Randomized Control Trial of Culturally Adapted Cognitive Processing Therapy for PTSD Substance Misuse and HIV Sexual Risk Behavior for Native American Women

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Project harmony: A systematic review and network meta-analysis of psychotherapy and pharmacologic trials for comorbid posttraumatic stress, alcohol, and other drug use disorders

We conducted a systematic review and network meta-analyses (NMA) of psychotherapy and pharmacologic treatments for individuals with co-occurring posttraumatic stress disorder (PTSD) and alcohol or other drug use disorder (AOD). A comprehensive search spanning 1995-2019 yielded a pool of 39 studies for systematic review, including 24 randomized controlled trials for the NMA. Study interventions were grouped by target of treatment (PTSD + AOD, PTSD-only, and AOD-only) and approach (psychotherapy or medication). Standardized mean differences (SMD) from the NMA yielded evidence that at the end of treatment, integrated, trauma-focused therapy for PTSD + AOD was more effective at reducing PTSD symptoms than integrated, non-trauma-focused therapy (SMD = -0.30), AOD-focused psychotherapy (SMD = -0.29), and other control psychotherapies (SMD = -0.43). End-of-treatment alcohol use severity was less for AOD medication compared to placebo medication (SMD = -0.36) and trauma-focused therapy for PTSD + placebo medication (SMD = -0.67), and less for trauma-focused psychotherapy + AOD medication compared to PTSD medication (SMD = -0.53), placebo medication (SMD = -0.50), and trauma-focused psychotherapy + placebo medication (SMD = -0.81). Key limitations include the small number of studies in the NMA for pharmacologic treatments and the lack of demographic diversity apparent in the existing literature. Findings suggest room for new studies that can address limitations in study sample composition, sample sizes, retention, and apply new techniques for conducting comparative effectiveness in PTSD + AOD treatment. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

Effectiveness of trauma-focused cognitive behavioral therapy compared to psychosocial counseling in reducing HIV risk behaviors, substance use, and mental health problems among orphans and vulnerable children in Zambia: a community-based randomized controlled trial

Orphans and vulnerable children (OVC) in sub-Saharan Africa are at high risk for HIV infection and transmission. HIV prevention and treatment efforts with OVC are hindered by mental health and substance use problems. This randomized controlled trial compared a mental health intervention, Trauma Focused Cognitive Behavioral Therapy (TF-CBT), to an enhanced version of an existing HIV Psychosocial Counseling (PC+) program among 610 adolescents who met PEPFAR criteria for OVC and had HIV risk behaviors in Lusaka, Zambia. Outcomes included HIV risk behaviors (e.g., risky sexual behaviors), mental health (internalizing symptoms, externalizing behaviors, PTSD) and substance use. At 12-month follow-up, there were significant within group reductions in both groups for all outcomes, with the only significant between group difference being for substance use, in which OVC who received TF-CBT had significantly greater reductions than OVC who received PC+. In a subgroup analysis of OVC with high levels of PTSD symptoms, TF-CBT was superior to PC + in reducing internalizing symptoms, functional impairment, and substance use. Findings support TF-CBT for reducing substance use among OVC. Subgroup analysis results suggest that a robust intervention such as TF-CBT is warranted for OVC with significant mental and behavioral health comorbidities. The similar performance of TF-CBT and PC + in the overall sample for risky sexual behavior and mild mental health problems indicates that enhancing existing psychosocial programs, such as PC, with standard implementation factors like having a defined training and supervision schedule (as was done to create PC+) may improve the efficacy of HIV risk reduction efforts.Clinical Trials Number: NCT02054780.

Addressing experiences of trauma within Indigenous-focused substance use residential treatment: a systematic review and environmental scan

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.

