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

Making trauma ecological momentary assessment studies FAIR: review of design considerations and data procedures

Background: Ecological momentary assessment (EMA) involves collecting data from people in their everyday lives one or more times per day over the course of days, weeks, or months. EMA has been used in the traumatic stress field to better understand how trauma-relevant symptoms, experiences, and behaviours occur under naturalistic conditions and in relation to one another. The FAIR principles specify that data should be Findable, Accessible, Interoperable, and Reusable to maximise the knowledge gained from individual research studies. However, it is unclear how EMA design decisions and data procedures might affect the implementation of these principles.Objective: We articulate key design considerations and data procedures when performing trauma EMA research and outline some challenges and recommendations for implementing the FAIR data principles in trauma EMA research.Method and Results: Using examples from existing trauma EMA studies, we discuss the decisions made when preparing a trauma EMA study; data processing and analytic procedures performed following data collection; and challenges that exist for their implementation, as well as practices that trauma EMA researchers can incorporate into their research to promote FAIR data.Conclusions: Implementing the FAIR data principles in trauma EMA research is critical to advancing scientific knowledge. Researchers should deposit their data in reputable repositories and include documentation detailing design decisions and the steps taken to clean and prepare data. Many challenges remain for the implementation of these practices including balancing privacy concerns and efforts to make trauma EMA data readily shareable.

A Randomized Clinical Trial of Prolonged Exposure Therapy With and Without Topiramate for Comorbid PTSD and Alcohol Use Disorder

OBJECTIVE

Posttraumatic stress disorder (PTSD) and alcohol use disorder (AUD) frequently co-occur. Prolonged exposure (PE) is an effective treatment for PTSD but shows smaller effects in patients with co-occurring AUD. Topiramate may help reduce alcohol use and PTSD symptoms. This double-blind, placebo-controlled outpatient clinical trial compared 12 sessions of PE plus either topiramate or placebo.

METHODS

One hundred U.S. veterans (mean age=45 years [SD=12], 84% men) with PTSD+AUD were randomly assigned to 16 weeks of treatment with PE+topiramate (up to 250 mg) or PE+placebo to examine effects on alcohol use and PTSD severity at posttreatment assessment and at 3- and 6-month follow-ups.

RESULTS

Percent heavy drinking days decreased significantly for both conditions but did not differ between groups. PTSD scores were lower in the PE+topiramate group than in the PE+placebo group at posttreatment assessment, but not at follow-ups. The same patterns were observed for loss of PTSD diagnosis and meaningful PTSD symptom change. Change in secondary outcomes (depression, quality of life) did not differ between conditions.

CONCLUSIONS

PE+topiramate was associated with a greater reduction in PTSD symptoms than PE+placebo during active treatment. The addition of topiramate led to more rapid and pronounced PTSD symptom reduction, which may be of benefit to patients. Because effects of topiramate were not maintained at longer-term follow-up, extending time on topiramate or additional strategies to prolong such effects may be useful. Topiramate did not show added benefit to PE for percent heavy drinking days or secondary outcomes.

Examining the longer-term efficacy of brief, alcohol-focused personalized feedback interventions for individuals with internalizing distress: Secondary analysis of a randomized controlled trial

BACKGROUND AND AIMS

Efficacy of brief alcohol interventions for young adults with internalizing distress (i.e. symptoms of depression, anxiety and stress) is unclear. We tested the moderating effect of internalizing distress on the efficacy of alcohol single- and multicomponent personalized feedback interventions (PFIs).

DESIGN

Secondary data were analyzed from a randomized controlled trial (RCT) testing the efficacy of single and multicomponent PFIs, compared with an attention-only control condition.

SETTING

Participants were sampled from two West Coast universities in the United States. All study protocols were completed online.

PARTICIPANTS

Participants (n = 1137) were college students (63% female; Mage = 20.1 years; 62.6% non-Hispanic white) who reported on internalizing distress at baseline. Some individuals reported clinically significant symptoms (depression: mild/moderate = 24.0%, severe/extremely severe = 10.5%; anxiety: mild/moderate = 19.6%, severe/extremely severe = 11.4%; and stress: mild/moderate = 37.5%, severe/extremely severe = 6.0%).

INTERVENTIONS

There were four different alcohol single-component PFIs administered and an attention-only PFI control. Alcohol PFIs varied in their complexity and single-component PFIs (i.e. personalized normative feedback) were compared with multicomponent PFI (i.e. containing additional alcohol-focused psychoeducation).

