. In conclusion, no differences emerged between African Americans and Caucasians in adherence to combination treatments for PTSD and A/SUD. Findings also suggest assessment and treatment of MDD among African Americans may improve treatment outcomes. More research is needed to determine whether the differential response to Seeking Safety and sertraline among African Americans compared to Caucasians can be replicated.
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Affiliation(s)
- Lesia M Ruglass
- a Department of Psychology , City College of New York of CUNY , New York , NY
| | - Annelisa Pedersen
- a Department of Psychology , City College of New York of CUNY , New York , NY
| | - Soumia Cheref
- b Department of Psychology , University of Houston , Houston , TX
| | - Mei-Chen Hu
- c Department of Psychiatry , Columbia University College of Physicians and Surgeons , New York , NY
| | - Denise A Hien
- d Gordon F. Derner Institute for Advanced Psychological Studies, Adelphi University and Department of Psychiatry , Columbia University College of Physicians and Surgeons , New York , NY
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Saunders EC, McGovern MP, Lambert-Harris C, Meier A, McLeman B, Xie H. The impact of addiction medications on treatment outcomes for persons with co-occurring PTSD and opioid use disorders. Am J Addict 2015; 24:722-31. [PMID: 26388539 DOI: 10.1111/ajad.12292] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2015] [Revised: 08/24/2015] [Accepted: 09/06/2015] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Previous research has been inconclusive about whether adding psychosocial treatment to medication assisted treatment (MAT) improves outcomes for patients with co-occurring psychiatric and opioid use disorders. This study evaluated the impact of MAT and psychosocial therapies on treatment outcomes for patients with co-occurring opioid use disorders and PTSD. METHODS Patients meeting criteria for PTSD and substance use disorders were randomly assigned to one of three treatment conditions: Standard Care (SC) alone, Integrated Cognitive Behavioral Therapy (ICBT) plus SC, or Individual Addiction Counseling (IAC) plus SC. Substance use and psychiatric symptoms were assessed at baseline and 6 months. Only patients with opioid use disorders were included in the present analyses (n = 126). Two-way ANOVAS and logistic regression analyses were used to examine associations between treatment conditions and MAT, for substance use and psychiatric outcomes. RESULTS MAT patients receiving ICBT had significantly decreased odds of a positive urine drug screen, compared to non-MAT patients receiving SC alone (OR = .07, 95% CI = .01, .81, p = .03). For PTSD symptoms, a significant MAT by psychosocial treatment condition interaction demonstrated that MAT patients had comparable declines in PTSD symptoms regardless of psychosocial treatment type (F(2, 88) = 4.74, p = .011). Non-MAT patients in ICBT had significantly larger reductions in PTSD. CONCLUSIONS AND SCIENTIFIC SIGNIFICANCE For patients with co-occurring opioid use disorders and PTSD, MAT plus ICBT is associated with more significant improvement in substance use. For non-MAT patients, ICBT is most beneficial for PTSD symptoms.
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Affiliation(s)
- Elizabeth C Saunders
- Dartmouth Psychiatric Research Center, Lebanon, New Hampshire.,Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Hanover, New Hampshire
| | - Mark P McGovern
- Department of Psychiatry, Geisel School of Medicine at Dartmouth, Hanover, New Hampshire.,Department of Community and Family Medicine, Geisel School of Medicine at Dartmouth, Hanover, New Hampshire
| | - Chantal Lambert-Harris
- Department of Psychiatry, Geisel School of Medicine at Dartmouth, Hanover, New Hampshire
| | - Andrea Meier
- Department of Psychiatry, Geisel School of Medicine at Dartmouth, Hanover, New Hampshire
| | - Bethany McLeman
- Dartmouth Psychiatric Research Center, Lebanon, New Hampshire
| | - Haiyi Xie
- Department of Community and Family Medicine, Geisel School of Medicine at Dartmouth, Hanover, New Hampshire
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Meier A, McGovern MP, Lambert-Harris C, McLeman B, Franklin A, Saunders EC, Xie H. Adherence and competence in two manual-guided therapies for co-occurring substance use and posttraumatic stress disorders: clinician factors and patient outcomes. THE AMERICAN JOURNAL OF DRUG AND ALCOHOL ABUSE 2015; 41:527-34. [PMID: 26286351 PMCID: PMC4698972 DOI: 10.3109/00952990.2015.1062894] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
BACKGROUND The challenges of implementing and sustaining evidence-based therapies into routine practice have been well-documented. OBJECTIVES This study examines the relationship among clinician factors, quality of therapy delivery, and patient outcomes. METHODS Within a randomized controlled trial, 121 patients with current co-occurring substance use and posttraumatic stress disorders were allocated to receive either manualized Integrated Cognitive Behavioral Therapy (ICBT) or Individual Addiction Counseling (IAC). Twenty-two clinicians from seven addiction treatment programs were trained and supervised to deliver both therapies. Clinician characteristics were assessed at baseline; clinician adherence and competence were assessed over the course of delivering both therapies; and patient outcomes were measured at baseline and 6-month follow-up. RESULTS Although ICBT was delivered at acceptable levels, clinicians were significantly more adherent to IAC (p < 0.05). At session 1, clinical female gender (p < 0.05) and lower education level (p < 0.05) were predictive of increased clinician adherence and competence across both therapies. Adherence and competence at session 1 in either therapy were significantly predictive of positive patient outcomes. ICBT adherence (p < 0.05) and competence (p < 0.01) were predictive of PTSD symptom reduction, whereas IAC adherence (p < 0.01) and competence (p < 0.01) were associated with decreased drug problem severity. CONCLUSIONS The differential impact of adherence and competence for both therapy types is consistent with their purported primary target: ICBT for PTSD and IAC for substance use. These findings also suggest the benefits of considering clinician factors when implementing manual-guided therapies. Future research should focus on diverse clinician samples, randomization of clinicians to therapy type, and prospective designs to evaluate models of supervision and quality monitoring.
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Affiliation(s)
- Andrea Meier
- Department of Psychiatry, Geisel School of Medicine at Dartmouth, 85 Mechanic Street, Suite B4-1, Lebanon, New Hampshire, USA
| | - Mark P. McGovern
- Departments of Psychiatry and of Community & Family Medicine, Geisel School of Medicine at Dartmouth, 85 Mechanic Street, Suite B4-1, Lebanon, New Hampshire, USA
| | - Chantal Lambert-Harris
- Department of Psychiatry, Geisel School of Medicine at Dartmouth, 85 Mechanic Street, Suite B4-1, Lebanon, New Hampshire, USA
| | - Bethany McLeman
- Dartmouth Psychiatric Research Center, 85 Mechanic Street, Suite B4-1, Lebanon, New Hampshire, USA
| | - Anna Franklin
- Dartmouth College, 85 Mechanic Street, Suite B4-1, Lebanon, New Hampshire, USA
| | - Elizabeth C. Saunders
- Dartmouth Psychiatric Research Center, 85 Mechanic Street, Suite B4-1, Lebanon, New Hampshire, USA
| | - Haiyi Xie
- Department of Community & Family Medicine, Geisel School of Medicine at Dartmouth, 85 Mechanic Street, Suite B4-1, Lebanon, New Hampshire, USA
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