Mental Health Clinician Practices and Perspectives on Treating Adults with Co-Occurring Posttraumatic Stress and Substance Use Disorders

OBJECTIVE

Posttraumatic stress disorder (PTSD) and substance use disorders (SUD) commonly co-occur and represent a complex, challenging clinical comorbidity. Meta-analytic studies and systematic reviews suggest that trauma-focused treatments are more efficacious than non-trauma focused interventions for co-occurring PTSD/SUD. However, relatively little is known about mental health clinicians' practices or preferences for treating co-occurring PTSD/SUD. The present study aimed to describe the current clinical practices of mental health clinicians who treat PTSD and/or SUD-related conditions and to assess interest in novel integrative treatments for PTSD/SUD.

METHODS

Licensed mental health clinicians (N = 76; Mage = 39.59, SD = 8.14) who treat PTSD and/or SUD completed an anonymous online survey from April 2021 to July 2021.

RESULTS

The majority (61.8%) of clinicians reported using integrative treatments for PTSD/SUD. The most commonly used trauma-focused treatments were 1) Cognitive Processing Therapy (CPT: 71.1%) and 2) Prolonged Exposure Therapy (PE: 68.4%) for PTSD. Approximately half (51.3%) of clinicians endorsed using Relapse Prevention (RP) for SUD. The vast majority (97.4%) of clinicians were somewhat or very interested in a new integrative CPT-RP intervention, and 94.7% of clinicians believed patients would be interested in a CPT-RP intervention. In the absence of an available evidence-based integrative treatment using CPT, 84.0% of clinicians reported modifying extant treatment protocols on their own to address PTSD and SUD concurrently.

CONCLUSIONS

The findings demonstrate mental health clinician support of integrative treatments for PTSD/SUD. The most commonly used trauma-focused intervention was CPT and clinicians expressed strong interest in an integrative intervention that combines CPT and RP. Implications for future treatment development are discussed.

A Community Engaged Approach in Adapting Motivational Interviewing and Skills Training for Native Americans With Experiences of Substance Misuse

OBJECTIVE

American Indian and Alaskan Natives (AIAN) are regenerating cultural knowledge and practices to adapt westernized evidence-based interventions to address health concerns such as substance use. This study describes the process of selecting, adapting, and implementing motivational interviewing plus cognitive behavior therapy (motivational interviewing + Skills Training; MIST) for use in a combined substance use intervention with a rural, Northwest tribal community.

METHODS

An established community and academic partnership worked together to make culturally mindful changes to MIST. The partnership incorporated community leaders/Elders (n = 7), providers (n = 9), and participants (n = 50) to implement an iterative process of adapting and implementing the adapted form of MIST.

RESULTS

Key adaptations included presenting concepts grounded in tribal values, providing examples from the community perspective, and incorporating cultural customs and traditions. Overall, the MIST adaptation was favorably received by participants, and the adaptation appeared feasible.

CONCLUSIONS

Adapted MIST appeared to be an acceptable intervention for this Native American community. Future research should evaluate the interventions efficacy in reducing substance use among this and other Native American communities. Future clinical research should consider strategies outlined in this adaptation as a potential process for working with Native American communities to implement culturally appropriate interventions.

Development and feasibility testing of an integrated PTSD and adherence intervention cognitive processing therapy-life steps (CPT-L) to improve HIV outcomes: Trial protocol

Despite high rates of Post-Traumatic Stress Disorder (PTSD) in persons living with HIV (PLWH) and poor HIV-related health outcomes associated with PTSD, an effective evidence-based treatment for PTSD symptoms in PLWH does not exist. Negative reinforcement conceptual models posit that avoidant behavior (hallmark symptom of PTSD) demonstrated by PLWH with co-occurring PTSD can contribute to poor antiretroviral therapy (ART) adherence. However, research evaluating the impact of evidence-based treatment for PTSD among HIV infected populations on HIV outcomes is scarce. The Cognitive Processing Therapy (CPT) protocol is an evidence-based PTSD treatment that may address internalized stigma with targeted modifications and improve ART adherence and subsequent viral suppression through reduction of avoidant coping. This study will be the first pilot open-label randomized control trial (RCT) to test feasibility of an integrated evidence-based PTSD treatment (CPT) with an adherence intervention (Lifesteps) delivered in a Ryan White clinic to improve PTSD symptoms, adherence to ART, and retention in HIV care. Primary aims are to (1) conduct theater testing of the CPT and Lifesteps research protocol and evaluate acceptability (n = 12) and (2) deliver a modified CPT protocol (CPT-Lifesteps, or CPT-L) in 60 PLWH/PTSD exploring impact of CPT-L on PTSD symptoms and HIV outcomes compared to a Lifesteps + Standard of Care condition. This innovative research extends PTSD treatment approaches as a paradigm to reduce barriers to ART adherence. Findings of this innovative study are significant because they support the Undetectable = Untransmittable (U[bond, double bond]U) campaign and can help prevent the transmission of HIV infection through increased viral suppression.