MEASUREMENTS

Baseline levels of internalizing distress were measured using the summed total of the Depression, Anxiety and Stress Scales (DASS). Drinking outcomes (alcohol consumption, peak eBAC, alcohol-related consequences) were measured at baseline, 3, 6 and 12 months post-intervention.

FINDINGS

Alcohol PFI (compared with attention-only control) reduced alcohol consumption and related consequences at 6-month [rate ratio (RR)Consumption = 0.85, P = 0.004] or 12-month follow-ups (RRConsumption = 0.76, P < 0.001; RRConsequences = 0.85, P = 0.020), regardless of baseline DASS score. Participants with higher DASS scores (compared with those with lower DASS scores) reported lower 6-month alcohol consumption after receiving a single-component intervention (RR = 0.80, P < 0.001). However, individuals with higher DASS scores (compared to those with lower DASS scores) reported more 6-month alcohol-related consequences after receiving a multicomponent intervention (RR = 0.78, P = 0.004).

CONCLUSIONS

Personalized feedback interventions may demonstrate efficacy towards reducing drinking in young adults and appear similarly beneficial across levels of internalizing distress, although lower-complexity interventions may be more efficacious.

Neural evidence of implicit emotion regulation deficits: An explorative study of comparing PTSD with and without alcohol dependence

BACKGROUND

Previous studies have identified psychiatric comorbidity, including alcohol dependence (AD), as a significant factor in treating posttraumatic stress disorder (PTSD), there is a lack of evidence on how best to treat comorbid PTSD and AD. Poor emotion regulation may be a key potential mechanism of PTSD and AD comorbidity.

METHODS

Seventy-four participants (48 women and 26 men) include three groups: a healthy control group (HC group, N = 20), a PTSD without alcohol dependence group (PTSD without AD group, N = 36), and a PTSD with alcohol dependence group (PTSD with AD group, N = 18). They completed the Shifted Attention Emotion Evaluation Task (SEAT) paradigm while undergoing fMRI.

RESULTS

Gender and hyperarousal symptoms were found to predict the risk of AD. In the whole-brain fMRI data, compared to PTSD without AD, the PTSD with AD group showed significant deactivations in the left middle Occipital Gyri (BA19_L), the right Rolandic Operculum (BA48_R), and the right Lingual Gyri (BA37_R). Furthermore, AD showed a significant correlation with the right Lingual Gyri (BA37_R) in individuals with PTSD.

CONCLUSION

These findings reveal possible neural mechanisms underlying the difference between PTSD patients with and without AD. These regions are involved in visual pathways, memory processing, and spatial cognition within the context of implicit emotion regulation. The observed alterations in these areas may serve as neural diagnostic markers for PTSD comorbid with AD and could be potential targets for developing novel treatments.

Pharmacological treatments for co-occurring PTSD and substance use disorders: A systematic review

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.

Dexmedetomidine HCL (BXCL501) as a potential treatment for alcohol use disorder and comorbid PTSD: A phase 1b, placebo-controlled crossover laboratory study

BACKGROUND AND OBJECTIVES

Noradrenergic dysregulation is important in the pathophysiology of posttraumatic stress disorder (PTSD) and alcohol use disorder (AUD); pharmacotherapies targeting adrenergic function have potential as treatment for comorbidity. Dexmedetomidine (sublingual film formulation-BXCL501; IGALMI) is a highly potent, selective ⍺2-adrenergic receptor agonist and may be superior to other pharmacotherapeutic approaches. A within subjects, phase 1b safety laboratory study was conducted to evaluate adverse effects of BXCL501 when combined with alcohol; BXCL501's potential efficacy was also explored.

METHODS

Heavy drinker participants with a diagnosis of or who were at risk for PTSD participated in three separate test days which included pretreatment with BXCL501 (40 µg, 80 µg or placebo) administered in a randomized, double-blind fashion, followed by three testing conditions: alcohol cue reactivity, trauma-induced reactivity, and IV ethanol administration. Safety outcomes included blood pressure (BP) and sedation. Exploratory outcomes included alcohol craving, trauma-induced anxiety and craving and subjective effects of alcohol.

RESULTS

Ten of twelve randomized participants competed the entire study. BXCL501 (80 µg) was associated with expected mild changes in BP and sedation; administration with alcohol did not affect those parameters. There were no clinically significant adverse effects. BXCL501 attenuated trauma-induced anxiety and attenuated subjective effects of alcohol.

