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The ASAM/AAAP Clinical Practice Guideline on the Management of Stimulant Use Disorder. J Addict Med 2024; 18:1-56. [PMID: 38669101 PMCID: PMC11105801 DOI: 10.1097/adm.0000000000001299] [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: 04/28/2024]
Abstract
The American Society of Addiction Medicine/American Academy of Addiction Psychiatry (ASAM/AAAP) Clinical Practice Guideline on the Management of Stimulant Use Disorder provides guidance on evidence-based strategies for the treatment of stimulant use disorders (StUDs), stimulant intoxication, and stimulant withdrawal, as well as secondary and tertiary prevention of harms associated with stimulant use. The Clinical Guideline Committee (CGC) comprised experts from ASAM and AAAP representing a range of clinical settings and patient populations. The guideline was developed following modified GRADE methodology. The process included a systematic literature review as well as several targeted supplemental searches. The CGC utilized Evidence to Decision tables to review available evidence and rate the strength of each recommendation. The clinical practice guideline was revised based on external stakeholder review. Key takeaways included: Contingency management represents the current standard of care for treatment of StUDs; Pharmacotherapies may be utilized off-label to treat StUDs; Acute stimulant intoxication can result in life-threatening complications that should be addressed in an appropriate level of care; Secondary and tertiary prevention strategies should be used to reduce harms related to risky stimulant use.
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Stevenson BL, Lee JY, Oslin DW, Polusny MA, Kehle-Forbes SM. The impact of substance use on posttraumatic stress disorder symptoms and treatment discontinuation. J Trauma Stress 2024; 37:257-266. [PMID: 38085564 DOI: 10.1002/jts.23002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2023] [Revised: 11/08/2023] [Accepted: 11/10/2023] [Indexed: 04/04/2024]
Abstract
This study examined the impact of ongoing substance use during posttraumatic stress disorder (PTSD) and substance use disorder (SUD) treatment on PTSD symptoms and treatment discontinuation. The study represents a secondary analysis of U.S. military veterans (N = 183) who participated in a randomized clinical trial for the treatment of both PTSD and SUD. Veterans mostly identified as Black (53.8%) or White (41.9%) and male (92.4%). Substance use, PTSD symptoms, and treatment discontinuation were measured at 4-week intervals throughout treatment. Predictors were the percentage of days with alcohol, cannabis, and other substance use (primarily cocaine and opioids) and the average number of alcoholic drinks per drinking day. Outcomes were PTSD symptoms and treatment discontinuation at concurrent and prospective assessments. Multilevel models accounted for the nested structure of the longitudinal data. Alcohol, cannabis, and other substance use did not predict PTSD symptoms or treatment discontinuation prospectively. Concurrently, we observed that as a participant's percentage of drinking days increased by 34.7% (i.e., 1 standard deviation), PTSD symptoms during the same period were 0.07 standard deviations higher (i.e., 1 point on the PCL), B = 0.03, p = .033. No other substances were related to PTSD symptoms concurrently. The findings demonstrate that PTSD symptoms improved regardless of substance use during exposure-based PTSD and SUD treatment, and treatment discontinuation was not associated with substance use. This study suggests that substance use during treatment cannot directly explain the poorer treatment outcomes observed in the literature on comorbid PTSD/SUD compared to PTSD-only populations.
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Affiliation(s)
- Brittany L Stevenson
- Minneapolis Veterans Affairs Healthcare System, Minneapolis, Minnesota, USA
- Department of Psychiatry and Behavioral Sciences, University of Minnesota, Minneapolis, Minnesota, USA
| | - Jenny Y Lee
- Minneapolis Veterans Affairs Healthcare System, Minneapolis, Minnesota, USA
| | - David W Oslin
- Philadelphia VA Medical Center and VISN 4 Mental Illness Research, Education, and Clinical Center (MIRECC), Philadelphia, Pennsylvania, USA
| | - Melissa A Polusny
- Minneapolis Veterans Affairs Healthcare System, Minneapolis, Minnesota, USA
- Department of Psychiatry and Behavioral Sciences, University of Minnesota, Minneapolis, Minnesota, USA
| | - Shannon M Kehle-Forbes
- Minneapolis Veterans Affairs Healthcare System, Minneapolis, Minnesota, USA
- Women's Health Sciences Division at VA Boston, National Center for PTSD, Boston, Massachusetts, USA
- Department of Medicine, University of Minnesota, Minneapolis, Minnesota, USA
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Ferkul S, Agabani Z, Minami O, Bormann J, Le Foll B, Lobo L, Hassan AN. The acceptability and feasibility of a virtual mantram program for patients with posttraumatic stress disorder and substance use disorders: mixed method results. BMC Complement Med Ther 2024; 24:9. [PMID: 38166894 PMCID: PMC10759462 DOI: 10.1186/s12906-023-04312-1] [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] [Received: 02/20/2023] [Accepted: 12/12/2023] [Indexed: 01/05/2024] Open
Abstract
BACKGROUND There is a need for expanded options for therapeutic interventions for patients with posttraumatic stress disorder (PTSD) and substance use disorder (SUD). The study aimed to examine evidence for the feasibility, safety, and acceptability of a virtual Mantram Repetition Program for adults with PTSD and SUD. METHODS This project utilized mixed-method design (explanatory sequential design) to collect quantitative and qualitative data to evaluate the program in terms of its feasibility and acceptability. The program took place over Webex, an encrypted virtual platform. The group ran over 8 weeks, was 90 min in length, and facilitated by two individuals per cohort. Each group had 4-5 participants given each group cycle. The study used the Mantram Repetition Program which is a brief mindfulness based non-tramua focused group intervention. RESULTS Out of 43 participants enrolled, 5 people (11.6%) did not commence the program and 8 (18.6%) participants dropped out after commencing the program, resulting in 35 completers (81.4% retention rate). Treatment completion and retention were above 70%. Qualitative data explained several aspects of the program's acceptability including delivery methods, informative material provided and gaining a practical mindful tool to manage symptoms. CONCLUSIONS This study showed quantitative and qualitative evidence of the Mantram Repetition Program's feasibility, acceptability and safety to be used with individuals with PTSD-SUD. Although further evaluation of virtual Mantram Program to control group in longitudinal trials is needed to identify how it compares with other interventions in the field. CLINICAL TRIAL REGISTRATION NUMBER NCT05058963, (28/09/2021).
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Affiliation(s)
- Sean Ferkul
- Department of Psychiatry, Campbell Family Mental Health Research Institute, Centre for Addiction and Mental Health, 100 Stokes Street, Third Floor, Toronto, ON, M6J 1H4, Canada
| | - Zena Agabani
- Department of Psychiatry, Campbell Family Mental Health Research Institute, Centre for Addiction and Mental Health, 100 Stokes Street, Third Floor, Toronto, ON, M6J 1H4, Canada
- Department of Pharmacology and Toxicology, Faculty of Medicine, University of Toronto, Toronto, ON, M5S 1A1, Canada
| | - Osamu Minami
- Department of Psychiatry, Campbell Family Mental Health Research Institute, Centre for Addiction and Mental Health, 100 Stokes Street, Third Floor, Toronto, ON, M6J 1H4, Canada
| | - Jill Bormann
- Hahn School of Nursing and Health Sciences, San Diego, CA, USA
- Beyster Institute of Nursing Research, San Diego, CA, USA
- University of San Diego, San Diego, CA, USA
| | - Bernard Le Foll
- Department of Psychiatry, Campbell Family Mental Health Research Institute, Centre for Addiction and Mental Health, 100 Stokes Street, Third Floor, Toronto, ON, M6J 1H4, Canada
- Department of Pharmacology and Toxicology, Faculty of Medicine, University of Toronto, Toronto, ON, M5S 1A1, Canada
- Department of Psychiatry, Faculty of Medicine, University of Toronto, Toronto, ON, Canada
- Institute of Medical Sciences, University of Toronto, Toronto, ON, M5S 1A1, Canada
- Waypoint Research Institute, Waypoint Centre for Mental Health Care, 500 Church Street, Penetanguishene, ON, L9M 1G3, Canada
| | - Leah Lobo
- Department of Psychiatry, Campbell Family Mental Health Research Institute, Centre for Addiction and Mental Health, 100 Stokes Street, Third Floor, Toronto, ON, M6J 1H4, Canada
| | - Ahmed N Hassan
- Department of Psychiatry, Campbell Family Mental Health Research Institute, Centre for Addiction and Mental Health, 100 Stokes Street, Third Floor, Toronto, ON, M6J 1H4, Canada.
- Department of Pharmacology and Toxicology, Faculty of Medicine, University of Toronto, Toronto, ON, M5S 1A1, Canada.
- Department of Psychiatry, Faculty of Medicine, University of Toronto, Toronto, ON, Canada.
- Institute of Medical Sciences, University of Toronto, Toronto, ON, M5S 1A1, Canada.
- Department of Psychiatry, King Abdulaziz University, Jeddah, Saudi Arabia.
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Polizzi CP, Sistad RE, Livingston NA, Brief D, Litwack S, Roy M, Solhan M, Rosenbloom D, Keane TM. Alcohol-Related Problems As Moderators of PTSD Symptom Change During Use of a Web-Based Intervention for Hazardous Drinking and PTSD. J Stud Alcohol Drugs 2024; 85:51-61. [PMID: 37796630 PMCID: PMC10846604 DOI: 10.15288/jsad.23-00094] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2023] [Accepted: 09/14/2023] [Indexed: 10/07/2023] Open
Abstract
OBJECTIVE Alcohol-related problems (e.g., physical, interpersonal, intrapersonal, impulse control, social responsibility) can have an impact on posttraumatic stress disorder (PTSD) symptoms during treatment. Evidence-based online self-help tools exist to target alcohol use and related problems and co-occurring PTSD symptoms. It is unknown to what degree individuals with varying alcohol-related problems respond differently to web-based interventions for hazardous alcohol use and PTSD. The current study evaluated specific alcohol-related problems as potential moderators of PTSD symptom changes during the VetChange online intervention while controlling for average daily alcohol use, gender, race, and age. METHOD We conducted a secondary analysis of a randomized controlled trial that included 600 post-9/11 veterans (518 men and 82 women). Mixed-effects regression models of alcohol-related problems on PTSD severity scores over time were performed separately in an initial intervention group (IIG; n = 404) and a delayed intervention group (DIG; n = 196) that was used as a comparison condition. RESULTS Interpersonal problems emerged as a moderator of PTSD symptom changes in IIG such that veterans endorsing greater interpersonal problems demonstrated larger reductions in PTSD symptoms throughout VetChange. There were no significant moderation effects in DIG. Non-White veterans reported significantly higher PTSD symptoms during VetChange. Post hoc analyses indicated that veterans with higher interpersonal problems were more likely to engage in online intervention content focused on identifying high-risk drinking situations and coping with symptoms. CONCLUSIONS Findings imply that veterans reporting alcohol-related interpersonal problems may benefit the most from, and be more motivated to use, online interventions for hazardous alcohol use and PTSD symptoms.
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Affiliation(s)
- Craig P. Polizzi
- U.S. Department of Veteran Affairs, Veterans Affairs Boston Healthcare System, Boston, Massachusetts
- Department of Psychiatry, Boston University Chobanian & Avedisian School of Medicine, Boston, Massachusetts
| | - Rebecca E. Sistad
- U.S. Department of Veteran Affairs, Veterans Affairs Boston Healthcare System, Boston, Massachusetts
- U.S. Department of Veteran Affairs, Minneapolis Veterans Affairs Healthcare System, Minneapolis, Minnesota
| | - Nicholas A. Livingston
- U.S. Department of Veteran Affairs, Veterans Affairs Boston Healthcare System, Boston, Massachusetts
- Department of Psychiatry, Boston University Chobanian & Avedisian School of Medicine, Boston, Massachusetts
- National Center for PTSD, Behavioral Science Division, Veterans Affairs Boston Healthcare System, Boston, Massachusetts
| | - Deborah Brief
- U.S. Department of Veteran Affairs, Veterans Affairs Boston Healthcare System, Boston, Massachusetts
- Department of Psychiatry, Boston University Chobanian & Avedisian School of Medicine, Boston, Massachusetts
| | - Scott Litwack
- U.S. Department of Veteran Affairs, Veterans Affairs Boston Healthcare System, Boston, Massachusetts
- Department of Psychiatry, Boston University Chobanian & Avedisian School of Medicine, Boston, Massachusetts
| | - Monica Roy
- U.S. Department of Veteran Affairs, Veterans Affairs Boston Healthcare System, Boston, Massachusetts
- Department of Psychiatry, Boston University Chobanian & Avedisian School of Medicine, Boston, Massachusetts
| | - Marika Solhan
- Department of Psychiatry, Boston University Chobanian & Avedisian School of Medicine, Boston, Massachusetts
- U.S. Department of Veterans Affairs, Boston Vet Center, Boston, Massachusetts
| | - David Rosenbloom
- Boston University School of Public Health, Boston, Massachusetts
| | - Terence M. Keane
- U.S. Department of Veteran Affairs, Veterans Affairs Boston Healthcare System, Boston, Massachusetts
- Department of Psychiatry, Boston University Chobanian & Avedisian School of Medicine, Boston, Massachusetts
- National Center for PTSD, Behavioral Science Division, Veterans Affairs Boston Healthcare System, Boston, Massachusetts
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Toombs E, Lund J, Kushnier L, Stopa A, Wendt DC, Mushquash CJ. Addressing experiences of trauma within Indigenous-focused substance use residential treatment: a systematic review and environmental scan. J Ethn Subst Abuse 2023:1-53. [PMID: 38146766 DOI: 10.1080/15332640.2023.2293943] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2023]
Abstract
Indigenous individuals in Canada disproportionally experience higher rates of substance use concerns. This study examined clinical practices currently implemented with Indigenous-led residential treatment facilities to simultaneously address substance use and post-traumatic stress. A systematic review of relevant literature retrieved published approaches to address these concurrent disorders with Indigenous individuals. This review retrieved 35 sources related to trauma and substance use treatment among Indigenous individuals or communities. Among these sources, all leveraged cultural approaches as a dual treatment for trauma symptoms and substance use. Inconsistent results were reported among those sources (n = 3) who analyzed comparisons with wait-list controls or used randomized-controlled designs. Using culture-as-treatment was elaborated upon in the second goal of this study: an environmental scan of Indigenous-led treatment programs and qualitative interviews with 10 treatment center staff to understand how programs may address both substance use and traumatic symptoms among Indigenous-led substance use treatment centers across Canada. When we searched the websites of these centers, we found that approximately 38% (16 of 43) of treatment centers discussed implementing some form of treatment that addressed trauma symptoms in conjunction with primary substance use. Among the 10 staff participants, all discussed how trauma can impede client success in treatment, and ACE-specific programming is useful within their respective treatment programs. Results showed that when manualized treatments are used, they must be adapted to meet the specific needs of Indigenous communities, and culture-as-treatment is a popular approach among Indigenous-led treatment centers, particularly for addressing trauma symptoms.
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Affiliation(s)
- Elaine Toombs
- Department of Psychology, Lakehead University, ON, Canada
- Dilico Anishinabek Family Care, Fort William First Nation, ON, Canada
| | - Jessie Lund
- Department of Psychology, Lakehead University, ON, Canada
| | | | - Ana Stopa
- Department of Psychology, Lakehead University, ON, Canada
| | | | - Christopher J Mushquash
- Department of Psychology, Lakehead University, ON, Canada
- Dilico Anishinabek Family Care, Fort William First Nation, ON, Canada
- Thunder Bay Regional Health Sciences Centre, ON, Canada
- Thunder Bay Regional Health Research Institute, ON, Canada
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Roberts NP, Lotzin A, Schäfer I. Psychological treatment of PTSD with comorbid substance use disorder (SUD): expert recommendations of the European Society for Traumatic Stress Studies (ESTSS). Eur J Psychotraumatol 2023; 14:2265773. [PMID: 37830207 PMCID: PMC10578096 DOI: 10.1080/20008066.2023.2265773] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2023] [Accepted: 09/25/2023] [Indexed: 10/14/2023] Open
Abstract
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.