A Systematic Review of Trauma and Substance Use in American Indian and Alaska Native Individuals: Incorporating Cultural Considerations

INTRODUCTION

Disproportionate rates of psychiatric disorders, like substance use and posttraumatic stress disorders (SUD and PTSD), exist among American Indian and Alaska Native (AI/AN) individuals. This review examines substance use and trauma in existing AI/AN literature and utilizes an AI/AN-specific model to culturally inform the relationship between these factors and provide recommendations for future research.

METHODS

We searched three databases through April 2021 for peer-reviewed articles that examined substance use and trauma in AI/AN individuals.

RESULTS

The search identified 289 articles and of those, 42 were eligible for inclusion, including 36 quantitative and 6 qualitative studies. Rates of lifetime trauma exposure varied from 21 to 98% and were correlated with increased rates of SUDs. A dose response of traumatic events also increased the likelihood of an SUD among reservation-based AI populations. Factors from the Indigenist Stress Coping model included cultural buffers such as traditional healing and cultural identity, which aided in recovery from SUD and trauma, and social stressors like boarding school attendance, discrimination, and historical loss.

CONCLUSIONS

SUD and trauma are highly correlated among AI/AN individuals though rates of PTSD are lower than might be expected suggesting resilience. However, this pattern may not be consistent across all AI/AN groups and further research is needed to better explain the existing relationship of SUD and PTSD and relevant historical and cultural factors. Further research is needed to culturally tailor, implement, and validate PTSD and SUD assessments and treatments to ameliorate these health inequities.

Modified Prolonged Exposure Therapy for Posttraumatic Stress Disorder with an 85-Year-Old Native American Cajun Man With Late-Onset Deafness: A Case Report

OBJECTIVES

Few studies of exposure therapy with adults 85 years and older exist. This case report presents results of prolonged exposure (PE) for posttraumatic stress disorder (PTSD) modified for an 85-year-old Native American Cajun man with late-onset deafness, who used a cochlear implant, and reported high Western/non-Native American acculturation. The following modifications were made primarily in response to the client's individual, disability-related barriers to completing the standard PE protocol: (a) inclusion of the client's spouse in aspects of treatment planning and homework assignments; (b) variable session length and frequency; (c) homework was limited to the daily practice of breathing retraining and in vivo exposure to triggering images; and (d) therapist reliance on nonverbal indicators of distress during imaginal exposures.

METHODS

The PTSD Checklist for DSM-5 (PCL-5) and 15-item Geriatric Depression Scale (GSD-15) were primary progress and outcome measures.

RESULTS

The modified treatment was associated with clinically significant decreases in baseline PTSD (19 points) and depressive (8 points) symptoms.

CONCLUSIONS

PE protocol modifications did not compromise treatment outcomes for this client.

CLINICAL IMPLICATIONS

PE protocols should be modified based on the individual needs of diverse older adults underrepresented in efficacy research.

Culturally tailored substance use interventions for Indigenous people of North America: a systematic review

Purpose–

The purpose of the current study is to conduct a systematic review of peer-reviewed work on culturally tailored interventions for alcohol and drug use in Indigenous adults in North America. Substance use has been reported as a health concern for many Indigenous communities. Indigenous groups experienced the highest drug overdose death rates in 2015, the largest percentage increase in the number of deaths over time from 1999 to 2015 compared to any other racial group. However, few Indigenous individuals report participating in treatment for alcohol or drug use, which may reflect the limited engagement that Indigenous groups have with treatment options that are accessible, effective and culturally integrative.