DISCUSSIONS AND CONCLUSIONS

BXCL501 is safe for use in humans who may drink alcohol while undergoing treatment. BXCL501 may be explored as a potential treatment for PTSD and AUD.

SCIENTIFIC SIGNIFICANCE

This is the first study to provide scientific support for BXCL501's potential to treat PTSD and comorbid AUD.

Lack of Premeditation Mediates the Relationship Between Adverse Childhood Experiences and Posttraumatic Stress Disorder in Individuals in Residential Treatment for Substance Use Disorder

Objective: Adverse Childhood Events (ACEs) are associated with increased vulnerability for posttraumatic stress disorder (PTSD), but not everyone who experiences ACEs develops PTSD. Impulsivity has gained interest as a potential mediator between ACEs and PTSD, given that both PTSD and ACEs have been closely related to impulsivity. However, less is known about the relationship within the context of substance use disorder (SUD), a population highly vulnerable to co-occurring PTSD. This study examined whether impulsivity mediates the relationship between ACEs and PTSD symptoms in adults seeking residential treatment for substance use disorder (SUD). Methods: N = 134 consenting adults in residential treatment for SUD completed questionnaires measuring impulsivity (UPPS-P), ACEs (ACEs Scale), and PTSD symptoms (PCL-5). Regression models tested our hypotheses that ACEs would predict PTSD symptoms and that impulsivity would mediate this relationship. Results: Two-thirds of participants met the PCL-5 score threshold for a provisional diagnosis of PTSD. ACEs score and impulsivity were significant direct predictors of PTSD symptoms (coeff = 2.23, p < .001; coeff = 1.03, p < .001). Among UPPS-P subconstructs, only lack of premeditation emerged as a partial mediator (z = 2.14, p = 0.032). Conclusions: Individuals with SUD experience adverse and traumatic events at alarming rates and are at increased risk for PTSD. Our mediation finding suggests that impulsivity and especially lack of premeditation may be clinically relevant in the development or maintenance of PTSD symptoms among individuals with SUD.

State of the Science: Treatment of comorbid posttraumatic stress disorder and substance use disorders

Posttraumatic stress disorder (PTSD) and substance use disorders (SUDs) co-occur at high rates, with research showing that up to nearly 60% of individuals with PTSD also suffer from an alcohol and/or drug use disorder. PTSD/SUD is complex; associated with adverse health, social, and economic outcomes; and can be challenging to treat. Over the past decade, the landscape of treatment research addressing PTSD/SUD has significantly expanded. Ongoing efforts aimed at developing and evaluating novel treatments for PTSD/SUD, encompassing both psychotherapy and pharmacotherapy approaches, are steadily advancing. As such, this State of the Science paper reviews the literature on the latest scientific advances in treating PTSD/SUD. Clinical practice guidelines for the treatment of PTSD/SUD are discussed, along with evidence-based psychotherapies and emerging interventions. Rigorously conducted clinical trials demonstrate that individual, manualized, trauma-focused treatments are the most efficacious psychotherapies to use among individuals with PTSD/SUD. Moreover, patients do not need to be abstinent to initiate or benefit from evidence-based PTSD treatment. To date, no medications have been established for this comorbidity. We highlight ongoing research on novel treatments for PTSD/SUD, such as new forms of integrated trauma-focused psychotherapies, pharmacological augmentation strategies, and technology-based enhancements. Finally, promising future directions for the field are discussed.

Posttraumatic Stress Disorder and Substance Use Disorder Screening, Assessment, and Treatment

PURPOSE OF REVIEW

We review prevalence, etiology, impact on treatment, and best practices for treatment of posttraumatic stress disorder (PTSD) in a substance use disorder (SUD) treatment setting. Recommendations are given related to screening, assessment, and symptom monitoring.

RECENT FINDINGS

PTSD and SUDs are highly comorbid. This comorbidity is associated with higher acuity, more difficulty completing treatment, and worse prognosis. Integrated treatment is recommended, and trauma-focused psychotherapies combined with pharmacotherapy show particular promise. PTSD is highly prevalent in substance using samples, negatively impacting treatment course and worsening prognosis. This comorbidity has been explained by a variety of models, with self-medication having garnered the most support. Trauma-focused psychotherapies combined with pharmacotherapy demonstrate the most efficacy and are recommended when treating co-occurring SUDs and PTSD. Specifically, prolonged exposure (PE), concurrent treatment of PTSD and SUDs using PE (COPE), and cognitive processing therapy (CPT) have been seen as promising trauma-focused treatments. Investigations into ways to best augment therapy are also underway, both through treatment format and neuromodulation. Several recommendations are given.