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Affiliation(s)
- Neil P. Roberts
- Cardiff & Vale University Health Board, Cardiff University, Cardiff, UK
| | - Annett Lotzin
- Center for Interdisciplinary Addiction Research, Department of Psychiatry and Psychotherapy, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Ingo Schäfer
- Center for Interdisciplinary Addiction Research, Department of Psychiatry and Psychotherapy, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
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O'Doherty L, Whelan M, Carter GJ, Brown K, Tarzia L, Hegarty K, Feder G, Brown SJ. Psychosocial interventions for survivors of rape and sexual assault experienced during adulthood. Cochrane Database Syst Rev 2023; 10:CD013456. [PMID: 37795783 PMCID: PMC10552071 DOI: 10.1002/14651858.cd013456.pub2] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/06/2023]
Abstract
BACKGROUND Exposure to rape, sexual assault and sexual abuse has lifelong impacts for mental health and well-being. Prolonged Exposure (PE), Cognitive Processing Therapy (CPT) and Eye Movement Desensitisation and Reprocessing (EMDR) are among the most common interventions offered to survivors to alleviate post-traumatic stress disorder (PTSD) and other psychological impacts. Beyond such trauma-focused cognitive and behavioural approaches, there is a range of low-intensity interventions along with new and emerging non-exposure based approaches (trauma-sensitive yoga, Reconsolidation of Traumatic Memories and Lifespan Integration). This review presents a timely assessment of international evidence on any type of psychosocial intervention offered to individuals who experienced rape, sexual assault or sexual abuse as adults. OBJECTIVES To assess the effects of psychosocial interventions on mental health and well-being for survivors of rape, sexual assault or sexual abuse experienced during adulthood. SEARCH METHODS In January 2022, we searched CENTRAL, MEDLINE, Embase, 12 other databases and three trials registers. We also checked reference lists of included studies, contacted authors and experts, and ran forward citation searches. SELECTION CRITERIA Any study that allocated individuals or clusters of individuals by a random or quasi-random method to a psychosocial intervention that promoted recovery and healing following exposure to rape, sexual assault or sexual abuse in those aged 18 years and above compared with no or minimal intervention, usual care, wait-list, pharmacological only or active comparison(s). We classified psychosocial interventions according to Cochrane Common Mental Disorders Group's psychological therapies list. DATA COLLECTION AND ANALYSIS We used the standard methodological procedures expected by Cochrane. MAIN RESULTS We included 36 studies (1991 to 2021) with 3992 participants randomly assigned to 60 experimental groups (3014; 76%) and 23 inactive comparator conditions (978, 24%). The experimental groups consisted of: 32 Cognitive Behavioural Therapy (CBT); 10 behavioural interventions; three integrative therapies; three humanist; five other psychologically oriented interventions; and seven other psychosocial interventions. Delivery involved 1 to 20 (median 11) sessions of traditional face-to-face (41) or other individual formats (four); groups (nine); or involved computer-only interaction (six). Most studies were conducted in the USA (n = 26); two were from South Africa; two from the Democratic Republic of the Congo; with single studies from Australia, Canada, the Netherlands, Spain, Sweden and the UK. Five studies did not disclose a funding source, and all disclosed sources were public funding. Participants were invited from a range of settings: from the community, through the media, from universities and in places where people might seek help for their mental health (e.g. war veterans), in the aftermath of sexual trauma (sexual assault centres and emergency departments) or for problems that accompany the experience of sexual violence (e.g. sexual health/primary care clinics). Participants randomised were 99% women (3965 participants) with just 27 men. Half were Black, African or African-American (1889 participants); 40% White/Caucasian (1530 participants); and 10% represented a range of other ethnic backgrounds (396 participants). The weighted mean age was 35.9 years (standard deviation (SD) 9.6). Eighty-two per cent had experienced rape or sexual assault in adulthood (3260/3992). Twenty-two studies (61%) required fulfilling a measured PTSD diagnostic threshold for inclusion; however, 94% of participants (2239/2370) were reported as having clinically relevant PTSD symptoms at entry. The comparison of psychosocial interventions with inactive controls detected that there may be a beneficial effect at post-treatment favouring psychosocial interventions in reducing PTSD (standardised mean difference (SMD) -0.83, 95% confidence interval (CI) -1.22 to -0.44; 16 studies, 1130 participants; low-certainty evidence; large effect size based on Cohen's D); and depression (SMD -0.82, 95% CI -1.17 to -0.48; 12 studies, 901 participants; low-certainty evidence; large effect size). Psychosocial interventions, however, may not increase the risk of dropout from treatment compared to controls, with a risk ratio of 0.85 (95% CI 0.51 to 1.44; 5 studies, 242 participants; low-certainty evidence). Seven of the 23 studies (with 801 participants) comparing a psychosocial intervention to an inactive control reported on adverse events, with 21 events indicated. Psychosocial interventions may not increase the risk of adverse events compared to controls, with a risk ratio of 1.92 (95% CI 0.30 to 12.41; 6 studies; 622 participants; very low-certainty evidence). We conducted an assessment of risk of bias using the RoB 2 tool on a total of 49 reported results. A high risk of bias affected 43% of PTSD results; 59% for depression symptoms; 40% for treatment dropout; and one-third for adverse events. The greatest sources of bias were problems with randomisation and missing outcome data. Heterogeneity was also high, ranging from I2 = 30% (adverse events) to I2 = 87% (PTSD). AUTHORS' CONCLUSIONS Our review suggests that survivors of rape, sexual violence and sexual abuse during adulthood may experience a large reduction in post-treatment PTSD symptoms and depressive symptoms after experiencing a psychosocial intervention, relative to comparison groups. Psychosocial interventions do not seem to increase dropout from treatment or adverse events/effects compared to controls. However, the number of dropouts and study attrition were generally high, potentially missing harms of exposure to interventions and/or research participation. Also, the differential effects of specific intervention types needs further investigation. We conclude that a range of behavioural and CBT-based interventions may improve the mental health of survivors of rape, sexual assault and sexual abuse in the short term. Therefore, the needs and preferences of individuals must be considered in selecting suitable approaches to therapy and support. The primary outcome in this review focused on the post-treatment period and the question about whether benefits are sustained over time persists. However, attaining such evidence from studies that lack an active comparison may be impractical and even unethical. Thus, we suggest that studies undertake head-to-head comparisons of different intervention types; in particular, of novel, emerging therapies, with one-year plus follow-up periods. Additionally, researchers should focus on the therapeutic benefits and costs for subpopulations such as male survivors and those living with complex PTSD.
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Affiliation(s)
- Lorna O'Doherty
- Institute for Health and Wellbeing, Coventry University, Coventry, UK
- Department of General Practice, The University of Melbourne, Melbourne, Australia
| | - Maxine Whelan
- Institute for Health and Wellbeing, Coventry University, Coventry, UK
| | - Grace J Carter
- Institute for Health and Wellbeing, Coventry University, Coventry, UK
| | - Katherine Brown
- Department of Psychology and Sports Science, University of Hertfordshire, Hatfield, UK
| | - Laura Tarzia
- Department of General Practice, The University of Melbourne, Melbourne, Australia
- The Royal Women's Hospital, Victoria, Australia
| | - Kelsey Hegarty
- Department of General Practice, The University of Melbourne, Melbourne, Australia
- The Royal Women's Hospital, Victoria, Australia
| | - Gene Feder
- Centre for Academic Primary Care, Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Sarah J Brown
- Faculty of Arts, Business and Law, Law School, USC: University of the Sunshine Coast, Sippy Downs, Australia
- Faculty of Health and Applied Sciences, University of the West of England, Bristol, UK
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Fremont R, Brown O, Feder A, Murrough J. Ketamine for Treatment of Posttraumatic Stress Disorder: State of the Field. FOCUS (AMERICAN PSYCHIATRIC PUBLISHING) 2023; 21:257-265. [PMID: 37404968 PMCID: PMC10316217 DOI: 10.1176/appi.focus.20230006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 07/06/2023]
Abstract
Posttraumatic stress disorder (PTSD) is a chronic and debilitating condition. Although several psychotherapeutic and pharmacological treatments are recommended for PTSD, many individuals do not respond to treatment or respond only partially, highlighting a critical need for additional treatments. Ketamine has the potential to address this therapeutic need. This review discusses how ketamine emerged as a rapid-acting antidepressant and has become a potential treatment for PTSD. A single dose of intravenous (IV) ketamine has been shown to facilitate rapid reduction of PTSD symptoms. Repeated IV ketamine administration significantly improved PTSD symptoms, compared with midazolam, in a predominantly civilian sample of individuals with PTSD. However, in a veteran and military population, repeated IV ketamine did not significantly reduce PTSD symptoms. Further study of ketamine as a treatment for PTSD is necessary, including which populations benefit most from this therapy and the potential benefits of combining psychotherapy and ketamine.
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Affiliation(s)
- Rachel Fremont
- Depression and Anxiety Center for Discovery and Treatment, Department of Psychiatry (all authors), and Nash Family Department of Neuroscience (Murrough), Icahn School of Medicine at Mount Sinai, New York
| | - Oneysha Brown
- Depression and Anxiety Center for Discovery and Treatment, Department of Psychiatry (all authors), and Nash Family Department of Neuroscience (Murrough), Icahn School of Medicine at Mount Sinai, New York
| | - Adriana Feder
- Depression and Anxiety Center for Discovery and Treatment, Department of Psychiatry (all authors), and Nash Family Department of Neuroscience (Murrough), Icahn School of Medicine at Mount Sinai, New York
| | - James Murrough
- Depression and Anxiety Center for Discovery and Treatment, Department of Psychiatry (all authors), and Nash Family Department of Neuroscience (Murrough), Icahn School of Medicine at Mount Sinai, New York
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9
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Wolitzky-Taylor K, Smit T, Vujanovic AA, Zvolensky MJ. Transdiagnostic Processes Linking Posttraumatic Stress Disorder Symptoms to Alcohol Use Severity. J Dual Diagn 2023; 19:97-110. [PMID: 37389859 DOI: 10.1080/15504263.2023.2225373] [Citation(s) in RCA: 1] [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: 07/01/2023]
Abstract
Objective: The high comorbidity between posttraumatic stress disorder (PTSD) and alcohol use disorder (AUD) is well-established and complex. However, there is a need to explore transdiagnostic constructs that may underlie this association to better understand what accounts for this comorbidity and to inform treatment development. Method: Thus, the present study utilized a large, cross-sectional dataset (N = 513; Mage = 38.25 years, SD = 10.07; 49.9% female), based on national recruitment, to (1) examine whether the associations between PTSD symptom severity (PCL-5) and alcohol use severity (AUDIT) were statistically mediated by (a) anxiety sensitivity (SSASI); and (b) difficulties with emotion regulation (DERS-16); and (2) examine whether coping motives for drinking moderate this indirect effect. Sex assigned at birth was included as a covariate. Results: When examining the hypothesized mediators (SSASI and DERS-16) in separate models, there was a statistically significant indirect effect of PCL-5 on AUDIT through both SSASI and DERS. However, when both SSASI and DERS were entered into a model simultaneously, only SSASI served as a statistically significant mediator. Coping motives for drinking did not moderate the observed indirect effect. Conclusions: The current findings highlight anxiety sensitivity and emotion regulation as transdiagnostic processes that may explain, at least partially, the relationship between PTSD symptom severity and alcohol use; however, stronger evidence was evident for anxiety sensitivity. These findings may help inform the development of refined, streamlined interventions for PTSD and alcohol use that directly target these processes.
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Affiliation(s)
- Kate Wolitzky-Taylor
- Integrated Substance Abuse Programs, Department of Psychiatry and Biobehavioral Sciences, Semel Institute for Neuroscience and Human Behavior, University of California - Los Angeles, Los Angeles, California, USA
| | - Tanya Smit
- Department of Psychology, University of Houston, Houston, Texas, USA
| | - Anka A Vujanovic
- Department of Psychology, University of Houston, Houston, Texas, USA
- HEALTH Institute, University of Houston, Houston, Texas, USA
| | - Michael J Zvolensky
- Department of Psychology, University of Houston, Houston, Texas, USA
- HEALTH Institute, University of Houston, Houston, Texas, USA
- Department of Behavioral Science, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
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10
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Haller H, Mitzinger D, Cramer H. The integration of yoga breathing techniques in cognitive behavioral therapy for post-traumatic stress disorder: A pragmatic randomized controlled trial. Front Psychiatry 2023; 14:1101046. [PMID: 37139325 PMCID: PMC10150115 DOI: 10.3389/fpsyt.2023.1101046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2022] [Accepted: 03/22/2023] [Indexed: 05/05/2023] Open
Abstract
Introduction In trauma-focused Cognitive Behavioral Therapy (TF-CBT), stabilization techniques are used before confrontation ones to increase stress/affect tolerance and thus effectiveness of CBT. This study investigated the effects of pranayama, meditative yoga breathing and breath holding techniques, as a complimentary stabilization technique in patients with post-traumatic stress disorder (PTSD). Methods Seventy-four PTSD-patients (84% female, 44.2 ± 13 years) were randomized to receive either pranayama at the beginning of each TF-CBT session or TF-CBT alone. The primary outcome was self-reported PTSD severity after 10 sessions of TF-CBT. Secondary outcomes included quality of life, social participation, anxiety, depression, distress tolerance, emotion regulation, body awareness, breath-holding duration, acute emotional reaction to stress, and adverse events (AEs). Intention-to-treat (ITT) and exploratory per-protocol (PP) analyses of covariance with 95% confidence intervals (CI) were performed. Results ITT analyses revealed no significant differences on primary or secondary outcomes, except for breath-holding duration in favor of pranayama-assisted TF-CBT (20.81 s, 95%CI = 13.05|28.60). PP analyses of 31 patients without AEs during pranayama revealed significantly lower PTSD severity (-5.41, 95%CI = -10.17|-0.64) and higher mental quality of life (4.89, 95%CI = 1.38|8.41) than controls. In contrast, patients with AEs during pranayama breath holding reported significantly higher PTSD severity (12.39, 95%CI = 5.08|19.71) than controls. Concurrent somatoform disorders were found to be a significant moderator of change in PTSD severity (p = 0.029). Conclusion In PTSD patients without concurrent somatoform disorders, the integration of pranayama into TF-CBT might reduce post-traumatic symptoms and increase mental quality of life more efficiently than TF-CBT alone. The results remain preliminary until they can be replicated by ITT analyses. Clinical trial registration ClinicalTrials.gov, identifier NCT03748121.
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Affiliation(s)
- Heidemarie Haller
- Center for Integrative Medicine and Planetary Health, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
- *Correspondence: Heidemarie Haller,
| | - Dietmar Mitzinger
- Center for Integrative Medicine and Planetary Health, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
| | - Holger Cramer
- Insititute of General Practice and Interprofessional Care, University Hospital Tübingen, Tübingen, Germany
- Bosch Health Campus, Stuttgart, Germany
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11
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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: 3] [Impact Index Per Article: 1.5] [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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Childhood Trauma and Dissociation Correlates in Alcohol Use Disorder: A Cross-Sectional Study in a Sample of 587 French Subjects Hospitalized in a Rehabilitation Center. Brain Sci 2022; 12:brainsci12111483. [DOI: 10.3390/brainsci12111483] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2022] [Revised: 10/21/2022] [Accepted: 10/24/2022] [Indexed: 11/06/2022] Open
Abstract
This study aimed to determine whether dissociative symptoms and childhood trauma (CT) may help identify a specific subgroup of patients among those hospitalized for alcohol use disorder (AUD). We assessed 587 patients hospitalized for an AUD in a French addiction rehabilitation center (cross-sectional study) regarding dissociative symptoms (DES-taxon), childhood trauma (CTQ), depression (BDI), anxiety (STAI-state and STAI-trait), posttraumatic stress disorder (PTSD; PCL-5), and AUD symptoms (AUDIT). We ran a hierarchical cluster analysis and compared the clusters in terms of dissociation and CT, as well as AUD, depressive, anxiety, and PTSD symptoms. We identified three clusters of patients: (1) patients with low AUD severity and low dissociation (LALD); (2) patients with high AUD severity and low dissociation (HALD); (3) patients with high AUD severity and high dissociation (HAHD). Patients from the HAHD group had significantly higher dissociation and more severe depression, anxiety, and PTSD symptoms than those with LALD and HALD. They also reported more emotional and sexual abuse than those with LALD. Among patients with an AUD, those with high dissociation may constitute an independent subgroup that exhibits a higher prevalence for CT and higher AUD severity, as well as higher depression, anxiety, and PTSD symptoms. Patients with more severe AUD and associated psychiatric symptoms should be systematically screened for dissociation and provided with tailor-based treatments.
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13
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Kaysen D, Jaffe AE, Shoenberger B, Walton TO, Pierce AR, Walker DD. Does Effectiveness of a Brief Substance Use Treatment Depend on PTSD? An Evaluation of Motivational Enhancement Therapy for Active-Duty Army Personnel. J Stud Alcohol Drugs 2022; 83:924-933. [PMID: 36484590 PMCID: PMC9756405 DOI: 10.15288/jsad.22-00011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2022] [Accepted: 05/02/2022] [Indexed: 01/14/2023] Open
Abstract
OBJECTIVE Posttraumatic stress disorder (PTSD) with comorbid substance use disorders (SUDs) has been associated with poorer treatment outcomes. The present study examined associations between provisional PTSD at baseline and 3 months with 6-month treatment outcomes from either a one-session motivational enhancement therapy (MET) or education intervention addressing substance use. METHOD Secondary analyses were conducted on a randomized clinical trial comparing a novel MET intervention to an educational intervention for Army personnel with SUD who were not engaged in SUD treatment (n = 242; 92.1% male). We compared three groups with complete data on baseline and 3-month provisional PTSD: individuals without provisional PTSD at baseline (n = 98), those with provisional PTSD remitted by 3 months (n = 42), and those with provisional PTSD unremitted at 3 months (n = 53) on alcohol use frequency, quantity, consequences, and related diagnoses. RESULTS Individuals with unremitted provisional PTSD were at increased risk for moderate/severe alcohol use disorder at 6 months relative to those without baseline provisional PTSD (odds ratio = 4.53, p = .007). The effect of MET on drinks per week at 6 months (controlling for baseline) differed with a significant effect of MET for individuals with remitted provisional PTSD (count ratio = 0.41, p = .005). CONCLUSIONS Both interventions were effective in reducing drinking even for those with provisional PTSD, although, compared with education, MET had slightly better effects on reducing drinking quantity for those with remitted PTSD. Findings suggest that PTSD remission may serve as an early prognostic indicator of long-term alcohol use changes, or alternatively, delivery of MET during heightened transitory distress may be most effective for reducing alcohol use.
