Effectiveness of EMDR in patients with substance use disorder and comorbid PTSD: study protocol for a randomized controlled trial

Diagnostic Accuracy of the Drug Use Disorder Identification Test and Its Short Form, the DUDIT-C, in German Adolescent Psychiatric Patients

Background

A common screening instrument for substance use disorders (SUDs) is the Drug Use Disorders Identification Test (DUDIT) which includes a short form regarding only drug consumption (DUDIT-C). We aim to assess if a German version of the DUDIT, adapted for adolescents, is a suitable screening instrument in a sample of adolescent psychiatric patients.

Methods

N = 124 (54 female) German adolescent (M = 15.6 + 1.5 years) psychiatric patients completed the DUDIT and received a diagnostic interview (MINI-KID) assessing DSM-5 SUD criteria. A confirmatory factor analysis (CFA), receiver operating characteristic (ROC) curves, the area under the curve (AUC), and Youden’s Index were calculated.

Results

A two-factor model of the DUDIT shows the best model fit (CFI = 0.995, SRMR = 0.055, RMSEA = 0.059, WRMR = 0.603). The DUDIT as well as the DUDIT-C show high diagnostic accuracy, with AUC = 0.95 and AUC = 0.88, respectively. For the DUDIT a cut-off value of 8.5 was optimal (sensitivity = 0.93, specificity = 0.91, J = 0.84), while for the DUDIT-C the optimal cut-off value was at 1.5 (sensitivity = 0.86, specificity = 0.84, J = 0.70).

Conclusion

This is the first psychometric evaluation of the DUDIT in German, adolescent psychiatric outpatients, using the DSM-5 diagnostic criteria. The DUDIT as well as the DUDIT-C are well suited for use in this population. Since in our sample only few patients presented with a mild or moderate SUD, our results need to be replicated in a sample of adolescents with mild SUD.

Principles of Care for Young Adults With Co-Occurring Psychiatric and Substance Use Disorders

Over 50% of young adults (defined as individuals aged 18-25 years) with substance use disorders (SUDs) have at least 1 co-occurring psychiatric disorder, and the presence of co-occurring disorders worsens SUD outcomes. Treatment of both co-occurring psychiatric disorders and SUDs in young adults is imperative for optimal treatment, yet many barriers exist to achieving this goal. We present a series of evidence-informed principles of care for young adults with co-occurring psychiatric disorders derived by a workgroup of experts convened by Boston Medical Center's Grayken Center for Addiction. The 3 principles are as follows: (1) young adults should receive integrated mental health and addiction care across treatment settings; (2) care should be responsive to the needs of young adults exposed to trauma and other adverse childhood experiences; and (3) treatment programs should regularly assess and respond to the evolving mental health needs, motivations, and treatment goals of young adults with co-occurring disorders. Our guidance for each principle is followed by a review of the evidence supporting that principle, as well as practice considerations for implementation. More research among young adults is critical to identify effective treatments and service systems for those with co-occurring disorders.

The architecture of co-morbidity networks of physical and mental health conditions in military veterans

Co-morbidity between medical and psychiatric conditions is commonly considered between individual pairs of conditions. However, an important alternative is to consider all conditions as part of a co-morbidity network, which encompasses all interactions between patients and a healthcare system. Analysis of co-morbidity networks could detect and quantify general tendencies not observed by smaller-scale studies. Here, we investigate the co-morbidity network derived from longitudinal healthcare records from approximately 1 million United States military veterans, a population disproportionately impacted by psychiatric morbidity and psychological trauma. Network analyses revealed marked and heterogenous patterns of co-morbidity, including a multi-scale community structure composed of groups of commonly co-morbid conditions. Psychiatric conditions including posttraumatic stress disorder were strong predictors of future medical morbidity. Neurological conditions and conditions associated with chronic pain were particularly highly co-morbid with psychiatric conditions. Across conditions, the degree of co-morbidity was positively associated with mortality. Co-morbidity was modified by biological sex and could be used to predict future diagnostic status, with out-of-sample prediction accuracy of 90-92%. Understanding complex patterns of disease co-morbidity has the potential to lead to improved designs of systems of care and the development of targeted interventions that consider the broader context of mental and physical health.