Behavioral activation for veterans with co-occurring alcohol use disorder and posttraumatic stress disorder: Basis and methodology for a pilot randomized controlled trial

BACKGROUND

Nearly 2 million U.S. veterans live with co-occurring alcohol use disorder and posttraumatic stress disorder (AUD/PTSD). Extant AUD/PTSD treatments emphasize symptom reduction, sometimes overlooking psychosocial functioning improvements, and have dropout rates as high as 50 %. Additionally, current approaches to measuring psychosocial functioning are limited to self-report. This study protocol describes a 1:1 parallel, two-arm, pilot randomized controlled trial comparing Behavioral Activation (BA) psychotherapy to Relapse Prevention (RP) psychotherapy for veterans with AUD/PTSD.

METHODS

Forty-six veterans with AUD/PTSD will be block-randomized to eight weekly, virtual, hour-long individual sessions of BA or RP. Clinical interview, self-report, and geospatial assessments will be administered at pre- and post-treatment. Select outcome and exploratory measures will be administered during treatment. Analyses will focus on trial feasibility, BA acceptability, and preliminary efficacy. Geospatial analyses will explore whether pre- to post-treatment changes in geospatial movement can be used to objectively measure treatment response. The study site and an independent Data and Safety Monitoring Board will monitor trial progress, safety, and quality. De-identified data from consenting participants will be submitted to a sponsor-designated data repository.

CONCLUSION

If successful, this trial could help to provide veterans with AUD/PTSD with a more acceptable treatment option. Positive findings would also lay groundwork for testing BA in civilians with AUD/PTSD. Finally, by incorporating novel geospatial methods and technologies, this study could potentially yield a new approach to objectively measuring AUD/PTSD recovery that could be used in other clinical trials. This study was registered in ClinicalTrials.gov (NCT06249386).

Stress Exposure and PTSD in a Cross-Sectional Residential Substance Use Treatment Sample

BACKGROUND

Aim 1 of this cross-sectional, observational study with people in residential treatment for substance use disorders (SUDs) was to document stress exposure. Aim 2 was to assess potential sociodemographic and health differences based on probable posttraumatic stress disorder (PTSD) status. Aim 3 was to assess relative contributions of Diagnostic and Statistical Manual (DSM)-congruent versus DSM-incongruent stressors (Criterion A vs non-Criterion A) to mental and physical health. We hypothesized that both types of stressors would significantly contribute to impairment across indicators and that DSM-congruent stressor exposure would be more strongly associated with impairment than DSM-incongruent exposure.

METHODS

We assessed exposure to DSM-congruent traumatic stressors and DSM-incongruent life stressors, PTSD and depressive symptoms, emotion regulation difficulties, substance use recovery capital, and physical/mental health-related quality of life among 136 people in residential SUD treatment who were 64% men, 36% women; 49% white, 41% Black, 11% multiracial/another race; 18% lesbian, gay, or bisexual (LGB+); mean age = 39.82 (standard deviation = 12.24) years.

RESULTS

Participants reported experiencing a mean of 9.76 (SD = 6.11) DSM-congruent events. Those with probable PTSD were younger and more likely to be LGB+ than those without probable PTSD (P < .05). Experiencing higher numbers of DSM-congruent events was associated with more severe PTSD and depressive symptoms, emotion regulation difficulties, and lower physical health-related quality of life (P < .05). DSM-incongruent stressor exposure was not independently associated with any indicators. Recovery capital was not associated with either type of stress exposure.

CONCLUSIONS

Stressful event exposure among people in residential SUD treatment is very high. Those who are younger or LGB+ in residential SUD treatment may be at greater risk of developing PTSD. DSM-congruent stressors are more consistently associated with mental health indicators than are DSM-incongruent stressors. Prioritizing treatment targets and identifying implementable treatment strategies can be challenging with this complex population.