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Affiliation(s)
- Debra Kaysen
- Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Palo Alto, California
- National Center for PTSD, Veterans Affairs Palo Alto Health Care System, Palo Alto, California
| | - Anna E. Jaffe
- Department of Psychology, University of Nebraska–Lincoln, Lincoln, Nebraska
| | | | - Thomas O. Walton
- School of Social Work, University of Washington, Seattle, Washington
| | | | - Denise D. Walker
- School of Social Work, University of Washington, Seattle, Washington
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Goudriaan AE, de Waal MM. Commentary on Nower et al: Patterns in pathways: underlying comorbidities and the importance of assessment. Addiction 2022; 117:2009-2010. [PMID: 35315144 PMCID: PMC9314676 DOI: 10.1111/add.15859] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2022] [Accepted: 02/24/2022] [Indexed: 12/18/2022]
Affiliation(s)
- Anna E. Goudriaan
- Arkin Mental Health Care, Jellinekand Amsterdam Institute for Addiction ResearchAmsterdamThe Netherlands,Amsterdam UMC, Department of PsychiatryUniversity of AmsterdamAmsterdamThe Netherlands,Amsterdam Public Health Research InstituteAmsterdamthe Netherlands
| | - Marleen M. de Waal
- Arkin Mental Health Care, Jellinekand Amsterdam Institute for Addiction ResearchAmsterdamThe Netherlands,Amsterdam UMC, Department of PsychiatryUniversity of AmsterdamAmsterdamThe Netherlands,Amsterdam Public Health Research InstituteAmsterdamthe Netherlands
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15
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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: 2.5] [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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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: 30] [Impact Index Per Article: 15.0] [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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17
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Badour CL, Flanagan JC, Allan NP, Gilmore AK, Gros DF, Killeen T, Korte KJ, Brown DG, Kolnogorova K, Back SE. Temporal dynamics of symptom change among veterans receiving an integrated treatment for posttraumatic stress disorder and substance use disorders. J Trauma Stress 2022; 35:546-558. [PMID: 34773928 PMCID: PMC9035042 DOI: 10.1002/jts.22769] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2020] [Revised: 07/30/2021] [Accepted: 08/09/2021] [Indexed: 11/07/2022]
Abstract
The present study examined temporal patterns of symptom change during treatment for comorbid posttraumatic stress disorders (PTSD) and substance use disorders (SUDs). We hypothesized that PTSD symptom severity would predict subsequent-session substance use and that this association would be particularly strong among patients who received an integrated treatment versus SUD-only treatment. Participants were 81 United States military veterans with current PTSD and an SUD who were enrolled in a 12-week, randomized controlled trial examining the efficacy of an integrated treatment called Concurrent Treatment of PTSD and Substance Use Disorders Using Prolonged Exposure (COPE) compared with cognitive behavioral relapse prevention therapy (RP). Lagged multilevel models indicated that PTSD symptom improvement did not significantly predict the likelihood of next-session substance use (likelihood of use: B = 0.03, SE = 0.02, p = .141; percentage of days using B = -0.02, SE = 0.01, p = .172. Neither substance use, B = 1.53, SE = 1.79, p = .391, nor frequency of use, B = 0.26, SE = 0.50, p = .612, predicted next-session PTSD symptom severity in either treatment condition. Stronger associations between PTSD symptoms and next-session substance use were expected given the self-medication hypothesis. Additional research is needed to better understand the temporal dynamics of symptom change as well as the specific mediators and mechanisms underlying symptom change.
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Affiliation(s)
- Christal L. Badour
- Department of Psychology, University of Kentucky, Lexington, Kentucky, USA
| | - Julianne C. Flanagan
- Department of Psychiatry & Behavioral Sciences, Medical University of South Carolina, Charleston, South Carolina, USA
- Mental Health Service Line, Ralph H. Johnson Veterans Affairs Medical Center, Charleston, South Carolina, USA
| | - Nicholas P. Allan
- Department of Psychology, Ohio University, Athens, Ohio, USA
- VA Center of Excellence for Suicide Prevention, VA Finger Lakes Health Care System, Canandaigua, New York, USA
| | - Amanda K. Gilmore
- Department of Health Policy & Behavioral Sciences, School of Public Health, Georgia State University, Atlanta, Georgia, USA
| | - Daniel F. Gros
- Department of Psychiatry & Behavioral Sciences, Medical University of South Carolina, Charleston, South Carolina, USA
- Mental Health Service Line, Ralph H. Johnson Veterans Affairs Medical Center, Charleston, South Carolina, USA
| | - Therese Killeen
- Department of Psychiatry & Behavioral Sciences, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Kristina J. Korte
- Psychiatry Department, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Delisa G. Brown
- Department of Psychiatry & Behavioral Sciences, Medical University of South Carolina, Charleston, South Carolina, USA
| | | | - Sudie E. Back
- Department of Psychiatry & Behavioral Sciences, Medical University of South Carolina, Charleston, South Carolina, USA
- Mental Health Service Line, Ralph H. Johnson Veterans Affairs Medical Center, Charleston, South Carolina, USA
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Pennington DL, Reavis JV, Cano MT, Walker E, Batki SL. The Impact of Exercise and Virtual Reality Executive Function Training on Cognition Among Heavy Drinking Veterans With Traumatic Brain Injury: A Pilot Feasibility Study. Front Behav Neurosci 2022; 16:802711. [PMID: 35391785 PMCID: PMC8981916 DOI: 10.3389/fnbeh.2022.802711] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2021] [Accepted: 02/22/2022] [Indexed: 12/19/2022] Open
Abstract
Executive function (EF) underlies self-control deficits in alcohol use disorder (AUD) and traumatic brain injury (TBI). Cognitive training is a promising adjunctive treatment targeting TBI- and AUD- related cognitive dysfunction. However, major limitations related to compliance and generalizability in the field of cognitive training exist. Physical activity is associated with enhanced cognitive performance across several executive functions and may enhance the benefits of cognitive training. Virtual reality provides multisensory embodied experiences which are likely to engage brain networks more efficiently than standard cognitive training systems, ultimately resulting in greater near- and far-transfer effects. This pilot study aimed to obtain feasibility data and a preliminary assessment of an enriched virtual reality (VR) EF training (EFT) intervention combined with exercise (NCT03786276). Using an 8-week randomized adaptive design study, 30 AUD treatment seeking U.S. Veterans completed nine sessions of exercise-only (n = 15) or gameplay control (n = 15) over 3 weeks, followed by a week-4 repeat assessment in Phase 1. Twenty-three participants completed and moved onto Phase II, where they completed up to nine sessions of VR-EFT plus exercise and completed a week-8 end-of-study assessment. Primary outcomes included feasibility to retain participants, usability, and satisfaction of using VR-EFT. Secondary and exploratory outcomes included within group assessment of change in cognitive function, alcohol use, alcohol craving, and post-concussive symptoms among the three treatment conditions.VR-EFT was feasible with moderate usability and high acceptability ratings.The most common VR-related adverse effect was motion sickness (n = 2/16, 12.5%). The VR-EFT condition was associated with significant improvement in inhibition-switching and visual scanning (both p < 0.05) during Phase II. Exercise-only was associated with significant improvements in cognitive inhibition, cognitive flexibility, reductions in alcohol craving, and number of standard alcohol drinks per week (all p ≤ 0.05). The gaming-control condition was associated with improvement in cognitive flexibility and visuospatial immediate recall (both p < 0.05) during Phase 1. Recruitment and retention of U.S. veterans with AUD and TBI into an exercise plus VR-EFT intervention is feasible, but technological barriers may impact usability. VR-EFT was associated with improvement in executive function domains that were targeted in as little as 3-week and nine sessions of VR-EFT exposure. Results are promising and indicate the need for a larger controlled investigation to assess the efficacy of VR-EFT to enhance treatment outcomes among AUD treatment-seeking U.S. veterans with co-occurring AUD and TBI. Clinical Trial Registration www.ClinicalTrials.gov, Identifier: NCT03786276.
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Affiliation(s)
- David L. Pennington
- Department of Psychiatry and Behavioral Sciences, University of California, San Francisco, San Francisco, CA, United States
- San Francisco Veterans Affairs Health Care System (SFVAHCS), San Francisco, CA, United States
- Northern California Institute for Research and Education (NCIRE), San Francisco, CA, United States
| | - Jill V. Reavis
- Department of Psychiatry and Behavioral Sciences, University of California, San Francisco, San Francisco, CA, United States
- San Francisco Veterans Affairs Health Care System (SFVAHCS), San Francisco, CA, United States
- Northern California Institute for Research and Education (NCIRE), San Francisco, CA, United States
- Department of Psychology, Palo Alto University, Palo Alto, CA, United States
| | - Monique T. Cano
- Department of Psychiatry and Behavioral Sciences, University of California, San Francisco, San Francisco, CA, United States
- San Francisco Veterans Affairs Health Care System (SFVAHCS), San Francisco, CA, United States
| | - Erica Walker
- Department of Psychiatry and Behavioral Sciences, University of California, San Francisco, San Francisco, CA, United States
- San Francisco Veterans Affairs Health Care System (SFVAHCS), San Francisco, CA, United States
- Northern California Institute for Research and Education (NCIRE), San Francisco, CA, United States
| | - Steven L. Batki
- Department of Psychiatry and Behavioral Sciences, University of California, San Francisco, San Francisco, CA, United States
- San Francisco Veterans Affairs Health Care System (SFVAHCS), San Francisco, CA, United States
- Northern California Institute for Research and Education (NCIRE), San Francisco, CA, United States
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Molina G, Whittaker A. Treatment of post-traumatic stress disorder and substance use disorder in adults with a history of adverse childhood experiences: A systematic review of psychological interventions. DRUG AND ALCOHOL DEPENDENCE REPORTS 2022; 2:100028. [PMID: 36845903 PMCID: PMC9948894 DOI: 10.1016/j.dadr.2022.100028] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/22/2021] [Revised: 12/12/2021] [Accepted: 01/17/2022] [Indexed: 11/18/2022]
Abstract
Background Adverse childhood experiences (ACEs) have long-term effects on adult health, including unresolved trauma and substance use disorder (SUD). There are hypotheses of a mediating role of emotion regulation. This systematic literature review and narrative synthesis assessed the effectiveness of psychological interventions on emotion regulation, PTSD and SUD symptoms. Methods Searches were conducted using the Cochrane Handbook for Systematic Reviews methodology. Eligible studies were randomised controlled trials (RCTs) and quasi-experimental psychological interventions published between 2009 and 2019. Study characteristics, results and methodological quality were systematically analysed. Results Thirteen studies, including nine RCTs, were selected. Integrated SUD and PTSD treatments consisted of Seeking Safety, exposure-based treatment, Trauma Recovery and Empowerment Model, and integrated cognitive behavioural therapy. Two studies reported emotion regulation. Five studies found a small to medium positive effect size of psychological interventions on PTSD outcomes. Two studies had a small positive effect size on SUD outcomes and two a small negative effect size. Attrition was high across most studies. Characteristics likely to affect the applicability of the review were described. Conclusion The review found some evidence of a small inconsistent positive effect of psychological interventions on PTSD outcomes, and no evidence of effect on SUD outcomes. The range of theoretical models was narrow. Overall quality was low with high clinical heterogeneity and missing key information, particularly on emotion regulation, an important transdiagnostic feature. Further research is required to establish interventions that can treat these multiple conditions with a focus on effectiveness, acceptability, and implementation in real life clinical practice.
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Key Words
- ACEs, adverse childhood experiences
- AEs, adverse events
- ATREM, Attachment-informed TREM
- CBT, Cognitive–Behavioural Therapy
- CI, confidence intervals
- CPTSD, complex PTSD
- DERS, Difficulties in Emotion Regulation Scale
- EMDR, eye movement desensitisation and reprocessing
- ER, emotion regulation
- FSP, family and social problems
- ICBT, Integrated CBT
- M, mean
- OR, odds ratio
- PRISMA, Preferred Reporting Items for Systematic Reviews and Meta-Analyses
- PTSD, post-traumatic stress disorder
- RCT, randomised control trial
- SD, standard deviation
- SS, Seeking Safety
- SUD, substance use disorder
- SWiM, Synthesis Without Meta-Analysis
- TREM, Trauma Recovery and Empowerment Model
- adverse childhood experiences
- emotion regulation
- posttraumatic stress disorder
- psychological interventions
- substance use disorder
- systematic review
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Affiliation(s)
- Genevieve Molina
- CeGIDD, Pôle Santé Publique et Médecine Sociale, CHU Toulouse, Hôpital La Grave, TSA 60033, 31059 Toulouse Cedex 9, France
| | - Anne Whittaker
- NMAHP Research Unit, Faculty of Health Sciences and Sport, Pathfoot Building, University of Stirling, FK9 4LA, Stirling, Scotland, UK
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Burgess-Hull AJ, Smith KE, Schriefer D, Panlilio LV, Epstein DH, Preston KL. Longitudinal patterns of momentary stress during outpatient opioid agonist treatment: A growth-mixture-model approach to classifying patients. Drug Alcohol Depend 2021; 226:108884. [PMID: 34229153 PMCID: PMC8377984 DOI: 10.1016/j.drugalcdep.2021.108884] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2021] [Revised: 05/25/2021] [Accepted: 06/10/2021] [Indexed: 11/27/2022]
Abstract
BACKGROUND We previously showed, in people starting treatment for opioid use disorder (OUD), that stress is neither necessary nor sufficient for lapses to drug use to occur, despite an association between the two. Both theoretical clarity and case-by-case prediction accuracy may require initial differentiation among patients. AIM To examine: (a) evidence for distinct overall trajectories of momentary stress during OUD treatment, (b) relationships between stress trajectory and treatment response, and (c) relationships between stress trajectory and momentary changes in stress and craving prior to lapses. METHODS We used ecological momentary assessment (EMA) to collect ratings of stress and craving 3x/day for up to 16 weeks in 211 outpatients during agonist treatment for OUD. With growth mixture models, we identified trajectories of stress. We used mixed effect models to examine trajectory-group differences in the dynamics of stress and craving just before lapses to any drug use. RESULTS We identified four trajectories of stress: Increasing (13.7 %); Moderate and Stable (23.7 %); Declining and Increasing (18 %); and Low (44.6 %). Overall drug use and opioid craving were lowest in the Low Stress group. Overall drug use was highest in the Moderate and Stable group. Alcohol use and opioid craving were highest in the Increasing Stress group. Opioid craving increased before lapse for most groups, but stress increased before lapses for only the Moderate and Stable group. CONCLUSION There are natural groupings of participants with distinct patterns of stress severity during OUD treatment. Momentary stress/craving/lapse associations may be better characterized when these groupings are considered first.
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Affiliation(s)
- Albert J. Burgess-Hull
- Address: National Institute on Drug Abuse, Intramural Research Program Clinical Pharmacology and Therapeutics Research Branch 251 Bayview Blvd. Suite 200, Room 01B606 Baltimore, Maryland, 21224, USA,
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Tran MTN, Luong QH, Le Minh G, Dunne MP, Baker P. Psychosocial Interventions for Amphetamine Type Stimulant Use Disorder: An Overview of Systematic Reviews. Front Psychiatry 2021; 12:512076. [PMID: 34220557 PMCID: PMC8245759 DOI: 10.3389/fpsyt.2021.512076] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2019] [Accepted: 05/06/2021] [Indexed: 12/28/2022] Open
Abstract
Introduction: Amphetamine-type stimulants (ATS) use is a global concern due to increased usage and the harm to physical, mental, and social well-being. The objective of this overview of systematic reviews is to summarise trial results of psychosocial interventions and describe their efficacy and safety. Methods: We searched seven bibliographic databases to November 2020 for systematic reviews examining ATS misuse treatment by psychosocial interventions. Given the apparent incompleteness of the included reviews, we undertook a supplemental meta-analysis of all eligible primary studies. Results: We included 11 systematic reviews of moderate to high quality and 39 primary studies which assessed the outcomes of psychosocial interventions on people who use ATS. The key findings include: (1) There were conflicting results about the effectiveness of psychosocial interventions among reviews, which may confuse decision-makers in selecting treatment. (2) In the supplemental meta-analysis, relative to usual care (only counselling or self-help materials), membership of a psychological intervention group was associated with an important reduction in drug usage [risk ratio (RR) 0.80, 95% CI: 0.75 to 0.85]. Patients in psychological interventions used injectables substantially less [odds ratio (OR) 0.35, 95% CI: 0.24 to 0.49]. The risk of unsafe sex in the psychosocial intervention group was lower than in the control group (RR 0.49, 95% CI: 0.34 to 0.71). The combination of therapies reduced 1.51 day using drugs in the preceding 30 days (95% CI: -2.36 to -0.67) compared to cognitive behavioural therapy intervention alone. (3) Compared to usual care, cognitive behavioural therapy was less likely to be retained at follow-up (RR 0.89, 95% CI: 0.82 to 0.97; high-quality evidence). However, the additional of contingency management strategy can make an important improvement upon retention (RR 1.42, 95%CI: 1.25 to 1.62). Authors' Conclusions: Integrated models are more effective than a single-treatment strategy. Comprehensive and sustained psychosocial interventions can help to reduce use of ATS and other drugs, risk behaviours and mental disorders, and significantly improve treatment adherence.