Childhood Trauma Predicts Less Remission from PTSD among Patients with Co-Occurring Alcohol Use Disorder and PTSD

Post-traumatic stress disorder (PTSD) is highly prevalent among patients hospitalized for an alcohol use disorder (AUD). Hospitalization can improve PTSD and AUD outcomes in some but not all patients, but we lack data on the baseline predictors of PTSD non-remission. This study aimed to determine the baseline risk factors for non-remitted PTSD in patients hospitalized for an AUD. Of 298 AUD inpatients recruited in a rehabilitation center (Le Courbat, France), we included 91 AUD inpatients with a co-occurring PTSD and a longitudinal assessment at baseline (T1) and before discharge (T2: 8 weeks later). Patients were assessed for PTSD diagnosis/severity (PCL-5=PTSD Checklist for DSM-5), different types of trauma including childhood trauma (LEC-5=Life Events Checklist for DSM-5/CTQ-SF=Childhood Trauma Questionnaire, Short-Form), and AUD diagnosis/severity (clinical interview/AUDIT=Alcohol Use Disorders Identification Test). Rate of PTSD remission between T1 and T2 was 74.1%. Non-remitted PTSD at T2 was associated with a history of childhood trauma (physical, emotional or sexual abuse, physical negligence), but not with other types of trauma experienced, nor baseline PTSD or AUD severity. Among patients hospitalized for an AUD with co-occurring PTSD, PTSD remission was more strongly related to the existence of childhood trauma than to AUD or PTSD severity at admission. These patients should be systematically screened for childhood trauma in order to tailor evidence-based interventions.

Review of EMDR Interventions for Individuals With Substance Use Disorder With/Without Comorbid Posttraumatic Stress Disorder

A large proportion (11%–60%) of people with posttraumatic stress disorder (PTSD) also suffer from substance use disorder (SUD). As the high cooccurrence of PTSD and SUD leads to a worsening of psychopathological severity, development and evaluation of integrated treatments become highly valuable for individuals presenting with both diagnoses. Eye movement desensitization and reprocessing (EMDR) therapy may fit these needs. This article summarized all studies that investigated EMDR treatment for SUD, to clarify whether EMDR might be a useful approach. A comprehensive Title/Abstract/Keyword search was conducted on PsycInfo, PsychArticle, PubMed, and Scopus databases. A total of 135 articles were retrieved, and 8 articles met inclusion/exclusion criteria. One RCT and one case study evaluated trauma-focused EMDR; one clinical RCT, one non-clinical RCT, one cross-over study, and one case study evaluated addiction-focused EMDR; and one quasi-experimental and one multiphase case study evaluated the combination of addiction-focused and trauma-focused EMDR. Results show that EMDR treatment consistently reduces posttraumatic symptoms, but that its effects on SUD symptoms are less evident. Although EMDR should be considered as a promising tool for this population due to its possible potential to improve SUD outcomes, further research is needed to see whether EMDR therapy, either trauma-focused or addiction-focused, is effective for SUD. We conclude with suggestions for future research and clinical practice in this area.

A Multicenter Phase II Rater-Blinded Randomized Controlled Trial to Compare the Effectiveness of Eye Movement Desensitization Reprocessing Therapy vs. Treatment as Usual in Patients With Substance Use Disorder and History of Psychological Trauma: A Study Design and Protocol