Cognitive processing therapy (CPT) versus individual drug counseling (IDC) for PTSD for veterans with opioid use disorder maintained on buprenorphine

BACKGROUND AND OBJECTIVES

There are high rates of comorbidity between posttraumatic stress disorder (PTSD) and opioid use disorder (OUD). Evidence-based trauma-focused psychotherapies such as Cognitive Processing Therapy (CPT) are a first-line treatment for PTSD. Veterans with OUD are treated primarily in substance use disorder (SUD) clinics where the standard of care is drug counseling; they often do not have access to first-line PTSD treatments. This study tested whether CPT can be conducted safely and effectively in veterans with comorbid OUD treated with buprenorphine.

METHODS

This 12-week, 2-site, randomized clinical trial (RCT) included open-label randomization to two groups: (a) CPT versus (b) Individual Drug Counselling (IDC) in veterans with PTSD and comorbid OUD who were maintained on buprenorphine (N = 38).

RESULTS

Veterans randomized to either IDC (n = 18) or CPT (n = 20) showed a significant reduction in self-reported PTSD symptoms over time as measured by the PTSD checklist (PCL-5) but there were no treatment group differences; there was some indication that reduction in PTSD symptoms in the CPT group were sustained in contrast to the IDC group. Recruitment was significantly impacted by COVID-19 pandemic, so this study serves as a proof-of-concept pilot study.

DISCUSSION AND CONCLUSIONS

Veterans with OUD and PTSD can safely and effectively participate in evidence-based therapy for PTSD; further work should confirm that trauma-focused treatment may be more effective in leading to sustained remission of PTSD symptoms than drug counseling.

SCIENTIFIC SIGNIFICANCE

This is the first study to evaluate CPT for PTSD in the context of buprenorphine treatment for OUD.

[Pharmacological treatment of posttraumatic stress disorder]

In addition to trauma-focussed psychotherapy, pharmacological treatment is often unavoidable, especially in patients with severe posttraumatic stress disorder (PTSD). As long as comorbid disorders do not dictate the pharmacotherapy approach, sertraline and paroxetine, along with other off-label prescribable substances approved in Germany, can be used for the treatment of PTSD. Venlafaxine, in particular, has shown good effectiveness in studies, whereas risperidone has shown lower effectiveness in augmentation. Overall, only a small to medium effect size is to be expected for all substances. Psychopharmacotherapy plays an important role in addressing sleep disorders, which are highly prevalent in PTSD. Treatment of trauma-related nightmares can be attempted with doxazosin or clonidine. In contrast, there are limited empirical data available for sleep disorders associated with PTSD, but the pharmacological treatment of insomnia can provide some guidance.

Posttraumatic stress disorder in people who use drugs: syringe services program utilization, treatment need, and preferences for onsite mental health care

BACKGROUND

Syringe services programs (SSPs) are critical healthcare access points for people with opioid use disorder (OUD) who face treatment utilization barriers. Co-locating care for common psychiatric comorbidities, like posttraumatic stress disorder (PTSD), at SSPs may reduce harms and enhance the health of individuals with OUD. To guide the development of onsite psychiatric care at SSPs, we collected quantitative survey data on the prevalence of PTSD, drug use patterns, treatment experiences associated with a probable PTSD diagnosis, and attitudes regarding onsite PTSD care in a convenience sample of registered SSP clients in New York City.

METHODS

Study participants were administered the PTSD Checklist for the DSM-5 (PCL-5) and asked about sociodemographic characteristics, current drug use, OUD and PTSD treatment histories, and desire for future SSP services using a structured interview. Probable PTSD diagnosis was defined as a PCL-5 score ≥ 31.

RESULTS

Of the 139 participants surveyed, 138 experienced at least one potentially traumatic event and were included in the present analysis. The sample was primarily male (n = 108, 78.3%), of Hispanic or Latinx ethnicity (n = 76, 55.1%), and middle-aged (M = 45.0 years, SD = 10.6). The mean PCL-5 score was 35.2 (SD = 21.0) and 79 participants (57.2%) had a probable PTSD diagnosis. We documented frequent SSP utilization, significant unmet PTSD treatment need, and high interest in onsite PTSD treatment.

CONCLUSIONS

Study findings point to the ubiquity of PTSD in people with OUD who visit SSPs, large gaps in PTSD care, and the potential for harm reduction settings like SSPs to reach people underserved by the healthcare system who have co-occurring OUD and PTSD.

The lived experiences and treatment needs of women with opioid use disorder and posttraumatic stress symptoms: A mixed methods study

INTRODUCTION

Women show a gender-specific risk for co-occurring opioid use disorder (OUD) and posttraumatic stress disorder (PTSD). Expert groups have called for the development of integrated treatments for women with OUD/PTSD, but there remains limited information on such interventions.