Design/methodology/approach–

Electronic searches were conducted from 2000 to April 21, 2021, using PsycINFO, Cumulative Index to Nursing and Allied Health Literature, MEDLINE and PubMed. Two reviewers classified abstracts for study inclusion, resulting in 18 studies.

Findings–

Most studies were conducted in the USA (89%). Interventions were largely implemented in Tribal/rural settings (61%), with a minority implemented in both Tribal and urban contexts (11%). Study samples ranged from 4 to 742 clients. Interventions were most often conducted in residential treatment settings (39%). Only one (6%) intervention focused on opioid use among Indigenous people. Most interventions addressed the use of both drugs and alcohol (72%), with only three (17%) interventions specifically intended to reduce alcohol use.

Originality/value–

The results of this research lend insight into the characteristics of culturally integrative treatment options for Indigenous groups and highlight the need for increased investment in research related to culturally tailored treatment across the diverse landscape of Indigenous populations.

Cognitive Processing Therapy or Relapse Prevention for comorbid Posttraumatic Stress Disorder and Alcohol Use Disorder: A randomized clinical trial

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).

Adapting narrative exposure therapy with a tribal community: A community-based approach

OBJECTIVE

American Indian (AI) individuals are at increased risk for present-day trauma exposure and associated negative outcomes, as well as ongoing effects of intergenerational trauma exposure and adversity. However, few empirically supported treatments exist that are specifically tailored and/or tested with AI communities. This study describes the process of selecting, adapting, and implementing narrative exposure therapy (NET) with an AI community.

METHODS

A community and academic partnership was formed and worked together to make culturally mindful changes to NET to best fit the needs of the community. The partnership incorporated community leaders/Elders (n = 7), providers (n = 11), and participants seeking treatment (n = 50) to implement an iterative process of adapting and implementing the adapted form of NET.

RESULTS

Key adaptions included addressing historical and intergenerational trauma, greater protections for confidentiality in a small community, and incorporation of cultural customs and traditions. Overall, the adapted form of NET was favorably received by the participants, and the implementation appeared to be feasible, with improved retention over past trials of adapted trauma-focused treatments with this community and with highly positive satisfaction ratings and feedback.

CONCLUSIONS

NET was shown to be an appropriate approach for this AI community and should be considered as a treatment option for other AI communities. Future work should consider strategies outlined in this adaption as well as following a similar process for working with AI communities to implement culturally appropriate interventions for trauma-related symptoms.

Systematic review of Indigenous involvement and content in mental health interventions and their effectiveness for Indigenous populations

OBJECTIVE

To assess the effects of psychological, psychosocial, educational and alternative interventions on mental health outcomes of Indigenous adult populations in Australia, Canada, New Zealand and the United States and the Indigenous involvement and content in each study.

METHODS

We systematically searched databases, key journals and gray literature, for records until June 2020. Eligible studies were in English or French and examined the impact of interventions on mental health outcomes including anxiety disorders, posttraumatic stress disorder, depression, psychological distress or stress for Indigenous adults (⩾16 years). Data were extracted using a modified Cochrane Data Extraction Form and the Template for Intervention Description and Replication. Quality was evaluated using the Effective Public Health Practice Project quality assessment form.

RESULTS

In total, 21 studies were eligible, comprising 8 randomized controlled trials, 10 single-group pre-post studies and 3 pre-post studies with comparison groups. Twenty studies had Indigenous individuals or organizations involved in some decision-making capacity, though extent of involvement varied widely. In total, 9 studies were rated moderate and 12 weak in the Effective Public Health Practice Project quality assessment. Eight studies measuring depression, three measuring posttraumatic stress disorder, three measuring psychological distress and two measuring stress showed statistically significant improvements following the intervention.