Background: Psychological trauma has a strong negative impact on the onset, course and prognosis of substance use disorders (SUD). Few trauma-oriented treatment approaches have been trialed, but preliminary evidence exists of the efficacy of Eye Movement Desensitization and Reprocessing (EMDR) therapy in improving clinical symptoms in SUD patients. Objective: To assess if EMDR therapy leads to: (1) reduced substance consumption; (2) an improvement in psychopathological and in trauma-related symptoms; and (3) an improvement in overall functioning. Our hypothesis is that the EMDR group will improve in all variables when compared to the treatment as usual (TAU) group at 6 and 12-months visits. Method: In this multicenter phase II rater-blinded randomized controlled trial, 142 SUD patients with a history of psychological trauma will be randomly assigned to EMDR (n = 71) or to TAU (n = 71). Patients in the EMDR group will receive 20 psychotherapeutic sessions of 60 min over 6 months. Substance use will be measured using the Timeline Followback Questionnaire, the Dependence Severity Scale and the Visual Analog Scale. Traumatic events will be measured by The Holmes-Rahe Life Stress Inventory, the Childhood Trauma Questionnaire Scale, the Global Assessment of Posttraumatic Stress Questionnaire, the Impact of Event Scale-Revised and the Dissociative Experiences Scale. Clinical symptomatology will be evaluated using the Hamilton Depression Rating Scale, the Young Mania Rating Scale and the Brief Psychiatric Rating Scale. Functionality will be assessed with the Functioning Assessment Short Test. All variables will be measured at baseline, post-treatment and 12 months as follow-up. Primary outcome: to test the efficacy of EMDR therapy in reducing the severity of substance use. The secondary outcomes: to test the efficacy in reducing trauma-related psychological symptoms and psychopathological symptoms and in improving overall functioning in patients with comorbid SUD and a history of psychological trauma. Conclusion: This study will provide evidence of whether EMDR therapy is effective in reducing addiction-related, trauma and clinical symptoms and in improving functionality in patients with SUD and a history of trauma. Clinical Trial Registration: The trial is registered at ClinicalTrials.gov, identifier: NCT03517592.

Metabolic and Electrophysiological Changes Associated to Clinical Improvement in Two Severely Traumatized Subjects Treated With EMDR-A Pilot Study

Neuroimaging represents a powerful tool to investigate the neurobiological correlates of Eye Movements Desensitization and Reprocessing (EMDR). The impact of EMDR on cortical and sub-cortical brain regions has been proven by several investigations demonstrating a clear association between symptoms disappearance and changes in cortical structure and functionality. The aim of this study was to assess by electroencephalography (EEG) and for the first time by positron emission tomography (PET) the changes occurring after EMDR therapy in two cases of psychological trauma following brain concussion and comatose state due to traffic accident. A 28 and a 29 years old men underwent extensive neuropsychological examination, which investigated: (i) categorical and phonological verbal fluency; (ii) episodic verbal memory; (iii) executive functions; (iv) visuospatial abilities; (v) attention and working memory as well as clinical assessment by means of psychopathological tests (CAPS, IES, BDI, SCL90R, and DES). They were then treated by eight sessions of EMDR. During the first session EEG monitoring was continuously performed and ¹⁸F-FDG PET scans, depicting brain metabolism, were acquired at rest within a week (T0). After the last session, in which the two clients were considered to be symptoms-free, neuropsychological, clinical, and PET assessment were repeated (T1). PET data were semi-quantitatively compared to a group of 18 normal controls, as for EEG the preferential cortical activations were disclosed by thresholding the individual z-score to a p < 0.05. There was a significant improvement in clinical condition for both clients associated with a significant decrease in CAPS scores. IES and BDI were found to be pathological at T0 and improved at T1 in only one subject. Visuo-constructive abilities and abstract reasoning improved after EMDR in both subjects. As for EEG, the most striking changes occurred in fronto-temporal-parietal cortex in subject 1 while subject 2 showed only minor changes. PET showed more pronounced metabolism in orbito-frontal and prefrontal cortex at T1 as compared to T0 in both subjects. In conclusion both clients had a clear clinical improvement in PTSD symptoms associated with metabolic and electrophysiological changes in limbic and associative cortex, respectively, highlighting the value of EMDR also in such extreme pathological conditions.