METHODS

This mixed-methods study interviewed and surveyed 10 women with current or past OUD and co-occurring posttraumatic stress symptoms (PTSS) and 16 providers who work with these women. Interviews and surveys queried patient participants' and providers' experiences of OUD/PTSS and how to best design an integrated, trauma-focused treatment for OUD/PTSD.

RESULTS

Patient participants (90 % white, 90 % mothers, Mage = 45.70) met criteria for severe, lifetime OUD and 40 % met a provisional diagnosis for PTSD. Four themes emerged for participants' experiences of OUD/PTSS: 1) numerous stressors; 2) shame; 3) multiple motivations to use opioids; and 4) a cycle of trauma and opioid use. Four themes emerged regarding patient participants' perceptions on the development of an OUD/PTSD treatment: 1) mixed attitudes towards medications for OUD; 2) barriers to treatment (e.g., insufficient treatments and contextual factors); 3) treatment facilitators (e.g., social support); and 4) preferences in treatment (e.g., trauma-focused, gender-focused, family content, ambivalence around group therapy). Providers (Mage = 38.94) were primarily white women (76.5 %). Two themes emerged from their experiences working with women with OUD/PTSS: 1) perceiving women to use opioids to regulate emotions and 2) gender differences in trauma types. Three themes emerged for providers' perceptions on the development of an OUD/PTSD treatment: 1) barriers to treatment (e.g., chaotic lives, contextual factors, family); 2) treatment facilitators (e.g., trust and external motivations); and 3) desired treatment modifications (e.g., stabilization, early skills in therapy, flexibility in therapy, social supports, safety guidelines, and assistance in identifying an index trauma). Most participants (90.0 %) and providers (93.5 %) preferred working on OUD/PTSD symptoms simultaneously rather than separately.

CONCLUSIONS

Findings demonstrate the need to modify integrated treatments to meet the preferences of providers and women with OUD/PTSS and OUD/PTSD. Treatments should consider therapeutic content, structure, contextual factors, social support, and PTSD severity to enhance uptake and reach.

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

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

Subjective stress and any drinking during alcohol treatment: Disentangling within and between person autoregressive effects

Alcohol use has been shown to increase stress, and there is some evidence that stress predicts subsequent alcohol use during treatment for alcohol use disorder (AUD), particularly among females who are more likely to report coping-motivated drinking. Gaining a better understanding of the processes by which stress and alcohol use are linked during treatment could potentially inform AUD treatment planning. The current study aimed to characterize the association between stress and drinking during the course of AUD treatment and whether there were sex differences in these associations. Secondary data analyses of the COMBINE study (N = 1375; 69% male, 76.3% non-Hispanic and white, average age of 44.4 years) were conducted to examine self-reported perceived stress and alcohol consumption across 16 weeks of treatment for AUD using a Bayesian random-intercept cross-lagged panel model. There was stronger evidence for any alcohol use predicting greater than typical stress in subsequent weeks and less strong evidence for stress increasing the subsequent probability of alcohol use, particularly among males. For females, greater stress predicted subsequent drinking earlier in the treatment period, and a lower probability of subsequent drinking in the last week of treatment. Interventions might specifically focus on targeting reductions in stress following drinking occasions.

Substance Use after Completion of an Intensive Treatment Program with Concurrent Treatment for Posttraumatic Stress Disorder and Substance Use among Veterans: Examining the Role of PTSD Symptoms

OBJECTIVE

Substance use disorders (SUDs) and posttraumatic stress disorder (PTSD) are costly and highly co-occurring diagnoses, particularly among veterans, suggesting a need to understand this comorbidity and effectively treat both disorders among this population.

METHODS

The current study aimed to examine substance use outcomes among post-9/11 veterans and service members (N = 48) who completed a two-week intensive outpatient program with concurrent treatment for and PTSD using Prolonged Exposure and substance use. Substance use was assessed at two weeks and three months posttreatment.

RESULTS

The intensive program had high completion rates and demonstrated decreases in substance use at two weeks and three months posttreatment. Additionally, lower PTSD symptoms at treatment completion were related to less substance use posttreatment.

CONCLUSIONS

Concurrent intensive treatment of PTSD and SUDs can lead to symptom improvement in a short period of time. Findings support the self-medication model, such that PTSD symptoms at treatment completion were related to substance use at follow-up.