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Affiliation(s)
- Mai Thi Ngoc Tran
- Faculty of Health, School of Public Health and Social Work, Queensland University of Technology (QUT), Brisbane, QLD, Australia
- Center for Training and Research on Substance Abuse-HIV, Hanoi Medical University, Hanoi, Vietnam
- Nursing and Midwifery Faculty, Hanoi Medical University, Hanoi, Vietnam
| | - Quang Hung Luong
- Faculty of Health, School of Public Health and Social Work, Queensland University of Technology (QUT), Brisbane, QLD, Australia
| | - Giang Le Minh
- Center for Training and Research on Substance Abuse-HIV, Hanoi Medical University, Hanoi, Vietnam
| | - Michael P. Dunne
- Faculty of Health, School of Public Health and Social Work, Queensland University of Technology (QUT), Brisbane, QLD, Australia
- Faculty of Law, Australian Centre of Health Law Research, Queensland University of Technology (QUT), Brisbane, QLD, Australia
- Institute for Community Health Research, Hue University of Medicine and Pharmacy, Hue University, Hue, Vietnam
| | - Philip Baker
- Faculty of Health, School of Public Health and Social Work, Queensland University of Technology (QUT), Brisbane, QLD, Australia
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Simon N, Robertson L, Lewis C, Roberts NP, Bethell A, Dawson S, Bisson JI. Internet-based cognitive and behavioural therapies for post-traumatic stress disorder (PTSD) in adults. Cochrane Database Syst Rev 2021; 5:CD011710. [PMID: 34015141 PMCID: PMC8136365 DOI: 10.1002/14651858.cd011710.pub3] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Therapist-delivered trauma-focused psychological therapies are effective for post-traumatic stress disorder (PTSD) and have become the accepted first-line treatments. Despite the established evidence-base for these therapies, they are not always widely available or accessible. Many barriers limit treatment uptake, such as the number of qualified therapists available to deliver the interventions; cost; and compliance issues, such as time off work, childcare, and transportation, associated with the need to attend weekly appointments. Delivering Internet-based cognitive and behavioural therapy (I-C/BT) is an effective and acceptable alternative to therapist-delivered treatments for anxiety and depression. OBJECTIVES To assess the effects of I-C/BT for PTSD in adults. SEARCH METHODS We searched MEDLINE, Embase, PsycINFO and the Cochrane Central Register of Controlled Trials to June 2020. We also searched online clinical trial registries and reference lists of included studies and contacted the authors of included studies and other researchers in the field to identify additional and ongoing studies. SELECTION CRITERIA We searched for RCTs of I-C/BT compared to face-to-face or Internet-based psychological treatment, psychoeducation, wait list, or care as usual. We included studies of adults (aged over 16 years), in which at least 70% of the participants met the diagnostic criteria for PTSD, according to the Diagnostic and Statistical Manual (DSM) or the International Classification of Diseases (ICD). DATA COLLECTION AND ANALYSIS Two review authors independently assessed abstracts, extracted data, and entered data into Review Manager 5. The primary outcomes were severity of PTSD symptoms and dropouts. Secondary outcomes included diagnosis of PTSD after treatment, severity of depressive and anxiety symptoms, cost-effectiveness, adverse events, treatment acceptability, and quality of life. We analysed categorical outcomes as risk ratios (RRs), and continuous outcomes as mean differences (MD) or standardised mean differences (SMDs), with 95% confidence intervals (CI). We pooled data using a fixed-effect meta-analysis, except where heterogeneity was present, in which case we used a random-effects model. We independently assessed the included studies for risk of bias and we evaluated the certainty of available evidence using the GRADE approach; we discussed any conflicts with at least one other review author, with the aim of reaching a unanimous decision. MAIN RESULTS We included 13 studies with 808 participants. Ten studies compared I-C/BT delivered with therapist guidance to a wait list control. Two studies compared guided I-C/BT with I-non-C/BT. One study compared guided I-C/BT with face-to-face non-C/BT. There was substantial heterogeneity among the included studies. I-C/BT compared with face-to-face non-CBT Very low-certainty evidence based on one small study suggested face-to-face non-CBT may be more effective than I-C/BT at reducing PTSD symptoms post-treatment (MD 10.90, 95% CI 6.57 to 15.23; studies = 1, participants = 40). There may be no evidence of a difference in dropout rates between treatments (RR 2.49, 95% CI 0.91 to 6.77; studies = 1, participants = 40; very low-certainty evidence). The study did not measure diagnosis of PTSD, severity of depressive or anxiety symptoms, cost-effectiveness, or adverse events. I-C/BT compared with wait list Very low-certainty evidence showed that, compared with wait list, I-C/BT may be associated with a clinically important reduction in PTSD post-treatment (SMD -0.61, 95% CI -0.93 to -0.29; studies = 10, participants = 608). There may be no evidence of a difference in dropout rates between the I-C/BT and wait list groups (RR 1.25, 95% CI 0.97 to 1.60; studies = 9, participants = 634; low-certainty evidence). I-C/BT may be no more effective than wait list at reducing the risk of a diagnosis of PTSD after treatment (RR 0.53, 95% CI 0.28 to 1.00; studies = 1, participants = 62; very low-certainty evidence). I-C/BT may be associated with a clinically important reduction in symptoms of depression post-treatment (SMD -0.51, 95% CI -0.97 to -0.06; studies = 7, participants = 473; very low-certainty evidence). Very low-certainty evidence also suggested that I-C/BT may be associated with a clinically important reduction in symptoms of anxiety post-treatment (SMD -0.61, 95% CI -0.89 to -0.33; studies = 5, participants = 345). There were no data regarding cost-effectiveness. Data regarding adverse events were uncertain, as only one study reported an absence of adverse events. I-C/BT compared with I-non-C/BT There may be no evidence of a difference in PTSD symptoms post-treatment between the I-C/BT and I-non-C/BT groups (SMD -0.08, 95% CI -0.52 to 0.35; studies = 2, participants = 82; very low-certainty evidence). There may be no evidence of a difference between dropout rates from the I-C/BT and I-non-C/BT groups (RR 2.14, 95% CI 0.97 to 4.73; studies = 2, participants = 132; I² = 0%; very low-certainty evidence). Two studies found no evidence of a difference in post-treatment depressive symptoms between the I-C/BT and I-non-C/BT groups (SMD -0.12, 95% CI -0.78 to 0.54; studies = 2, participants = 84; very low-certainty evidence). Two studies found no evidence of a difference in post-treatment symptoms of anxiety between the I-C/BT and I-non-C/BT groups (SMD 0.08, 95% CI -0.78 to 0.95; studies = 2, participants = 74; very low-certainty evidence). There were no data regarding cost-effectiveness. Data regarding adverse effects were uncertain, as it was not discernible whether adverse effects reported were attributable to the intervention. AUTHORS' CONCLUSIONS While the review found some beneficial effects of I-C/BT for PTSD, the certainty of the evidence was very low due to the small number of included trials. This review update found many planned and ongoing studies, which is encouraging since further work is required to establish non-inferiority to current first-line interventions, explore mechanisms of change, establish optimal levels of guidance, explore cost-effectiveness, measure adverse events, and determine predictors of efficacy and dropout.
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Affiliation(s)
- Natalie Simon
- Division of Psychological Medicine and Clinical Neurosciences, School of Medicine, Cardiff University, Cardiff, UK
| | - Lindsay Robertson
- Cochrane Common Mental Disorders, University of York, York, UK
- Centre for Reviews and Dissemination, University of York, York, UK
| | - Catrin Lewis
- Division of Psychological Medicine and Clinical Neurosciences, School of Medicine, Cardiff University, Cardiff, UK
| | - Neil P Roberts
- Division of Psychological Medicine and Clinical Neurosciences, School of Medicine, Cardiff University, Cardiff, UK
- Psychology & Psychological Therapies Directorate, Cardiff and Vale University Health Board, Cardiff, UK
| | - Andrew Bethell
- Institute of Psychology, Health and Society, University of Liverpool, Liverpool, UK
- Changing Minds UK, Warrington, UK
| | - Sarah Dawson
- Cochrane Common Mental Disorders, University of York, York, UK
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Jonathan I Bisson
- Division of Psychological Medicine and Clinical Neurosciences, School of Medicine, Cardiff University, Cardiff, UK
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Abstract
Background: PTSD and substance use disorder (SUD) frequently co-occur. Estimates of life time PTSD amongst SUD patients range from 26% to 52%, with estimates of current PTSD between 15% and 42%. Amongst individual diagnosed with PTSD estimates of comorbid substance abuse range from 19% to 35% and comorbid alcohol abuse from 36% to 52% (Roberts, Roberts, Jones, & Bisson, 2016). PTSD-SUD comorbidity presents many clinical challenges for treating clinicians. Individuals with PTSD-SUD present with a more severe clinical profile, tend to have poorer functioning and wellbeing, and inferior treatment outcomes. Clinicians view this comorbidity to be substantially more difficult to treat than either disorder alone (Schäfer & Lotzin, 2018). There are now a number of well-established psychological therapies for PTSD. These include prolonged exposure, cognitive therapy, cognitive processing therapy and EMDR (Bisson et al., 2019). However, patients with PTSD-SUD comorbidity are often excluded from clinical trials of psychological intervention. Clinicians are therefore often uncertain about how best to implement effective treatment, and traditionally, patients with this comorbidity have been offered treatment sequentially. This normally involves referral for to PTSD treatment only after completion of treatment for addiction (Roberts, Back, Mueser, & Murray, 2020). However, there are concerns about whether this approach causes some patients to ‘fall through the cracks’ between services and there is debate about whether integrated or simultaneous approaches might be more effective. A number of integrated treatment approaches have been developed. These are often grouped into past focused treatments, which include components of exposure-based trauma processing; and present focused treatments, which focus more on improving current coping skills (see Roberts et al., 2020). Recent reviews have tended to report more support for exposure-based approaches, particularly in relation to PTSD outcomes (Roberts et al., 2020), although findings have been based on a small number of studies and high drop-out from treatment has been noted as a problem across different approaches. Most recent guidelines (e.g. ISTSS 2018 – see NICE 2018; Bisson et al., 2019) have not included scoping questions to address issues of comorbidity, and there are no widely accepted guidelines about how to deliver optimal care and treatment for such individuals. Objectives and methodology: To describe the work of a task force which has been established to develop expert recommendations for the psychological treatment of this comorbidity for ESTSS, following principles used in guideline development through two stages. Stage 1. Update of a systematic review and meta-analysis (Roberts et al., 2016) of RCTs of psychological interventions aimed at treating comorbid PTSD and SUD, with the aim of establishing the current evidence base for a number of approaches including:
Trauma focused CBT trauma focused treatments plus treatment as usual for SUD, such as COPE Present focused treatments such as Seeking Safety plus treatment as usual for SUD Integrated cognitive restructuring-based interventions plus treatment as usual for SUD EMDR plus treatment as usual for SUD.
The working group also seeks to investigate whether there is evidence for different models of treatment delivery: i.e. sequential treatments, vs. integrated treatments delivered by the same therapist vs simultaneous treatments delivered by different therapists. Treatment recommendations will be based on the strength and quality of the findings addressing which will be evaluated through the GRADE approach. Stage 2. It is anticipated that many of the challenges faced in clinical practice are unlikely to be addressed through the Stage 1 process, where there is limited high-quality evidence to make evidence-based recommendations. Stage 2 will involve the collation good practice/consensus point recommendations made in trusted methodologically rigorous treatment guidelines and expert guidance publications. Findings and Recommendations: This project is currently ongoing. The presentation will provide an update of the progress of the working group, share preliminary findings where these are available and make recommendations for future research.
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Fordham B, Sugavanam T, Edwards K, Hemming K, Howick J, Copsey B, Lee H, Kaidesoja M, Kirtley S, Hopewell S, das Nair R, Howard R, Stallard P, Hamer-Hunt J, Cooper Z, Lamb SE. Cognitive-behavioural therapy for a variety of conditions: an overview of systematic reviews and panoramic meta-analysis. Health Technol Assess 2021; 25:1-378. [PMID: 33629950 PMCID: PMC7957459 DOI: 10.3310/hta25090] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Cognitive-behavioural therapy aims to increase quality of life by changing cognitive and behavioural factors that maintain problematic symptoms. A previous overview of cognitive-behavioural therapy systematic reviews suggested that cognitive-behavioural therapy was effective for many conditions. However, few of the included reviews synthesised randomised controlled trials. OBJECTIVES This project was undertaken to map the quality and gaps in the cognitive-behavioural therapy systematic review of randomised controlled trial evidence base. Panoramic meta-analyses were also conducted to identify any across-condition general effects of cognitive-behavioural therapy. DATA SOURCES The overview was designed with cognitive-behavioural therapy patients, clinicians and researchers. The Cochrane Library, MEDLINE, EMBASE, PsycINFO, Cumulative Index to Nursing and Allied Health Literature, Child Development & Adolescent Studies, Database of Abstracts of Reviews of Effects and OpenGrey databases were searched from 1992 to January 2019. REVIEW METHODS Study inclusion criteria were as follows: (1) fulfil the Centre for Reviews and Dissemination criteria; (2) intervention reported as cognitive-behavioural therapy or including one cognitive and one behavioural element; (3) include a synthesis of cognitive-behavioural therapy trials; (4) include either health-related quality of life, depression, anxiety or pain outcome; and (5) available in English. Review quality was assessed with A MeaSurement Tool to Assess systematic Reviews (AMSTAR)-2. Reviews were quality assessed and data were extracted in duplicate by two independent researchers, and then mapped according to condition, population, context and quality. The effects from high-quality reviews were pooled within condition groups, using a random-effect panoramic meta-analysis. If the across-condition heterogeneity was I2 < 75%, we pooled across conditions. Subgroup analyses were conducted for age, delivery format, comparator type and length of follow-up, and a sensitivity analysis was performed for quality. RESULTS A total of 494 reviews were mapped, representing 68% (27/40) of the categories of the International Classification of Diseases, Eleventh Revision, Mortality and Morbidity Statistics. Most reviews (71%, 351/494) were of lower quality. Research on older adults, using cognitive-behavioural therapy preventatively, ethnic minorities and people living outside Europe, North America or Australasia was limited. Out of 494 reviews, 71 were included in the primary panoramic meta-analyses. A modest effect was found in favour of cognitive-behavioural therapy for health-related quality of life (standardised mean difference 0.23, 95% confidence interval 0.05 to 0.41, prediction interval -0.05 to 0.50, I2 = 32%), anxiety (standardised mean difference 0.30, 95% confidence interval 0.18 to 0.43, prediction interval -0.28 to 0.88, I2 = 62%) and pain (standardised mean difference 0.23, 95% confidence interval 0.05 to 0.41, prediction interval -0.28 to 0.74, I2 = 64%) outcomes. All condition, subgroup and sensitivity effect estimates remained consistent with the general effect. A statistically significant interaction effect was evident between the active and non-active comparator groups for the health-related quality-of-life outcome. A general effect for depression outcomes was not produced as a result of considerable heterogeneity across reviews and conditions. LIMITATIONS Data extraction and analysis were conducted at the review level, rather than returning to the individual trial data. This meant that the risk of bias of the individual trials could not be accounted for, but only the quality of the systematic reviews that synthesised them. CONCLUSION Owing to the consistency and homogeneity of the highest-quality evidence, it is proposed that cognitive-behavioural therapy can produce a modest general, across-condition benefit in health-related quality-of-life, anxiety and pain outcomes. FUTURE WORK Future research should focus on how the modest effect sizes seen with cognitive-behavioural therapy can be increased, for example identifying alternative delivery formats to increase adherence and reduce dropout, and pursuing novel methods to assess intervention fidelity and quality. STUDY REGISTRATION This study is registered as PROSPERO CRD42017078690. FUNDING This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 25, No. 9. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Beth Fordham
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Thavapriya Sugavanam
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Katherine Edwards
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Karla Hemming
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - Jeremy Howick
- Faculty of Philosophy, University of Oxford, Oxford, UK
| | - Bethan Copsey
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Hopin Lee
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Milla Kaidesoja
- Department of Psychology and Logopedics, University of Helsinki, Helsinki, Finland
| | - Shona Kirtley
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Sally Hopewell
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Roshan das Nair
- Department of Psychiatry and Applied Psychology, University of Nottingham, Nottingham, UK
- Institute of Mental Health, Nottinghamshire Healthcare NHS Foundation Trust, Nottingham, UK
| | - Robert Howard
- Division of Psychiatry, University College London, London, UK
| | | | | | - Zafra Cooper
- Department of Psychiatry, Yale School of Medicine, New Haven, CT, USA
| | - Sarah E Lamb
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
- College of Medicine and Health, University of Exeter, Exeter, UK
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Patel R, Redmond NM, Kesten JM, Linton MJ, Horwood J, Wilcox D, Munafo J, Coast J, Macleod J, Jeal N. Drug Use in Street Sex worKers (DUSSK) study: results of a mixed methods feasibility study of a complex intervention to reduce illicit drug use in drug dependent female sex workers. BMJ Open 2020; 10:e036491. [PMID: 33323428 PMCID: PMC7745311 DOI: 10.1136/bmjopen-2019-036491] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2019] [Revised: 10/13/2020] [Accepted: 11/05/2020] [Indexed: 12/02/2022] Open
Abstract
OBJECTIVES The majority of female street-based sex workers (SSWs) are dependent on illicit drugs and sell sex to fund their drug use. They typically face multiple traumatic experiences, starting at a young age, which continue through sex work involvement. Their trauma-related symptoms tend to increase when drug use is reduced, hindering sustained reduction. Providing specialist trauma care to address post-traumatic stress disorder (PTSD) alongside drug treatment may therefore improve treatment outcomes. Aims to (1) evaluate recruitment and retention of participants; (2) examine intervention experiences and acceptability; and (3) explore intervention costs using a mixed methods feasibility study. SETTING Female SSW charity premises in a large UK inner city. PARTICIPANTS Females aged 18 years or older, who have sold sex on the street and used heroin and/or crack cocaine at least once a week in the last calendar month. INTERVENTION Female SSW-only drug treatment groups in a female SSW-only setting delivered by female staff. Targeted PTSD screening then treatment of positive diagnoses with eye movement desensitisation and reprocessing (EMDR) therapy by female staff from a specialist National Health Service trauma service. RESULTS (1) Of 125 contacts, 11 met inclusion criteria and provided informed consent, 4 reached the intervention final stage, (2) service providers said working in collaboration with other services was valuable, the intervention was worthwhile and had a positive influence on participants. Participants viewed recruitment as acceptable and experienced the intervention positively. The unsettled nature of participant's lives was a key attendance barrier. (3) The total cost of the intervention was £11 710, with staff costs dominating. CONCLUSIONS Recruitment and retention rates reflected study inclusion criteria targeting women with the most complex needs. Two participants received EMDR demonstrating that the three agencies working together was feasible. Staff heavy costs highlight the importance of supporting participant attendance to minimise per participant costs in a future trial.