CONCLUSION

A wide range of interventions demonstrated mental health improvements. However, it is difficult to draw generalizable conclusions on intervention effectiveness, given heterogeneity among studies. Studies should employ a thorough assessment of the Indigenous involvement and content of their interventions for reporting and for critical consideration of the implications of their research and whether they address Indigenous determinants of mental health.

A participant-randomized pilot hybrid II trial of group cognitive processing therapy for incarcerated persons with posttraumatic stress and substance use disorder symptoms: study protocol and rationale

BACKGROUND

Trauma exposure and drug addiction go hand-in-hand for the 2.17 million people who are incarcerated in US prisons; prevalence of both exceed 80% among this population. This manuscript describes the rationale and methods for a participant-randomized effectiveness-implementation hybrid type II pilot trial designed to: 1) examine the effectiveness of Cognitive Processing Therapy group (CPT), an evidence-based psychotherapy for posttraumatic stress disorder (PTSD), for reducing post-release drug use and PTSD symptoms when adapted for and delivered in prisons; and 2) provide data on implementation outcomes associated with the use of implementation facilitation as a strategy for supporting uptake of CPT in prisons.

METHOD

Participants in the effectiveness portion of the trial (N = 120) will be incarcerated men and women who are randomly assigned to one of two group therapies: CPT or a control condition (PTSD coping skills group; PCS). Participants will complete assessment measures three times: pre-treatment, post-treatment, and 3 months following release from incarceration. CPT groups will be led by prison counselors who are receiving implementation facilitation to support their efforts. PCS groups will be led by trained clinicians on the research team. Implementation outcomes will include acceptability, appropriateness, adoption, feasibility, fidelity, and sustainability. After enrollment ends, the research team will monitor CPT sustainment and recidivism outcomes of study participants for one year.

DISCUSSION

This study will lay the groundwork for a larger study of interventions for co-occurring PTSD and SUD in prisons and, critically, inform the development of strategies (such as implementation facilitation) for supporting their uptake in routine practice.

TRIAL REGISTRATION

NCT04007666 , clinicaltrials.gov, 24 June 2019, 02 September 2021.

The Health Effects of a Cherokee Grounded Culture and Leadership Program

Introduction: Indigenous youth and young adults endure some of the highest rates of physical and mental health problems in the United States compared to their non-Indigenous counterparts. Colonization, oppression, and discrimination play a substantial role in these inequitable disease rates. However, culture (e.g., identity, participation, and connection) relates to the prevention of and recovery from illness in Indigenous populations. The Remember the Removal program aims to teach Indigenous youth and young adults tribally specific culture, history, and language to put them on a trajectory to become informed and culturally connected community leaders. We examined the program’s effects on health. Method: Thirty Remember the Removal program participants, mainly young adults, completed surveys four times: before the program’s start, at the end of the training period, at the program’s end, and at a six-month follow-up. Various indicators of physical, mental, spiritual, and cultural health and well-being were measured at each time period. Paired t-tests were completed to compare baseline scores to each subsequent time interval. Results: At program completion, and as indicated with an asterisk at the six month follow-up, participants had statistically significantly improved diet and exercise measures (e.g., reduced sugary, salty, and fatty foods, reduced soda consumption, increased fruit consumption, and improved self-efficacy for exercise), improved mental health indicators (e.g., reduced stress, anxiety, depression*, anger*, post-traumatic stress disorder, and microaggressions*, and improved positive mental health) and improved social and cultural connection (e.g., social support, Cherokee identity*, Cherokee values). Discussion: This is one of the first quantitative studies to demonstrate the profound effects that cultural learning and connection have on the health and well-being of Indigenous people and practices. It also demonstrates the specificity and effectiveness of a program created by and for tribal citizens. Future programs with Indigenous populations should work to center cultural connection and ensure that programs are created and directed by tribal community members.