Treating posttraumatic stress disorder and alcohol use disorder comorbidity: Current pharmacological therapies and the future of MDMA-integrated psychotherapy

Posttraumatic stress disorder (PTSD) and alcohol use disorder (AUD) frequently co-occur in patients who have experienced trauma. This comorbidity leads to a vicious cycle where PTSD symptoms beget heavy drinking and vice versa. There are no FDA-approved medications to treat PTSD-AUD; therefore, individuals suffering from this comorbidity are treated with medication approved to treat the disorders separately or with off-label pharmacological interventions. However, these medications are limited in their efficacy for treating PTSD-AUD comorbidity. Emerging research on the nonclassical psychedelic drug 3,4-methylenedioxymethamphetamine (MDMA) suggests that it may be an effective drug used in conjunction with psychotherapy. The following reviews the current research for clinical pharmacotherapies, as well as MDMA-integrative psychotherapy as they pertain to PTSD and AUD in isolation and co-occurrence. Future directions for the role of psychedelic-integrative therapy for the treatment of this comorbidity are discussed.

Sex and Gender Differences in Co-Occurring Alcohol Use Disorder and PTSD

Purpose of Review

Research demonstrates a strong association between alcohol use disorder (AUD) and posttraumatic stress disorder (PTSD). However, less is known about sex- and gender-based differences among individuals with AUD + PTSD. This narrative review examines recent literature in this area and aims to be a reference for future research endeavors.

Recent Findings

Extant literature shows that intertwining biological systems increase females' risk of developing PTSD and experiencing more adverse effects from AUD compared to males. Sex-based physiological differences further interact with gendered sociocultural environments to influence the risk of AUD + PTSD. Emerging research suggests potential gender-specific pathways between PTSD, coping, and AUD which may inform prevention and treatment. However, barriers to care are often gender-specific and tailored approaches are needed to improve reach and uptake.

Summary

Additional research is needed to examine intersectional and contextual factors that synergistically influence sex/gender differences in AUD + PTSD, particularly beyond cisgender identities, and mechanisms of action.

Integrated behavioral treatments for comorbid anxiety and substance use disorders: A model for understanding integrated treatment approaches and meta-analysis to evaluate their efficacy

INTRODUCTION

Substance use disorders (SUD) and anxiety disorders are highly comorbid, and this comorbidity is associated with poor clinical outcomes. Emerging research in the last decade has shifted from addressing these problems separately to the development and evaluation of behavioral treatments that integrate care for anxiety disorders (or elevated symptoms of anxiety) and SUD.

METHODS

An extensive literature search revealed a sufficient number of studies (K=11) to conduct a meta-analysis comparing the efficacy of integrated SUD/anxiety disorder behavioral treatment to SUD treatment alone on substance use and anxiety symptom outcomes. Randomized clinical trials including those with SUD and either anxiety disorders or elevations in constructs implicated in the maintenance of anxiety disorder/SUD comorbidity were included. This study meta-analyzes the effects of these studies.

RESULTS

Integrated treatments outperformed SUD treatments alone on both substance use and anxiety outcomes, with small to moderate effects favoring integrated treatments. There was no significant heterogeneity across studies in the primary analyses, such that moderator analyses to identify variables that yielded differential patterns of effect sizes were not conducted.

DISCUSSION

Integrated treatments for SUD/anxiety disorders demonstrate an incremental but significant and clinically meaningful improvement over SUD treatment alone for SUD/anxiety disorder comorbidity. Implications for future research and clinical practice paradigm shifting are discussed.

Psychological treatment of PTSD with comorbid substance use disorder (SUD): expert recommendations of the European Society for Traumatic Stress Studies (ESTSS)

Background: Post-traumatic stress disorder (PTSD) and substance use disorder (SUD) are often comorbid and difficult to treat. The availability of evidence-based treatment guidelines is very limited and there is significant uncertainty about what best practice looks like.Objective: This paper describes the methodology used to develop expert recommendations for the assessment and psychological treatment of PTSD and comorbid SUD and presents the final recommendations.Methodology: A small committee of experts in the field of PTSD and SUD was formed on behalf of the European Society for Traumatic Stress Studies (ESTSS) Board. The committee developed recommendations based on a two-stage process. In the first stage a systematic review of randomised controlled trials of psychological interventions aimed at treating PTSD-SUD comorbidity was completed, and other recent relevant reviews systematic were also considered. To complement the recommendations based on systematic review, the second stage involved the review and collation of existing guidance, good practice and consensus recommendations made in methodologically rigorous clinical practice guidelines.Results: The two-stage process resulted in 9 recommendations related to assessment and 21 recommendations related to treatment planning and delivery.Conclusions: To our knowledge, this is the first attempt to provide expert recommendations based on a systematic review of the literature and through collation of guidance provided in other authoritative and reliable sources. These expert recommendations will provide helpful guidance to clinicians and service providers in both addiction and mental health settings about appropriate clinical care for those with PTSD SUD comorbidity.