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Affiliation(s)
- Rita Patel
- NIHR ARC West, University Hospitals Bristol NHS Foundation Trust, Bristol, UK
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Niamh M Redmond
- NIHR ARC West, University Hospitals Bristol NHS Foundation Trust, Bristol, UK
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Joanna M Kesten
- NIHR ARC West, University Hospitals Bristol NHS Foundation Trust, Bristol, UK
- Population Health Sciences & NIHR Health Protection Research Unit in Evaluation of Interventions, University of Bristol, Bristol, UK
| | - Myles-Jay Linton
- NIHR ARC West, University Hospitals Bristol NHS Foundation Trust, Bristol, UK
- Population Health Sciences & Health Economics Bristol, University of Bristol, Bristol, UK
| | - Jeremy Horwood
- NIHR ARC West, University Hospitals Bristol NHS Foundation Trust, Bristol, UK
- Population Health Sciences & Centre for Academic Primary Care, University of Bristol, Bristol, UK
| | - David Wilcox
- Acer Unit, Blackberry Hill Hospital, Avon and Wiltshire Mental Health Partnership NHS Trust, Bristol, UK
| | - Jess Munafo
- Acer Unit, Blackberry Hill Hospital, Avon and Wiltshire Mental Health Partnership NHS Trust, Bristol, UK
| | - Joanna Coast
- NIHR ARC West, University Hospitals Bristol NHS Foundation Trust, Bristol, UK
- Population Health Sciences & Health Economics Bristol, University of Bristol, Bristol, UK
| | - John Macleod
- NIHR ARC West, University Hospitals Bristol NHS Foundation Trust, Bristol, UK
- Population Health Sciences & Centre for Academic Primary Care, University of Bristol, Bristol, UK
| | - Nicola Jeal
- NIHR ARC West, University Hospitals Bristol NHS Foundation Trust, Bristol, UK
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
- Devon Sexual Health - North Devon, Northern Devon Healthcare NHS Trust, Barnstaple, UK
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Borho A, Viazminsky A, Morawa E, Schmitt GM, Georgiadou E, Erim Y. The prevalence and risk factors for mental distress among Syrian refugees in Germany: a register-based follow-up study. BMC Psychiatry 2020; 20:362. [PMID: 32641014 PMCID: PMC7346482 DOI: 10.1186/s12888-020-02746-2] [Citation(s) in RCA: 45] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2020] [Accepted: 06/19/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Mental disorders among refugees as well as their risk factors are already well documented in cross-sectional reports. However, longitudinal follow-up designs are widely lacking. Therefore, the aim of this study was to examine the change of the prevalence of mental disorders among Syrian refugees with German residence permission, taking into account their increasing length of stay in Germany, and to uncover the change in their relationship to pre- and post-migration risk factors. METHODS This study formed part of a register-based follow-up study with two measurement points in Erlangen (Germany). At the first time of recruitment in 2017, 200 of the 518 Syrian refugees with residence permission living in Erlangen took part. During the second survey timeframe 1.5 years later, in 2019, 108 of the former 200 Syrian refugees participated again and formed the total sample for this follow-up study. The survey instruments included demographics, migration-related variables and symptoms of post-traumatic stress (Essen Trauma Inventory, ETI), depression (Patient Health Questionnaire - PHQ-9) and generalized anxiety disorder (GAD-7). RESULTS At the time of the first survey, 26.9% of the participants exceeded the cut-off for a clinically relevant depression diagnosis, 16.7% for an anxiety disorder and 13.9% for a PTSD diagnosis. At the second measurement point, it was 30.6% for depression, 15.7% for an anxiety disorder and 13.0% for PTSD. No significant changes between the measurement points were found for any of the disorders. In multiple linear regression analyses, higher perceived discrimination, a higher number of traumatic experiences and a shorter duration of residence permission were shown to be the most important pre- and post-migration predictors of psychological stress independent of the time of measurement. CONCLUSIONS There is strong empirical evidence that the prevalence rates of mental distress among refugees are significantly higher compared to the overall population. However, it has not yet become clear how these prevalence rates change with an increasing length of stay in the host countries. The results of our study indicate that the psychological burden on this refugee population remains consistently high over time, despite partly improved living conditions, and confirm the importance of therapeutic interventions.
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Affiliation(s)
- Andrea Borho
- Department of Psychosomatic Medicine and Psychotherapy, Friedrich-Alexander University Erlangen-Nürnberg (FAU), Erlangen, Germany.
| | - Andre Viazminsky
- grid.5330.50000 0001 2107 3311Department of Psychosomatic Medicine and Psychotherapy, Friedrich-Alexander University Erlangen-Nürnberg (FAU), Erlangen, Germany
| | - Eva Morawa
- grid.5330.50000 0001 2107 3311Department of Psychosomatic Medicine and Psychotherapy, Friedrich-Alexander University Erlangen-Nürnberg (FAU), Erlangen, Germany
| | | | - Ekaterini Georgiadou
- grid.5330.50000 0001 2107 3311Department of Psychosomatic Medicine and Psychotherapy, Friedrich-Alexander University Erlangen-Nürnberg (FAU), Erlangen, Germany ,Department of Psychiatry and Psychotherapy, Paracelsus Medical University, Nuremberg, Germany
| | - Yesim Erim
- grid.5330.50000 0001 2107 3311Department of Psychosomatic Medicine and Psychotherapy, Friedrich-Alexander University Erlangen-Nürnberg (FAU), Erlangen, Germany
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Krausz MR, Wong JSH, Moazen-Zadeh E, Jang KL. Been There, Done That: Lessons from Vancouver's Efforts to Stem the Tide of Overdose Deaths. CANADIAN JOURNAL OF PSYCHIATRY. REVUE CANADIENNE DE PSYCHIATRIE 2020; 65:377-380. [PMID: 32174152 PMCID: PMC7265609 DOI: 10.1177/0706743720912860] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Affiliation(s)
- Michael R Krausz
- Department of Psychiatry, University of British Columbia, Vancouver, British Columbia, Canada
| | - James S H Wong
- Department of Psychiatry, University of British Columbia, Vancouver, British Columbia, Canada
| | - Ehsan Moazen-Zadeh
- Department of Psychiatry, University of British Columbia, Vancouver, British Columbia, Canada.,Department of Psychiatry, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Kerry L Jang
- Department of Psychiatry, University of British Columbia, Vancouver, British Columbia, Canada
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Managing Pain and Psychosocial Care in IBD: a Primer for the Practicing Gastroenterologist. Curr Gastroenterol Rep 2020; 22:20. [PMID: 32185521 DOI: 10.1007/s11894-020-0757-7] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
PURPOSE OF REVIEW This review focuses on the relationship between trauma and pain in inflammatory bowel disease (IBD), and offers effective treatment strategies. RECENT FINDINGS Recent evidence points to bidirectional pathways between psychiatric disorders and IBD. The impact of trauma and development of post-traumatic stress symptoms on IBD disease course is beginning to be appreciated including its relationship with pain. First-line treatments for both psychiatric and chronic pain disorders include behavioral interventions such as cognitive behavioral therapy, hypnosis, and mindfulness, and there is emerging evidence studying Acceptance and Commitment Therapy and telehealth interventions. Pharmacological treatments using neuromodulators can also be beneficial. An integrated care team, such as a subspecialty medical home model, can provide the best patient experience and address comprehensive care needs efficiently and effectively. Psychosocial factors impact IBD course and necessitate effective management. Despite the significant limitations of research, particularly lack of clinical trials examining behavioral and pharmacotherapy interventions in IBD, effective treatments exist and are best utilized in an integrated care setting.
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Lewis C, Roberts NP, Gibson S, Bisson JI. Dropout from psychological therapies for post-traumatic stress disorder (PTSD) in adults: systematic review and meta-analysis. Eur J Psychotraumatol 2020; 11:1709709. [PMID: 32284816 PMCID: PMC7144189 DOI: 10.1080/20008198.2019.1709709] [Citation(s) in RCA: 121] [Impact Index Per Article: 30.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2019] [Revised: 10/27/2019] [Accepted: 10/29/2019] [Indexed: 02/01/2023] Open
Abstract
Background: Despite the established efficacy of psychological therapies for post-traumatic stress disorder (PTSD) there has been little systematic exploration of dropout rates. Objective: To ascertain rates of dropout across different modalities of psychological therapy for PTSD and to explore potential sources of heterogeneity. Method: A systematic review of dropout rates from randomized controlled trials (RCTs) of psychological therapies was conducted. The pooled rate of dropout from psychological therapies was estimated and reasons for heterogeneity explored using meta-regression. Results:: The pooled rate of dropout from RCTs of psychological therapies for PTSD was 16% (95% CI 14-18%). There was evidence of substantial heterogeneity across studies. We found evidence that psychological therapies with a trauma-focus were significantly associated with greater dropout. There was no evidence of greater dropout from therapies delivered in a group format; from studies that recruited participants from clinical services rather than via advertisements; that included only military personnel/veterans; that were limited to participants traumatized by sexual traumas; that included a higher proportion of female participants; or from studies with a lower proportion of participants who were university educated. Conclusions: Dropout rates from recommended psychological therapies for PTSD are high and this appears to be particularly true of interventions with a trauma focus. There is a need to further explore the reasons for dropout and to look at ways of increasing treatment retention.
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Affiliation(s)
- Catrin Lewis
- National Centre for Mental Health (NCMH), Division of Psychological Medicine and Clinical Neurosciences, Cardiff University School of Medicine, Cardiff, UK
| | - Neil P Roberts
- National Centre for Mental Health (NCMH), Division of Psychological Medicine and Clinical Neurosciences, Cardiff University School of Medicine, Cardiff, UK.,Psychology and Psychological Therapies, Cardiff & Vale University Health Board, Cardiff, UK.,Cardiff University Traumatic Stress Service, Cardiff & Vale University Health Board, Cardiff, UK
| | - Samuel Gibson
- National Centre for Mental Health (NCMH), Division of Psychological Medicine and Clinical Neurosciences, Cardiff University School of Medicine, Cardiff, UK
| | - Jonathan I Bisson
- National Centre for Mental Health (NCMH), Division of Psychological Medicine and Clinical Neurosciences, Cardiff University School of Medicine, Cardiff, UK
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Brunet A, Ayrolles A, Gambotti L, Maatoug R, Estellat C, Descamps M, Girault N, Kalalou K, Abgrall G, Ducrocq F, Vaiva G, Jaafari N, Krebs MO, Castaigne E, Hanafy I, Benoit M, Mouchabac S, Cabié MC, Guillin O, Hodeib F, Durand-Zaleski I, Millet B. Paris MEM: a study protocol for an effectiveness and efficiency trial on the treatment of traumatic stress in France after the 2015-16 terrorist attacks. BMC Psychiatry 2019; 19:351. [PMID: 31703570 PMCID: PMC6842179 DOI: 10.1186/s12888-019-2283-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2018] [Accepted: 09/11/2019] [Indexed: 11/11/2022] Open
Abstract
BACKGROUND The Paris and Nice terrorist attacks affected a thousand of trauma victims and first-line responders. Because there were concerns that this might represent the first of several attacks, there was a need to quickly enhance the local capacities to treat a large number of individuals suffering from trauma-related disorders. Since Reconsolidation Therapy (RT) is brief, relatively easy to learn, well tolerated and effective, it appeared as the ideal first-line treatment to teach to clinicians in this context. METHODS This study protocol is a two-arm non-randomized, multicenter controlled trial, comparing RT to treatment as usual for the treatment of trauma-related disorders. RT consists of actively recalling one's traumatic event under the influence of the ß-blocker propranolol, once a week, for 10-25 min with a therapist, over 6 consecutive weeks. This protocol evaluates the feasibility, effectiveness, and cost-utility of implementing RT as part of a large multi-center (N = 400) pragmatic trial with a one-year follow-up. DISCUSSION Paris MEM is the largest trial to date assessing the efficiency of RT in the aftermath of a large-scale man-made disaster. RT could possibly reinforce the therapeutic arsenal for the treatment of patients suffering from trauma-related disorders, not only for communities in western countries but also worldwide for terror- or disaster-stricken communities. TRIAL REGISTRATION Clinical Trials (ClinicalTrials.gov). June 3, 2016. NCT02789982.
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Affiliation(s)
- A. Brunet
- Département de Psychiatrie adulte, boulevard de l’Hôpital, 75013 Paris, France
- Department of Psychiatry, McGill University, Montréal, Canada
| | - A. Ayrolles
- Département de Psychiatrie adulte, boulevard de l’Hôpital, 75013 Paris, France
- Département de Psychiatrie adulte, Hôpital Universitaire de la Pitié Salpêtrière, Assistance Publique - Hôpitaux de Paris, boulevard de l’Hôpital, 75013 Paris, France
| | - L. Gambotti
- Département de Psychiatrie adulte, Hôpital Universitaire de la Pitié Salpêtrière, Assistance Publique - Hôpitaux de Paris, boulevard de l’Hôpital, 75013 Paris, France
| | - R. Maatoug
- Département de Psychiatrie adulte, boulevard de l’Hôpital, 75013 Paris, France
- Département de Psychiatrie adulte, Hôpital Universitaire de la Pitié Salpêtrière, Assistance Publique - Hôpitaux de Paris, boulevard de l’Hôpital, 75013 Paris, France
| | - C. Estellat
- Département de Psychiatrie adulte, Hôpital Universitaire de la Pitié Salpêtrière, Assistance Publique - Hôpitaux de Paris, boulevard de l’Hôpital, 75013 Paris, France
| | - M. Descamps
- Département de Psychiatrie adulte, boulevard de l’Hôpital, 75013 Paris, France
- Department of Psychiatry, McGill University, Montréal, Canada
| | - N. Girault
- Département de Psychiatrie adulte, boulevard de l’Hôpital, 75013 Paris, France
- Département de Psychiatrie adulte, Hôpital Universitaire de la Pitié Salpêtrière, Assistance Publique - Hôpitaux de Paris, boulevard de l’Hôpital, 75013 Paris, France
| | - K. Kalalou
- Unité de recherche clinique, EPS de Ville Evrard, G03, 5 rue du Dr Delafontaine, 93200 Saint-Denis, France
| | - G. Abgrall
- Assistance Publique - Hôpitaux de Paris -, Hôtel-Dieu, 75004 Paris, France
| | - F. Ducrocq
- France CHRU de Lille, Pôle de Psychiatrie Médecine Légale et Santé en milieu Pénitentiaire, SCA-Lab CNRS UMR 9193, 59037 cedex Lille, France
| | - G. Vaiva
- France CHRU de Lille, Pôle de Psychiatrie Médecine Légale et Santé en milieu Pénitentiaire, SCA-Lab CNRS UMR 9193, 59037 cedex Lille, France
| | - N. Jaafari
- CIC INSERM U802, CHU de Poitiers, Unité de recherche clinique intersectorielle en psychiatrie du Centre Hospitalier Henri Laborit, 86022 Poitiers, France
| | - M. O. Krebs
- Centre Hospitalier Sainte Anne, Service Hospitalo-Universitaire, Faculté de Médecine Paris Descartes, Université Paris Descartes, Paris, France
| | - E. Castaigne
- Service de Psychiatrie, CHU de Bicêtre, HUPS, APHP 78, rue du général Leclerc, 94270 Le Kremlin Bicêtre, France
| | - I. Hanafy
- CH Marne La Vallée, Service de Médecine Légale, 77420 Marne-La-Vallée, France
| | - M. Benoit
- Clinical Neuroscience Department Hospital Pasteur 1, France University of Côte d’Azur, 30 avenue de la voie, 06002 NICE cedex 1 Romaine, France
| | - S. Mouchabac
- Département de psychiatrie et de psychologie médicale de l’adulte, Hôpital universitaire Saint-Antoine, Université Pierre et Marie Curie, Paris VI - AP-HP, 184 rue du Faubourg-Saint-Antoine, 75012 Paris, France
| | - M. C. Cabié
- Pôle Paris 11 Les Hôpitaux de Saint Maurice, 12-14 rue Val d’Osne, 94410 St Maurice, France
| | - O. Guillin
- Service Hospitalo-universitaire, CH du Rouvray, 4 rue Paul Eluard, 76300 Sotteville-lès-Rouen, France
- unité Inserm U1079 Faculté de médecine et de pharmacie, 76000 Rouen, France
| | - F. Hodeib
- Département de Psychiatrie adulte, boulevard de l’Hôpital, 75013 Paris, France
- Département de Psychiatrie adulte, Hôpital Universitaire de la Pitié Salpêtrière, Assistance Publique - Hôpitaux de Paris, boulevard de l’Hôpital, 75013 Paris, France
| | - I. Durand-Zaleski
- ECEVE, UMR 1123 URCEco Ile de France Hôtel Dieu, 1 place du Parvis de Notre Dame, 75004 Paris, France
| | - B. Millet
- Département de Psychiatrie adulte, boulevard de l’Hôpital, 75013 Paris, France
- Département de Psychiatrie adulte, Hôpital Universitaire de la Pitié Salpêtrière, Assistance Publique - Hôpitaux de Paris, boulevard de l’Hôpital, 75013 Paris, France
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Meulewaeter F, De Pauw SSW, Vanderplasschen W. Mothering, Substance Use Disorders and Intergenerational Trauma Transmission: An Attachment-Based Perspective. Front Psychiatry 2019; 10:728. [PMID: 31681040 PMCID: PMC6813727 DOI: 10.3389/fpsyt.2019.00728] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2019] [Accepted: 09/11/2019] [Indexed: 01/23/2023] Open
Abstract
Background: A growing body of research underlines that interpersonal trauma in childhood leads to heightened susceptibility for substance use disorders (SUDs) in later life. Little research has been conducted on parenting experiences of mothers in recovery from substance use, taking into account their own upbringing as a child and the potential aftermath of interpersonal childhood trauma. Methods: Through in-depth qualitative interviews, 23 mothers with SUDs reflected on parenting experiences and parent-child bonding, related to both their children and parents. Interviews were transcribed verbatim and data were analyzed adopting thematic analysis. Results: Throughout the narratives, consequences of trauma on mothers' sense of self and its subsequent impact on parenting arose as salient themes. Five latent mechanisms of intergenerational trauma transmission were identified: 1) early interpersonal childhood trauma experiences in mothers; 2) trauma as a precursor of substance use; 3) substance use as a (self-fooling) enabler of parental functioning; 4) continued substance use impacting parental functioning; and 5) dysfunctional parental functioning and its relational impact upon offspring. Discussion: Findings suggest disruptive attachment can increase the vulnerability for SUDs on the one hand, but can be an expression of underlying trauma on the other, hence serving as a covert mechanism by which trauma can be transmitted across generations. Results indicate the need for preventive, attachment-based and trauma-sensitive interventions targeted at disruptive intergenerational patterns.