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

OBJECTIVE

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

METHOD

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

RESULTS

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

CONCLUSION

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

Opportunities for improving data sharing and FAIR data practices to advance global mental health

It is crucial to optimize global mental health research to address the high burden of mental health challenges and mental illness for individuals and societies. Data sharing and reuse have demonstrated value for advancing science and accelerating knowledge development. The FAIR (Findable, Accessible, Interoperable, and Reusable) Guiding Principles for scientific data provide a framework to improve the transparency, efficiency, and impact of research. In this review, we describe ethical and equity considerations in data sharing and reuse, delineate the FAIR principles as they apply to mental health research, and consider the current state of FAIR data practices in global mental health research, identifying challenges and opportunities. We describe noteworthy examples of collaborative efforts, often across disciplinary and national boundaries, to improve Findability and Accessibility of global mental health data, as well as efforts to create integrated data resources and tools that improve Interoperability and Reusability. Based on this review, we suggest a vision for the future of FAIR global mental health research and suggest practical steps for researchers with regard to study planning, data preservation and indexing, machine-actionable metadata, data reuse to advance science and improve equity, metrics and recognition.

Comorbid posttraumatic stress disorder and alcohol use disorder in low- and middle-income countries: A narrative review

Much of the research on posttraumatic stress disorder (PTSD) and alcohol use disorder (AUD) has been conducted in high-income countries (HICs). However, PTSD and AUD commonly co-occur (PTSD + AUD) are both associated with high global burden of disease, and disproportionately impact those in low- and middle-income countries (LMICs). This narrative review attempts to synthesize the research on prevalence, impact, etiological models, and treatment of PTSD + AUD drawing from research conducted in HICs and discussing the research that has been conducted to date in LMICs. The review also discusses overall limitations in the field, including a lack of research on PTSD + AUD outside of HICs, issues with measurement of key constructs, and limitations in sampling strategies across comorbidity studies. Future directions are discussed, including a need for rigorous research studies conducted in LMICs that focus on both etiological mechanisms and on treatment approaches.

Data sharing and re-use in the traumatic stress field: An international survey of trauma researchers

BACKGROUND

The FAIR data principles aim to make scientific data more Findable, Accessible, Interoperable, and Reusable. In the field of traumatic stress research, FAIR data practices can help accelerate scientific advances to improve clinical practice and can reduce participant burden. Previous studies have identified factors that influence data sharing and re-use among scientists, such as normative pressure, perceived career benefit, scholarly altruism, and availability of data repositories. No prior study has examined researcher views and practices regarding data sharing and re-use in the traumatic stress field.

OBJECTIVE

To investigate the perspectives and practices of traumatic stress researchers around the world concerning data sharing, re-use, and the implementation of FAIR data principles in order to inform development of a FAIR Data Toolkit for traumatic stress researchers.

METHOD

A total of 222 researchers from 28 countries participated in an online survey available in seven languages, assessing their views on data sharing and re-use, current practices, and potential facilitators and barriers to adopting FAIR data principles.

RESULTS

The majority of participants held a positive outlook towards data sharing and re-use, endorsing strong scholarly altruism, ethical considerations supporting data sharing, and perceiving data re-use as advantageous for improving research quality and advancing the field. Results were largely consistent with prior surveys of scientists across a wide range of disciplines. A significant proportion of respondents reported instances of data sharing and re-use, but gold standard practices such as formally depositing data in established repositories were reported as infrequent. The study identifies potential barriers such as time constraints, funding, and familiarity with FAIR principles.

CONCLUSIONS

These results carry crucial implications for promoting change and devising a FAIR Data Toolkit tailored for traumatic stress researchers, emphasizing aspects such as study planning, data preservation, metadata standardization, endorsing data re-use, and establishing metrics to assess scientific and societal impact.