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Simon N, McGillivray L, Roberts NP, Barawi K, Lewis CE, Bisson JI. Acceptability of internet-based cognitive behavioural therapy (i-CBT) for post-traumatic stress disorder (PTSD): a systematic review. Eur J Psychotraumatol 2019; 10:1646092. [PMID: 31497259 PMCID: PMC6719262 DOI: 10.1080/20008198.2019.1646092] [Citation(s) in RCA: 37] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2019] [Revised: 06/26/2019] [Accepted: 07/03/2019] [Indexed: 11/28/2022] Open
Abstract
Background: Internet-delivered Cognitive Behavioural Therapy (i-CBT) offers potential as an alternative, accessible, clinically and cost-effective treatment for post-traumatic stress disorder (PTSD), but little is known about its acceptability. Objective: To review the available evidence to understand the acceptability of i-CBT for PTSD. Method: We undertook a mixed-methods systematic review according to Cochrane Collaboration Guidelines, of randomised controlled trials (RCTs) of i-CBT for adults with PTSD. We examined included studies for measures of acceptability, and possible proxy indicators of acceptability, including dropout rates, which were meta-analysed as risk ratios (RRs). Results: Ten studies with 720 participants were included. We found i-CBT to be acceptable according to specific acceptability measures, and suggestions for acceptability according to some proxy measures of i-CBT programme usage. There was, however, evidence of greater dropout from i-CBT than waitlist (RR 1.39, CI 1.03-1.88; 8 studies; participants = 585) and no evidence of a difference in dropout between i-CBT and i-non-CBT (RR 2.14, CI 0.97-4.73; participants = 132; 2 studies). Conclusion: i-CBT appears a potentially acceptable intervention for adults with PTSD. We identified clinical and research questions, including the status of proxy indicators, and call for standardised, consistent treatment acceptability measurement.
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Affiliation(s)
- Natalie Simon
- Division of Psychological Medicine and Clinical Neurosciences, Cardiff University School of Medicine, Cardiff, UK
| | - Leah McGillivray
- Division of Psychological Medicine and Clinical Neurosciences, Cardiff University School of Medicine, Cardiff, UK
| | - Neil P. Roberts
- Division of Psychological Medicine and Clinical Neurosciences, Cardiff University School of Medicine, Cardiff, UK
- Psychology and Psychological Therapies Directorate, Cardiff and Vale University Health Board, Cardiff, UK
| | - Kali Barawi
- Division of Psychological Medicine and Clinical Neurosciences, Cardiff University School of Medicine, Cardiff, UK
| | - Catrin E. Lewis
- Division of Psychological Medicine and Clinical Neurosciences, Cardiff University School of Medicine, Cardiff, UK
| | - Jonathan I. Bisson
- Division of Psychological Medicine and Clinical Neurosciences, Cardiff University School of Medicine, Cardiff, UK
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Grov EK, Dahl AA. Golf as Therapy for Individuals With Mental Health or Substance Use Disorders. J Psychosoc Nurs Ment Health Serv 2019; 57:44-51. [PMID: 31188463 DOI: 10.3928/02793695-20190528-02] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2019] [Accepted: 04/04/2019] [Indexed: 11/20/2022]
Abstract
The current study was undertaken to explore the experiences of individuals with mental health problems or substance use when introduced to systematic golf activities. The study examined the perceived impact of golf activities on participants' physical and mental health, social contact, and daily activities, as well as their overall evaluation of involvement in a Golf as Therapy group. This qualitative, cross-sectional study gathered data from 12 individual interviews. Qualitative content analysis based on the information from meaning units, subcategories, categories, and themes determined the interpretation of manifest and latent concepts. The findings revealed a positive influence on health and social well-being in addition to positive changes in daily activities. The main theme that arose from the data was Shaping a New Direction in Life, elaborated by the categories of ameliorated physical fitness, creation of a social meeting place, improved focus and concentration, practical help and support, and reduced mental symptom burden. [Journal of Psychosocial Nursing and Mental Health Services, 57(10), 44-51.].
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de Waal MM, Dekker JJM, Kikkert MJ, Christ C, Chmielewska J, Staats MWM, van den Brink W, Goudriaan AE. Self-wise, Other-wise, Streetwise (SOS) training, an intervention to prevent victimization in dual-diagnosis patients: results from a randomized clinical trial. Addiction 2019; 114:730-740. [PMID: 30461111 PMCID: PMC6590185 DOI: 10.1111/add.14500] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2018] [Revised: 09/18/2018] [Accepted: 11/05/2018] [Indexed: 11/27/2022]
Abstract
BACKGROUND AND AIMS Patients with co-occurring substance use and other mental disorders are vulnerable to crime victimization, yet no evidence-based preventive interventions exist. Our aim was to test the efficacy of a new intervention, Self-wise, Other-wise, Streetwise training (SOS training), to prevent victimization in these dual-diagnosis patients as an add-on to care as usual. DESIGN Multi-site single-blind parallel randomized controlled trial. SETTING Three sites within one psychiatric service in Amsterdam, the Netherlands. PARTICIPANTS Adult in-patients and out-patients with dual diagnosis (n = 250), who were predominantly male (70.4%), aged on average 42.1 years, and diagnosed with 3.7 DSM-IV disorders. INTERVENTION AND COMPARATOR Care as usual, consisting of pharmacotherapy combined with individual psychotherapy, group psychotherapy and/or supportive counselling (n = 125) was compared with care as usual plus SOS training: a 6-week, 12-session manualized group training focused on enhancing emotion regulation skills, conflict resolution skills and street skills (n = 125). MEASUREMENTS Victimization was assessed with the Safety Monitor, the Dutch equivalent of the International Crime Victims Survey, in a face-to-face assessment. The primary outcome measure was treatment response (yes/no), with 'yes' defined as reporting at least a 50% reduction in the number of past-year victimization incidents at the 14-month follow-up compared with baseline. Analyses were performed according to the intention-to-treat principle. FINDINGS The proportion of participants achieving treatment response for total victimization was 54.0% in the control group and 67.6% in the experimental group, a significant difference [odds ratio (OR) = 1.78, 95% confidence interval (CI) = 1.02-3.11, P = 0.042]. Treatment response for violent victimization was achieved by 68.7% of the control group and 79.3% of the experimental group (OR = 1.75, 95% CI = 0.91-3.34, P = 0.092). With a Bayes factor of 2.26, this result was inconclusive. CONCLUSIONS Among dual-diagnosis patients, care as usual plus Self-wise, Other-wise, Streetwise training was more effective in preventing victimization than care as usual alone.
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Affiliation(s)
- Marleen M. de Waal
- Department of Psychiatry, Amsterdam Institute for Addiction ResearchAmsterdam UMC, University of AmsterdamAmsterdamthe Netherlands,Department of ResearchArkin Mental Health CareAmsterdamthe Netherlands
| | - Jack J. M. Dekker
- Department of ResearchArkin Mental Health CareAmsterdamthe Netherlands,Department of Clinical PsychologyVU University AmsterdamAmsterdamthe Netherlands
| | | | - Carolien Christ
- Department of ResearchArkin Mental Health CareAmsterdamthe Netherlands,Department of PsychiatryGGZ inGeest and VU University Medical CenterAmsterdamthe Netherlands
| | - Jaga Chmielewska
- Arkin Mental Health CareDivision MentrumAmsterdamthe Netherlands
| | | | - Wim van den Brink
- Department of Psychiatry, Amsterdam Institute for Addiction ResearchAmsterdam UMC, University of AmsterdamAmsterdamthe Netherlands
| | - Anna E. Goudriaan
- Department of Psychiatry, Amsterdam Institute for Addiction ResearchAmsterdam UMC, University of AmsterdamAmsterdamthe Netherlands,Department of ResearchArkin Mental Health CareAmsterdamthe Netherlands
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Valiente-Gómez A, Moreno-Alcázar A, Radua J, Hogg B, Blanco L, Lupo W, Pérez V, Robles-Martínez M, Torrens M, Amann BL. 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. Front Psychiatry 2019; 10:108. [PMID: 30930801 PMCID: PMC6428746 DOI: 10.3389/fpsyt.2019.00108] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2018] [Accepted: 02/13/2019] [Indexed: 12/27/2022] Open
Abstract
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.
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Affiliation(s)
- Alicia Valiente-Gómez
- Centre Fòrum Research Unit, Institut de Neuropsiquiatria i Addiccions, Barcelona, Spain
- IMIM (Hospital del Mar Medical Research Institute), Barcelona, Spain
- Centro de Investigación Biomédica en Red de Salud Mental, Madrid, Spain
- Institut de Neuropsiquiatria i Addiccions, Hospital del Mar, Barcelona, Spain
- Department of Psychiatry, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Ana Moreno-Alcázar
- Centre Fòrum Research Unit, Institut de Neuropsiquiatria i Addiccions, Barcelona, Spain
- IMIM (Hospital del Mar Medical Research Institute), Barcelona, Spain
- Centro de Investigación Biomédica en Red de Salud Mental, Madrid, Spain
| | - Joaquim Radua
- Institut d'Investigacions Biomèdiques August Pi i Sunyer, Barcelona, Spain
- Department of Psychosis Studies, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, United Kingdom
- Department of Clinical Neuroscience, Centre for Psychiatry Research, Karolinska Institutet, Stockholm, Sweden
| | - Bridget Hogg
- Centre Fòrum Research Unit, Institut de Neuropsiquiatria i Addiccions, Barcelona, Spain
- IMIM (Hospital del Mar Medical Research Institute), Barcelona, Spain
| | - Laura Blanco
- Benito Menni Complex Assistencial en Salut Mental, Sant Boi de Llobregat, Spain
- Department of Personality, Evaluation and Psychological Treatments, University of Barcelona, Barcelona, Spain
| | - W. Lupo
- Centre Fòrum Research Unit, Institut de Neuropsiquiatria i Addiccions, Barcelona, Spain
| | - Víctor Pérez
- IMIM (Hospital del Mar Medical Research Institute), Barcelona, Spain
- Centro de Investigación Biomédica en Red de Salud Mental, Madrid, Spain
- Institut de Neuropsiquiatria i Addiccions, Hospital del Mar, Barcelona, Spain
- Department of Psychiatry, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Maria Robles-Martínez
- IMIM (Hospital del Mar Medical Research Institute), Barcelona, Spain
- Institut de Neuropsiquiatria i Addiccions, Hospital del Mar, Barcelona, Spain
- RETICS-Redes Temáticas de Investigación Cooperativa en Salud en Trastornos Adictivos, Barcelona, Spain
| | - Marta Torrens
- IMIM (Hospital del Mar Medical Research Institute), Barcelona, Spain
- Institut de Neuropsiquiatria i Addiccions, Hospital del Mar, Barcelona, Spain
- Department of Psychiatry, Universitat Autònoma de Barcelona, Barcelona, Spain
- RETICS-Redes Temáticas de Investigación Cooperativa en Salud en Trastornos Adictivos, Barcelona, Spain
| | - Benedikt L. Amann
- Centre Fòrum Research Unit, Institut de Neuropsiquiatria i Addiccions, Barcelona, Spain
- IMIM (Hospital del Mar Medical Research Institute), Barcelona, Spain
- Centro de Investigación Biomédica en Red de Salud Mental, Madrid, Spain
- Institut de Neuropsiquiatria i Addiccions, Hospital del Mar, Barcelona, Spain
- Department of Psychiatry, Universitat Autònoma de Barcelona, Barcelona, Spain
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Nass GCM, van Rens LW, Dijkstra BAG. Clinicians' perceptions for indicating and contra-indicating integrated treatment for SUD and comorbid PTSD, a vignette study. SUBSTANCE ABUSE TREATMENT PREVENTION AND POLICY 2019; 14:7. [PMID: 30782179 PMCID: PMC6381656 DOI: 10.1186/s13011-019-0194-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 07/05/2018] [Accepted: 01/31/2019] [Indexed: 01/22/2023]
Abstract
Background Posttraumatic Stress Disorder (PTSD) is more common in patients with Substance Use Disorder (SUD) than in the general population. Although international guidelines recommend integrated treatment clinicians are still hesitant in offering integrated treatment and more concrete recommendations are needed. This study aims to contribute to a practice-based guideline through the exploration of practice-based decision criteria to determine the indication and treatment of SUD and PTSD. Methods A vignette study to explore the views of experienced clinicians on the treatment of SUD and PTSD. Results Thirty-one experienced clinicians working in Dutch addiction care facilities filled in 15 vignettes resulting in 465 scored vignettes. Respondents did not report any contra-indications for integrated treatment and the perceived relationship between SUD and PTSD was found to be an important factor in the indication of integrated treatment. Conclusions For integrated treatment to be offered to all eligible patients more training and schooling in trauma treatment and comorbid psychopathology is needed for all disciplines involved. Inpatient treatment options are necessary when patients need external support due to psychiatric or physical vulnerabilities. Further research into the effect of the relationship between SUD and PTSD on treatment execution and effectiveness is needed and can contribute to future treatment guidelines.
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Affiliation(s)
| | | | - Boukje Arnolda Gerdina Dijkstra
- NISPA, Nijmegen Institute for Scientist-Practitioners in Addiction, Radboud University, P.O. Box 6909, 6503, GK, Nijmegen, The Netherlands
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Shalev AY, Gevonden M, Ratanatharathorn A, Laska E, van der Mei WF, Qi W, Lowe S, Lai BS, Bryant RA, Delahanty D, Matsuoka YJ, Olff M, Schnyder U, Seedat S, deRoon‐Cassini TA, Kessler RC, Koenen KC. Estimating the risk of PTSD in recent trauma survivors: results of the International Consortium to Predict PTSD (ICPP). World Psychiatry 2019; 18:77-87. [PMID: 30600620 PMCID: PMC6313248 DOI: 10.1002/wps.20608] [Citation(s) in RCA: 111] [Impact Index Per Article: 22.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
A timely determination of the risk of post-traumatic stress disorder (PTSD) is a prerequisite for efficient service delivery and prevention. We provide a risk estimate tool allowing a calculation of individuals' PTSD likelihood from early predictors. Members of the International Consortium to Predict PTSD (ICPP) shared individual participants' item-level data from ten longitudinal studies of civilian trauma survivors admitted to acute care centers in six countries. Eligible participants (N=2,473) completed an initial clinical assessment within 60 days of trauma exposure, and at least one follow-up assessment 4-15 months later. The Clinician-Administered PTSD Scale for DSM-IV (CAPS) evaluated PTSD symptom severity and diagnostic status at each assessment. Participants' education, prior lifetime trauma exposure, marital status and socio-economic status were assessed and harmonized across studies. The study's main outcome was the likelihood of a follow-up PTSD given early predictors. The prevalence of follow-up PTSD was 11.8% (9.2% for male participants and 16.4% for females). A logistic model using early PTSD symptom severity (initial CAPS total score) as a predictor produced remarkably accurate estimates of follow-up PTSD (predicted vs. raw probabilities: r=0.976). Adding respondents' female gender, lower education, and exposure to prior interpersonal trauma to the model yielded higher PTSD likelihood estimates, with similar model accuracy (predicted vs. raw probabilities: r=0.941). The current model could be adjusted for other traumatic circumstances and accommodate risk factors not captured by the ICPP (e.g., biological, social). In line with their use in general medicine, risk estimate models can inform clinical choices in psychiatry. It is hoped that quantifying individuals' PTSD risk will be a first step towards systematic prevention of the disorder.
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Affiliation(s)
- Arieh Y. Shalev
- Department of PsychiatryNew York University School of MedicineNew YorkNYUSA
| | - Martin Gevonden
- Department of Biological Psychology Vrije Universiteit Amsterdam The Netherlands
| | | | - Eugene Laska
- Department of PsychiatryNew York University School of MedicineNew YorkNYUSA
| | | | - Wei Qi
- Department of PsychiatryNew York University School of MedicineNew YorkNYUSA
| | - Sarah Lowe
- Department of PsychologyMontclair State UniversityMontclairNJUSA
| | - Betty S. Lai
- Department of Counseling, Developmental and Educational PsychologyLynch School of Education, Boston CollegeChestnut HillMAUSA
| | - Richard A. Bryant
- School of PsychologyUniversity of New South WalesSydneyNSW Australia
| | | | - Yutaka J. Matsuoka
- Division of Health Care ResearchCenter for Public Health Sciences, National Cancer Center JapanTokyoJapan
| | - Miranda Olff
- Department of PsychiatryUniversity of Amsterdam, Amsterdam, The Netherlands, and Arq Psychotrauma Expert GroupDiemenThe Netherlands
| | | | - Soraya Seedat
- Department of PsychiatryStellenbosch UniversityParowCape TownSouth Africa
| | | | | | - Karestan C. Koenen
- Department of EpidemiologyHarvard T.H. Chan School of Public HealthBostonMAUSA
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38
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Lo Coco G, Melchiori F, Oieni V, Infurna MR, Strauss B, Schwartze D, Rosendahl J, Gullo S. Group treatment for substance use disorder in adults: A systematic review and meta-analysis of randomized-controlled trials. J Subst Abuse Treat 2019; 99:104-116. [PMID: 30797382 DOI: 10.1016/j.jsat.2019.01.016] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2018] [Revised: 01/21/2019] [Accepted: 01/22/2019] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND AIMS From residential programs to outpatient services, group therapy permeates the clinical field of substance misuse. While several group interventions for substance use disorders (SUDs) have demonstrated effectiveness, the existing evidence on group therapy has not been systematically reviewed. The current meta-analysis aims to provide estimates of the efficacy of group therapy for SUDs in adults using rigorous methods. METHODS We included studies comparing group psychotherapy to no treatment control groups, individual psychotherapy, medication, self-help groups, and other active treatments applying no specific psychotherapeutic techniques for patients with substance use disorder. The primary outcome was abstinence, and the secondary outcomes were frequency of substance use and symptoms of substance use disorder, anxiety, depression, general psychopathology, and attrition. A comprehensive search was conducted in Medline, Web of Science, CENTRAL, and PsycINFO, complemented by a manual search. Random-effects meta-analyses were run separately for different types of control groups. RESULTS Thirty-three studies were included. Significant small effects of group therapy were found on abstinence compared to no treatment, individual therapy, and other treatments. Effects on substance use frequency and SUD symptoms were not significant, but significant moderately sized effects emerged for mental state when group therapy was compared to no treatment. There were no differences in abstinence rates between group therapy and control groups. These results were robust in sensitivity analyses and there was no indication of publication bias. CONCLUSIONS The current findings represent the best available summary analysis of group therapy for SUDs in adults, however cautious interpretation is warranted given the limitations of the available data.
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Affiliation(s)
- Gianluca Lo Coco
- University of Palermo, Department of Psychology, Educational Sciences and Human Movement, Palermo, Italy.
| | | | | | | | - Bernhard Strauss
- University Hospital Jena, Friedrich Schiller University Jena, Institute of Psychosocial Medicine and Psychotherapy, Jena, Germany
| | - Dominique Schwartze
- University Hospital Jena, Friedrich Schiller University Jena, Institute of Psychosocial Medicine and Psychotherapy, Jena, Germany
| | - Jenny Rosendahl
- University Hospital Jena, Friedrich Schiller University Jena, Institute of Psychosocial Medicine and Psychotherapy, Jena, Germany
| | - Salvatore Gullo
- University of Palermo, Department of Psychology, Educational Sciences and Human Movement, Palermo, Italy
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39
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Anderson CA. Adolescent Substance Use and Effects on the Birth Experience. Issues Ment Health Nurs 2018; 39:988-997. [PMID: 30111219 DOI: 10.1080/01612840.2018.1479904] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
Depression, violence, and infant complications are recognized risk factors for negative birth experiences. Substance use, which often co-occurs with these risk factors, is unexplored for its role upon the birth experience. The frequency of these risk factors among childbearing adolescents suggests a need for research in this area. This study revealed direct and indirect effects by all risk factors on the adolescent's birth experience. Implications for nursing practice suggest collaboration between maternal child health and mental health nurses in prenatal, hospital, and follow-up healthcare settings to provide essential assessment of risk factors and resources and referrals across the perinatal period.
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Affiliation(s)
- Cheryl Ann Anderson
- a College of Nursing and Health Innovation , University of Texas at Arlington , Arlington , Texas , USA
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40
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Jeal N, Patel R, Redmond NM, Kesten JM, Ramsden S, Macleod J, Coast J, Telfer M, Wilcox D, Nowland G, Horwood J. Drug use in street sex workers (DUSSK) study protocol: a feasibility and acceptability study of a complex intervention to reduce illicit drug use in drug-dependent female street sex workers. BMJ Open 2018; 8:e022728. [PMID: 30391916 PMCID: PMC6231566 DOI: 10.1136/bmjopen-2018-022728] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2018] [Revised: 09/05/2018] [Accepted: 09/25/2018] [Indexed: 11/03/2022] Open
Abstract
INTRODUCTION Poor health of sex workers continues to be a source of international concern. Sex work is frequently linked with problematic drug use and drug-dependent sex workers typically work on the street, experiencing the greatest risks to health compared with the general population. Street sex workers (SSWs) are much more likely to have experienced incidences of physical and sexual assault, increasing their risk of developing post-traumatic stress disorder (PTSD). We have developed a novel complex intervention designed to reduce illicit drug use in drug-dependent female SSWs which involves: female SSW drug treatment groups (provided by a specialist charity) in a female SSW setting (female sex worker charity premises) provided by female-only staff, PTSD care with eye movement desensitisation and reprocessing (EMDR) therapy provided by female staff from National Health Service (NHS) mental health services. METHODS AND ANALYSIS A mixed methods study investigating the feasibility and acceptability of this intervention to inform the design of a future randomised controlled trial. The study aims to recruit up to 30 participants from November 2017 to March 2018 at a single site, with the intervention being delivered until December 2018. It will gather quantitative data using questionnaires and group attendance. Drug treatment group observations and in-depth interviews undertaken with up to 20 service users and 15 service providers to examine experiences and acceptability of the intervention. Study feasibility will be assessed by evaluating the recruitment and retention of participants to the intervention; the feasibility of NHS and third sector organisations working closely to coordinate care for a SSW population; the potential for specialist NHS mental health services to screen and provide EMDR therapy for drug-dependent SSWs and potential costs of implementing the intervention. ETHICS AND DISSEMINATION This study was approved by South West-Frenchay Research Ethics Committee (REC reference: 17/SW/0033; IRAS ID: 220631) and the Health Research Authority (HRA). Findings will be disseminated through research conferences and peer-reviewed journals.
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Affiliation(s)
- Nicola Jeal
- University Hospitals Bristol NHS Foundation Trust (UHBT), Bristol, UK
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Rita Patel
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
- The National Institute for Health Research Collaboration for Leadership in Applied Health Research and Care West (NIHR CLAHRC West), University Hospitals Bristol NHS Foundation Trust (UHBT), Bristol, UK
| | - Niamh M Redmond
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
- The National Institute for Health Research Collaboration for Leadership in Applied Health Research and Care West (NIHR CLAHRC West), University Hospitals Bristol NHS Foundation Trust (UHBT), Bristol, UK
| | - Joanna M Kesten
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
- The National Institute for Health Research Collaboration for Leadership in Applied Health Research and Care West (NIHR CLAHRC West), University Hospitals Bristol NHS Foundation Trust (UHBT), Bristol, UK
- The National Institute for Health Research Health Protection Research Unit in Evaluation of Interventions, University of Bristol, Bristol, UK
| | - Sophie Ramsden
- University Hospitals Bristol NHS Foundation Trust (UHBT), Bristol, UK
| | - John Macleod
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
- Centre for Academic Primary Care, Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Joanna Coast
- The National Institute for Health Research Collaboration for Leadership in Applied Health Research and Care West (NIHR CLAHRC West), University Hospitals Bristol NHS Foundation Trust (UHBT), Bristol, UK
- Health Economics at Bristol, Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | | | - David Wilcox
- Avon and Wiltshire Mental Health Partnership NHS Trust, Bristol, UK
| | | | - Jeremy Horwood
- The National Institute for Health Research Collaboration for Leadership in Applied Health Research and Care West (NIHR CLAHRC West), University Hospitals Bristol NHS Foundation Trust (UHBT), Bristol, UK
- Centre for Academic Primary Care, Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
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41
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Japuntich SJ, Arditte Hall KA, Joos CM, Rasmusson AM, Pineles SL. Methods to reduce false reporting of substance abstinence in clinical research. Int J Methods Psychiatr Res 2018; 27:e1603. [PMID: 29314410 PMCID: PMC6877230 DOI: 10.1002/mpr.1603] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2017] [Revised: 11/01/2017] [Accepted: 11/13/2017] [Indexed: 12/16/2022] Open
Abstract
OBJECTIVES Substance use may influence study results in human subjects research. This study aims to report the concordance between self-report and biochemical assessments of substance use and test the effect of methods to reduce false reports of abstinence in trauma-exposed women participating in a research study. METHODS In this pilot study, substance use was assessed during telephone prescreening and via self-report and biochemical verification (i.e., urine toxicology and alcohol breathalyzer tests) at an in-person evaluation. Due to the high number of participants who tested positive for substances despite self-reporting abstinence during prescreening, study procedures were modified to disincentivize false self-reports of substance use two thirds of the way through recruitment. New potential participants were explicitly informed during prescreening and informed consent that a positive drug or alcohol test during screening would result in exclusion from the study and withholding of payment. RESULTS Prior to modifying study methods, 20% of participants who had reported abstinence during the telephone prescreen had a positive substance use test at the in-person visit. Modifying study procedures resulted in an 81% decrease in positive substance use assessments. CONCLUSIONS Adoption of this methodology may decrease inadvertent confounding of clinical research outcomes by undetected and/or misreported substance use.
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Affiliation(s)
- Sandra J. Japuntich
- Centers for Behavioral and Preventive MedicineThe Miriam HospitalProvidenceRhode IslandUSA
- Department of Psychiatry and Human BehaviorAlpert Medical School of Brown UniversityProvidenceRhode IslandUSA
| | - Kimberly A. Arditte Hall
- National Center for PTSD, Women's Health Sciences DivisionVA Boston Healthcare SystemBostonMassachusettsUSA
- Department of PsychiatryBoston University School of MedicineBostonMassachusettsUSA
| | - Celina M. Joos
- Department of PsychologyPennsylvania State UniversityState CollegePennsylvaniaUSA
| | - Ann M. Rasmusson
- National Center for PTSD, Women's Health Sciences DivisionVA Boston Healthcare SystemBostonMassachusettsUSA
- Department of PsychiatryBoston University School of MedicineBostonMassachusettsUSA
| | - Suzanne L. Pineles
- National Center for PTSD, Women's Health Sciences DivisionVA Boston Healthcare SystemBostonMassachusettsUSA
- Department of PsychiatryBoston University School of MedicineBostonMassachusettsUSA
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42
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Qi W, Ratanatharathorn A, Gevonden M, Bryant R, Delahanty D, Matsuoka Y, Olff M, deRoon-Cassini T, Schnyder U, Seedat S, Laska E, Kessler RC, Koenen K, Shalev A. Application of data pooling to longitudinal studies of early post-traumatic stress disorder (PTSD): the International Consortium to Predict PTSD (ICPP) project. Eur J Psychotraumatol 2018; 9:1476442. [PMID: 29938009 PMCID: PMC6008580 DOI: 10.1080/20008198.2018.1476442] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/01/2018] [Accepted: 04/23/2018] [Indexed: 12/11/2022] Open
Abstract
Background: Understanding the development of post-traumatic stress disorder (PTSD) is a precondition for efficient risk assessment and prevention planning. Studies to date have been site and sample specific. Towards developing generalizable models of PTSD development and prediction, the International Consortium to Predict PTSD (ICPP) compiled data from 13 longitudinal, acute-care based PTSD studies performed in six different countries. Objective: The objectives of this study were to describe the ICPP's approach to data pooling and harmonization, and present cross-study descriptive results informing the longitudinal course of PTSD after acute trauma. Methods: Item-level data from 13 longitudinal studies of adult civilian trauma survivors were collected. Constructs (e.g. PTSD, depression), measures (questions or scales), and time variables (days from trauma) were identified and harmonized, and those with inconsistent coding (e.g. education, lifetime trauma exposure) were recoded. Administered in 11 studies, the Clinician Administered PTSD Scale (CAPS) emerged as the main measure of PTSD diagnosis and severity. Results: The pooled data set included 6254 subjects (39.9% female). Studies' average retention rate was 87.0% (range 49.1-93.5%). Participants' baseline assessments took place within 2 months of trauma exposure. Follow-up durations ranged from 188 to 1110 days. Reflecting studies' inclusion criteria, the prevalence of baseline PTSD differed significantly between studies (range 3.1-61.6%), and similar differences were observed in subsequent assessments (4.3-38.2% and 3.8-27.0% for second and third assessments, respectively). Conclusion: Pooling data from independently collected studies requires careful curation of individual data sets for extracting and optimizing informative commonalities. However, it is an important step towards developing robust and generalizable prediction models for PTSD and can exceed findings of single studies. The large differences in prevalence of PTSD longitudinally cautions against using any individual study to infer trauma outcome. The multiplicity of instruments used in individual studies emphasizes the need for common data elements in future studies.
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Affiliation(s)
- Wei Qi
- Department of Psychiatry, New York University School of Medicine, New York, NY, USA
| | - Andrew Ratanatharathorn
- Department of Epidemiology, Columbia University Mailman School of Public Health, New York , USA
| | - Martin Gevonden
- Department of Psychiatry, New York University School of Medicine, New York, NY, USA
| | - Richard Bryant
- Faculty of Science, University of New South Wales School of Psychology, Kensington, Australia
| | - Douglas Delahanty
- Department of Psychological Sciences, Kent State University, Kent, OH, USA
| | - Yutaka Matsuoka
- Division of Health Care Research, National Cancer Center, Center for Public Health Sciences, Tokyo, Japan
| | - Miranda Olff
- Department of Psychiatry, University of Amsterdam Academic Medical Center, Amsterdam-Zuidoost, The Netherlands
| | | | - Ulrich Schnyder
- Department of Psychiatry, University of Zurich School of Medicine, Zurich, Switzerland
| | - Soraya Seedat
- Department of Psychiatry, Stellenbosch University School of Medicine and Health Sciences, Cape Town, South Africa
| | - Eugene Laska
- Department of Psychiatry, New York University School of Medicine, New York, NY, USA
| | - Ronald C. Kessler
- Department of Health Care Policy, Harvard Medical School, Boston, MA, USA
| | - Karestan Koenen
- Department of Epidemiology, Harvard University T.H. Chan School of Public Health, Boston, MA, USA
| | - Arieh Shalev
- Department of Psychiatry, New York University School of Medicine, New York, NY, USA
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43
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Inoue R, Talukdar G, Takao K, Miyakawa T, Mori H. Dissociated Role of D-Serine in Extinction During Consolidation vs. Reconsolidation of Context Conditioned Fear. Front Mol Neurosci 2018; 11:161. [PMID: 29872376 PMCID: PMC5972189 DOI: 10.3389/fnmol.2018.00161] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2017] [Accepted: 04/30/2018] [Indexed: 01/03/2023] Open
Abstract
Extinction-based exposure therapy is widely used for the treatment of anxiety disorders, such as post-traumatic stress disorder (PTSD). D-serine, an endogenous co-agonist at the glycine-binding site of the N-methyl-D-aspartate-type glutamate receptor (NMDAR), has been shown to be involved in extinction of fear memory. Recent findings suggest that the length of time between the initial learning and an extinction session is a determinant of neural mechanism involved in fear extinction. However, how D-serine is involved in extinction of fear memory at different timings remains unclear. In the present study, we investigated the role of D-serine in immediate, delayed and post-retrieval extinction (P-RE) of contextual fear memory using wild-type (WT) and serine racemase (SRR) knockout (KO) mice that exhibit 90% reduction in D-serine content in the hippocampus. We found that SRR disruption impairs P-RE, facilitates immediate extinction (IE), but has no effect on delayed extinction (DE) of contextual fear memories. The impaired P-RE of contextual fear memory in SRRKO mice was associated with increased expression of the GluA1 subunit of the α-amino-3-hydroxy-5-methyl-4-isoxazolepropionic acid-type glutamate receptor (AMPAR) in the hippocampal synaptic membrane fraction after P-RE, and this increase of AMPAR and impaired P-RE were rescued by the administration of D-serine to SRRKO mice. Our findings suggest that D-serine is differentially involved in the regulation of contextual fear extinction depending on the timing of behavioral intervention, and that combining D-serine or other drugs, enhancing the NMDAR function, with P-RE may achieve optimal outcomes for the treatment of PTSD.
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Affiliation(s)
- Ran Inoue
- Department of Molecular Neuroscience, Graduate School of Medicine and Pharmaceutical Sciences, University of Toyama, Toyama, Japan
| | - Gourango Talukdar
- Department of Molecular Neuroscience, Graduate School of Medicine and Pharmaceutical Sciences, University of Toyama, Toyama, Japan
| | - Keizo Takao
- Life Science Research Center, University of Toyama, Toyama, Japan.,Section of Behavior Patterns, Center for Genetic Analysis of Behavior, National Institute for Physiological Sciences, Aichi, Japan.,Genetic Engineering and Functional Genomics Group, Frontier Technology Center, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Tsuyoshi Miyakawa
- Section of Behavior Patterns, Center for Genetic Analysis of Behavior, National Institute for Physiological Sciences, Aichi, Japan.,Genetic Engineering and Functional Genomics Group, Frontier Technology Center, Graduate School of Medicine, Kyoto University, Kyoto, Japan.,Division of Systems Medical Science, Institute for Comprehensive Medical Science, Fujita Health University, Toyoake, Japan
| | - Hisashi Mori
- Department of Molecular Neuroscience, Graduate School of Medicine and Pharmaceutical Sciences, University of Toyama, Toyama, Japan
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44
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Louie E, Giannopoulos V, Baillie A, Uribe G, Byrne S, Deady M, Teesson M, Baker A, Haber PS, Morley KC. Translating Evidence-Based Practice for Managing Comorbid Substance Use and Mental Illness Using a Multimodal Training Package. J Dual Diagn 2018; 14:111-119. [PMID: 29488830 DOI: 10.1080/15504263.2018.1437496] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
OBJECTIVE Comorbid mental health and substance use problems are highly prevalent in substance use treatment settings and generally lead to poorer treatment outcomes. Pathways to Comorbidity Care (PCC) is a multimodal training program developed to encourage an integrated service approach to improve clinicians capacity to identify and manage comorbid substance use and mental health outcomes within public drug and alcohol treatment settings. METHODS In this paper we describe the concepts underlying the PCC package and the use of implementation science to assess and overcome potential barriers, including clinicians preferences, knowledge about best practice, and professional culture. RESULTS The training components include didactic seminars, group workshops run by a local clinical champion on relevant subjects such as motivational interviewing and cognitive behavioral therapy, individual clinical consultation, and feedback with a senior clinical psychologist. The PCC also includes an online portal containing comorbidity resources including manuals, guidelines, and booster webinars. Finally, we describe the evaluation of PCC implementation. CONCLUSIONS Drug and alcohol services need to be equipped to treat the majority of comorbid mental health conditions in their clients. We anticipate that this multimodal training package, which applies the principles of implementation science, will facilitate effective and integrated care for these vulnerable clients.
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Affiliation(s)
- Eva Louie
- a Discipline of Addiction Medicine , National Health and Medical Research Council (NHMRC) Centre for Excellence in Mental Health and Substance Use, The University of Sydney , New South Wales , Australia
| | - Vicki Giannopoulos
- a Discipline of Addiction Medicine , National Health and Medical Research Council (NHMRC) Centre for Excellence in Mental Health and Substance Use, The University of Sydney , New South Wales , Australia
| | - Andrew Baillie
- b Faculty of Health Sciences , National Health and Medical Research Council (NHMRC) Centre for Excellence in Mental Health and Substance Use, The University of Sydney , New South Wales , Australia
| | - Gabriela Uribe
- a Discipline of Addiction Medicine , National Health and Medical Research Council (NHMRC) Centre for Excellence in Mental Health and Substance Use, The University of Sydney , New South Wales , Australia
| | - Simon Byrne
- a Discipline of Addiction Medicine , National Health and Medical Research Council (NHMRC) Centre for Excellence in Mental Health and Substance Use, The University of Sydney , New South Wales , Australia
| | - Mark Deady
- c National Drug and Alcohol Research Centre , National Health and Medical Research Council (NHMRC) Centre for Excellence in Mental Health and Substance Use, University of New South Wales (UNSW) , Australia
| | - Maree Teesson
- c National Drug and Alcohol Research Centre , National Health and Medical Research Council (NHMRC) Centre for Excellence in Mental Health and Substance Use, University of New South Wales (UNSW) , Australia
| | - Amanda Baker
- d School of Medicine and Public Health University of Newcastle , New South Wales , Australia
| | - Paul S Haber
- a Discipline of Addiction Medicine , National Health and Medical Research Council (NHMRC) Centre for Excellence in Mental Health and Substance Use, The University of Sydney , New South Wales , Australia.,e Drug Health Services , Royal Prince Alfred Hospital , Camperdown , New South Wales , Australia
| | - Kirsten C Morley
- a Discipline of Addiction Medicine , National Health and Medical Research Council (NHMRC) Centre for Excellence in Mental Health and Substance Use, The University of Sydney , New South Wales , Australia
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45
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Chen JA, Owens MD, Browne KC, Williams EC. Alcohol-related and mental health care for patients with unhealthy alcohol use and posttraumatic stress disorder in a National Veterans Affairs cohort. J Subst Abuse Treat 2018; 85:1-9. [PMID: 29291765 PMCID: PMC5753430 DOI: 10.1016/j.jsat.2017.11.007] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2017] [Revised: 09/27/2017] [Accepted: 11/17/2017] [Indexed: 11/17/2022]
Abstract
OBJECTIVE Unhealthy alcohol use and posttraumatic stress disorder (PTSD) frequently co-occur. Patients with both conditions have poorer functioning and worse treatment adherence compared to those with either condition alone. Therefore, it is possible that PTSD, when co-occurring with unhealthy alcohol use, may influence receipt of evidence-based alcohol-related care and mental health care. We evaluated receipt of interventions for unhealthy alcohol use and receipt of mental health follow-up care among patients screening positive for unhealthy alcohol use with and without PTSD in a national sample from the Veterans Health Administration (VA). METHODS National clinical and administrative data from VA's electronic medical record were used to identify all patients who screened positive for unhealthy alcohol use (AUDIT-C score≥5) between 10/1/09-5/30/13. Unadjusted and adjusted Poisson regression models were fit to estimate the relative rate and prevalence of receipt of: brief interventions (advice to reduce or abstain from drinking≤14days after positive screening), specialty addictions treatment for alcohol use disorder (AUD; documented visit≤365days after positive screening), pharmacotherapy for AUD (filled prescription≤365days after positive screening), and mental health care ≤14days after positive screening for patients with and without PTSD (documented with ICD-9 CM codes). In secondary analyses, we tested effect modification by both severity of unhealthy alcohol use and age. RESULTS Among 830,825 patients who screened positive for unhealthy alcohol use, 140,388 (16.9%) had documented PTSD. Of the full sample, 71.6% received brief interventions, 10.3% received specialty AUD treatment, 3.1% received pharmacotherapy for AUD, and 24.0% received mental health care. PTSD was associated with increased likelihood of receiving all types of care. Adjusted relative rates were 1.04 (95% CI 1.03-1.05) for brief interventions, 1.06 (1.05-1.08) for specialty AUD treatment, 1.35 (1.31-1.39) for AUD pharmacotherapy, and 1.82 (1.80-1.84) for mental health care. Alcohol use severity modified effects of PTSD for specialty AUD treatment, AUD pharmacotherapy, and mental health care such that effects were maintained at lower severity but attenuated among patients with severe unhealthy alcohol use. Age modified all effects with the strength of the association between PTSD and care outcomes being strongest for younger (18-29years) and older veterans (65+ years) and weaker or non-significant for middle-aged veterans (30-44 and 45-64years). CONCLUSIONS In this large national sample of patients with unhealthy alcohol use, PTSD was associated with increased likelihood of receiving alcohol-related and mental health care. PTSD does not appear to be a barrier to care among VA patients with unhealthy alcohol use.
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Affiliation(s)
- Jessica A Chen
- Health Services Research & Development (HSR&D), Seattle-Denver Center of Innovation for Veteran-Centered Value-Driven Care, Veterans Affairs (VA) Puget Sound Health Care System, 1660 S. Columbian Way, S-152, Seattle, WA 98108, USA; Department of Health Services, University of Washington, 1959 NE Pacific St., Magnuson Health Sciences Center, Room H-680, Box 357660, Seattle, WA 98195-7660, USA.
| | - Mandy D Owens
- Health Services Research & Development (HSR&D), Seattle-Denver Center of Innovation for Veteran-Centered Value-Driven Care, Veterans Affairs (VA) Puget Sound Health Care System, 1660 S. Columbian Way, S-152, Seattle, WA 98108, USA; Department of Health Services, University of Washington, 1959 NE Pacific St., Magnuson Health Sciences Center, Room H-680, Box 357660, Seattle, WA 98195-7660, USA.
| | - Kendall C Browne
- Health Services Research & Development (HSR&D), Seattle-Denver Center of Innovation for Veteran-Centered Value-Driven Care, Veterans Affairs (VA) Puget Sound Health Care System, 1660 S. Columbian Way, S-152, Seattle, WA 98108, USA; Center of Excellence in Substance Abuse Treatment and Education, Veterans Affairs (VA) Puget Sound Health Care System, 1660 S. Columbian Way, Seattle, WA 98108, USA; Department of Psychiatry & Behavioral Sciences, University of Washington, 1959 NE Pacific Street, Box 356560, Room BB1644, Seattle, WA 98195-6560, USA.
| | - Emily C Williams
- Health Services Research & Development (HSR&D), Seattle-Denver Center of Innovation for Veteran-Centered Value-Driven Care, Veterans Affairs (VA) Puget Sound Health Care System, 1660 S. Columbian Way, S-152, Seattle, WA 98108, USA; Department of Health Services, University of Washington, 1959 NE Pacific St., Magnuson Health Sciences Center, Room H-680, Box 357660, Seattle, WA 98195-7660, USA.
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46
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Vujanovic AA, Smith LJ, Green CE, Lane SD, Schmitz JM. Development of a novel, integrated cognitive-behavioral therapy for co-occurring posttraumatic stress and substance use disorders: A pilot randomized clinical trial. Contemp Clin Trials 2018; 65:123-129. [PMID: 29287668 PMCID: PMC5803416 DOI: 10.1016/j.cct.2017.12.013] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2017] [Revised: 12/23/2017] [Accepted: 12/24/2017] [Indexed: 01/11/2023]
Abstract
Posttraumatic stress disorder (PTSD) and substance use disorders (SUD) are complex psychiatric conditions that commonly co-occur. No evidence-based, 'gold standard' treatments for PTSD/SUD comorbidity are currently available. The present pilot randomized clinical trial was designed to evaluate the feasibility and preliminary efficacy of a novel, integrated cognitive-behavioral treatment approach for PTSD/SUD, entitled Treatment of Integrated Posttraumatic Stress and Substance Use (TIPSS), as compared to standard cognitive-behavioral treatment (CBT) for SUD. The TIPSS program integrates cognitive processing therapy with CBT for SUD for the treatment of co-occurring PTSD/SUD. Both treatment conditions are comprised of 12, 60-minute individual psychotherapy sessions, delivered twice-weekly over six weeks. Primary aims examine whether TIPSS, compared to standard CBT for SUD, reduces: (1) PTSD symptoms and (2) substance use outcomes (i.e., self-report, objective). Secondary aims examine whether (a) trauma- and substance cue reactivity and (b) distress tolerance (i.e., actual or perceived ability to withstand uncomfortable emotional or physical states) are significant mechanisms of change. The study was recently closed to new enrollment. Participants included adults with substance dependence and at least four symptoms of PTSD.
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Affiliation(s)
| | - Lia J Smith
- Department of Psychology, University of Houston, United States
| | - Charles E Green
- Department of Psychiatry and Behavioral Sciences, McGovern Medical School, University of Texas Health Science Center at Houston, Houston, United States
| | - Scott D Lane
- Department of Psychiatry and Behavioral Sciences, McGovern Medical School, University of Texas Health Science Center at Houston, Houston, United States
| | - Joy M Schmitz
- Department of Psychiatry and Behavioral Sciences, McGovern Medical School, University of Texas Health Science Center at Houston, Houston, United States
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Flanagan JC, Jones JL, Jarnecke AM, Back SE. Behavioral Treatments for Alcohol Use Disorder and Post-Traumatic Stress Disorder. Alcohol Res 2018; 39:181-192. [PMID: 31198657 PMCID: PMC6561400] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Alcohol use disorder (AUD) and post-traumatic stress disorder (PTSD) are highly prevalent and debilitating psychiatric conditions that commonly co-occur. Individuals with comorbid AUD and PTSD incur heightened risk for other psychiatric problems (e.g., depression and anxiety), impaired vocational and social functioning, and poor treatment outcomes. This review describes evidence-supported behavioral interventions for treating AUD alone, PTSD alone, and comorbid AUD and PTSD. Evidence-based behavioral interventions for AUD include relapse prevention, contingency management, motivational enhancement, couples therapy, 12-step facilitation, community reinforcement, and mindfulness. Evidence-based PTSD interventions include prolonged exposure therapy, cognitive processing therapy, eye movement desensitization and reprocessing, psychotherapy incorporating narrative exposure, and present-centered therapy. The differing theories behind sequential versus integrated treatment of comorbid AUD and PTSD are presented, as is evidence supporting the use of integrated treatment models. Future research on this complex, dual-diagnosis population is necessary to improve understanding of how individual characteristics, such as gender and treatment goals, affect treatment outcome.
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Affiliation(s)
- Julianne C Flanagan
- Julianne C. Flanagan, Ph.D., is an associate professor in the Department of Psychiatry and Behavioral Sciences, Medical University of South Carolina, Charleston, South Carolina. Jennifer L. Jones, M.D., is a postdoctoral fellow in the Department of Psychiatry and Behavioral Sciences, Medical University of South Carolina, Charleston, South Carolina. Amber M. Jarnecke, Ph.D., is a postdoctoral fellow in the Department of Psychiatry and Behavioral Sciences, Medical University of South Carolina, Charleston, South Carolina. Sudie E. Back, Ph.D., is a professor in the Department of Psychiatry and Behavioral Sciences, Medical University of South Carolina, and a staff psychologist at the Ralph H. Johnson VA Medical Center, Charleston, South Carolina
| | - Jennifer L Jones
- Julianne C. Flanagan, Ph.D., is an associate professor in the Department of Psychiatry and Behavioral Sciences, Medical University of South Carolina, Charleston, South Carolina. Jennifer L. Jones, M.D., is a postdoctoral fellow in the Department of Psychiatry and Behavioral Sciences, Medical University of South Carolina, Charleston, South Carolina. Amber M. Jarnecke, Ph.D., is a postdoctoral fellow in the Department of Psychiatry and Behavioral Sciences, Medical University of South Carolina, Charleston, South Carolina. Sudie E. Back, Ph.D., is a professor in the Department of Psychiatry and Behavioral Sciences, Medical University of South Carolina, and a staff psychologist at the Ralph H. Johnson VA Medical Center, Charleston, South Carolina
| | - Amber M Jarnecke
- Julianne C. Flanagan, Ph.D., is an associate professor in the Department of Psychiatry and Behavioral Sciences, Medical University of South Carolina, Charleston, South Carolina. Jennifer L. Jones, M.D., is a postdoctoral fellow in the Department of Psychiatry and Behavioral Sciences, Medical University of South Carolina, Charleston, South Carolina. Amber M. Jarnecke, Ph.D., is a postdoctoral fellow in the Department of Psychiatry and Behavioral Sciences, Medical University of South Carolina, Charleston, South Carolina. Sudie E. Back, Ph.D., is a professor in the Department of Psychiatry and Behavioral Sciences, Medical University of South Carolina, and a staff psychologist at the Ralph H. Johnson VA Medical Center, Charleston, South Carolina
| | - Sudie E Back
- Julianne C. Flanagan, Ph.D., is an associate professor in the Department of Psychiatry and Behavioral Sciences, Medical University of South Carolina, Charleston, South Carolina. Jennifer L. Jones, M.D., is a postdoctoral fellow in the Department of Psychiatry and Behavioral Sciences, Medical University of South Carolina, Charleston, South Carolina. Amber M. Jarnecke, Ph.D., is a postdoctoral fellow in the Department of Psychiatry and Behavioral Sciences, Medical University of South Carolina, Charleston, South Carolina. Sudie E. Back, Ph.D., is a professor in the Department of Psychiatry and Behavioral Sciences, Medical University of South Carolina, and a staff psychologist at the Ralph H. Johnson VA Medical Center, Charleston, South Carolina
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Dworkin ER, Bergman HE, Walton TO, Walker DD, Kaysen DL. Co-Occurring Post-Traumatic Stress Disorder and Alcohol Use Disorder in U.S. Military and Veteran Populations. Alcohol Res 2018; 39:161-169. [PMID: 31198655 PMCID: PMC6561402] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
Co-occurring post-traumatic stress disorder (PTSD) and alcohol use disorder (AUD) are costly and consequential public health problems that negatively affect the health and well-being of U.S. military service members and veterans. The disproportionate burden of comorbid PTSD and AUD among U.S. military service members and veterans may be due to unique factors associated with military service, such as aspects of military culture, deployment, and trauma exposure. This review addresses the prevalence of co-occurring PTSD and AUD in military and veteran populations, population-specific factors that contribute to development of the comorbid conditions, and evidence-based treatments that have promise for addressing these conditions in military and veteran populations. Future directions for research and practice relevant to military and veteran populations are discussed.
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Abstract
Intimate partner violence (IPV) is common worldwide and occurs in more than one-third of American women and psychiatric patients. As well as physical injuries, it may cause mental health sequelae, such as depression, anxiety, posttraumatic stress disorder, psychosis, inability to trust others, self-harm, and a host of psychosomatic conditions, that may be referred to psychiatrists. It is imperative that psychiatrists know the risk factors, how to assist disclosure of IPV, and how to safely respond. Psychiatrists must know the best evidence-based management of IPV and its mental health sequelae to best assist patients who have been exposed to IPV.
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Affiliation(s)
- Donna Eileen Stewart
- University of Toronto, 200 Elizabeth Street, EN-7-229, Toronto, Ontario M5G 2C4, Canada; Toronto General Hospital Research Institute, 200 Elizabeth Street, 7EN-229, Toronto, Ontario M5G 2C4, Canada; Centre for Mental Health, University Health Network, 200 Elizabeth Street, 7EN-229, Toronto, Ontario M5G 2C4, Canada.
| | - Simone Natalie Vigod
- University of Toronto, 200 Elizabeth Street, EN-7-229, Toronto, Ontario M5G 2C4, Canada; Women's College Hospital and Research Institute, 76 Grenville Street, Room 7234, Toronto, Ontario M5S 1B2, Canada
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50
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Kok T, De Haan HA, Sensky T, van der Meer M, De Jong CAJ. Using the Pictorial Representation of Illness and Self Measure (PRISM) to Quantify and Compare Suffering From Trauma and Addiction. J Dual Diagn 2017; 13:101-108. [PMID: 28368709 DOI: 10.1080/15504263.2017.1293867] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
OBJECTIVE In a sample of people with substance use disorder who had experienced psychological trauma, this study aimed to quantify differences in perceived suffering due to addiction-related problems and to trauma-related problems. METHODS The sample comprised 146 inpatients with substance use disorder: 25% had posttraumatic stress disorder (PTSD), 21% had subthreshold PTSD; and the remainder constituted the trauma-only group. PTSD, substance use disorder, and suffering were assessed using validated instruments. Suffering was measured using the Pictorial Representation of Illness and Self Measure (PRISM). RESULTS No differences were found among the PTSD, subthreshold PTSD, and trauma-only group in the suffering attributed to addiction-related problems. Those in the PTSD group appraised their suffering due to trauma-related problems as greater than the other groups. In the PTSD group, but not the subthreshold PTSD group, suffering due to trauma-related problems was appraised as greater than that due to addiction-related problems. CONCLUSIONS This is the first study to demonstrate quantitative comparisons between different health problems using the "common currency" of suffering. Our results indicate that even among those in an inpatient substance use disorder treatment program, comorbid PTSD may be more personally salient and cause greater suffering, with implications for therapeutic interventions available on substance use disorder treatment programs.
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Affiliation(s)
- Tim Kok
- a Tactus Addiction Treatment and Nijmegen Institute for Scientist-Practitioners in Addiction , Enschede , The Netherlands
| | - Hein A De Haan
- a Tactus Addiction Treatment and Nijmegen Institute for Scientist-Practitioners in Addiction , Enschede , The Netherlands
| | - Tom Sensky
- b Centre for Mental Health , Imperial College London , London , United Kingdom
| | | | - Cornelis A J De Jong
- a Tactus Addiction Treatment and Nijmegen Institute for Scientist-Practitioners in Addiction , Enschede , The Netherlands
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