IAPT CBT treatment for PTSD following COVID-19-related intensive care admission – a case study

The current case study was conducted as part of the National Health Services and Health Education England implemented IAPT top-up training in trauma-focused cognitive therapy for post-traumatic stress disorder (PTSD). There has been an increase in the number of clients presenting to IAPT with COVID-19 intensive care unit PTSD since the pandemic. However, there are no current unitary guidelines for psychological therapy for this population. Treatment of PTSD using individual trauma-focused cognitive therapy has been shown to be effective for ICU-PTSD. The National Institute for Health and Care Excellence treatment guidelines recommend adapting existing protocols. This study describes how these recommendations were used in the treatment of COVID-19 ICU-PTSD in a 46-year-old male. It illustrates the use of trauma-focused cognitive therapy for PTSD and how ICU trauma memories including hallucinations were conceptualised. It also illustrates how the challenges of co-morbid panic attacks, long COVID and remote working were managed. The client attended 16 individual, 60- to 90-minute video sessions of trauma-focused cognitive therapy, conducted weekly via Microsoft Teams over a period of five months. The treatment plan was conducted in collaboration with the client’s general practitioner, physiotherapists, cardiopulmonary specialists, and his family. Treatment included a timeline, written narrative and imaginal reliving. It also applied stimulus discrimination, behavioural experiments and site visit. At the end of treatment, the client no longer showed clinically important symptoms of PTSD as assessed on the PCL-5 and interview. This was sustained at 3-month follow-up.

Key learning aims.

It is hoped that the reader will increase their understanding of the following: (1)

Psychosocial Interventions for Alcohol and/or Drug Misuse and Use Disorders in Women: A Systematic Review

Background: Although men and women who misuse substances have different needs, no rigorous systematic literature review has been conducted examining psychosocial substance use interventions for women across a broad range of types of therapeutic approaches and populations. Materials and Methods: PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines were used to guide this review. English language, peer-reviewed research articles indexed in PubMed, PsycINFO, CINAHL Complete, and Web of Science through May 6, 2021, were searched. Peer-reviewed articles were included in the review if they were written in English; described a randomized controlled trial of a psychosocial intervention to reduce substance misuse and related problems in women; and reported quantitative data on alcohol or illicit drug use as an outcome that was linked to the interventions. Results: A total of 51 articles met eligibility criteria, reflecting a broad array of interventions with different levels of methodological rigor. Several, but not most, interventions were tailored to meet the needs of specific subgroups of women, but evidence regarding the efficacy of tailoring was inconclusive. Overall, 61% of studies reported one or more positive substance-related intervention effects, with target substance (alcohol only vs. other drugs only or both alcohol and other drugs) and intervention dosage associated with intervention success. Conclusions: Fewer studies targeting alcohol only reported one or more positive intervention outcomes. This warrants further study, given that polysubstance use is the norm, not the exception. Future research might also focus on reducing treatment barriers to women, as this has the potential to improve overall treatment outcomes for this population.

Trauma-informed Approaches to Substance Use Interventions with Indigenous Peoples: A Scoping Review

Indigenous Peoples experience disproportionately higher rates of problematic substance use. These problems are situated in a context of individual and intergenerational trauma from colonization, residential schools, and racist and discriminatory practices, policies, and services. Therefore, substance use interventions need to adopt a trauma-informed approach. We aimed to synthesize and report the current literature exploring the intersection of trauma and substance use interventions for Indigenous Peoples. Fourteen databases were searched using keywords for Indigenous Peoples, trauma, and substance use. Of the 1373 sources identified, 117 met inclusion criteria. Literature on trauma and substance use with Indigenous Peoples has increased in the last 5 years (2012-2016, n = 29; 2017-2021, n = 48), with most literature coming from the United States and Canada and focusing on historical or intergenerational trauma. Few articles focused on intersectional identities such as 2SLGBTQIA+ (n = 4), and none focused on veterans. There were limited sources (n = 25) that reported specific interventions at the intersection of trauma and substance use. These sources advocate for multi-faceted, trauma-informed, and culturally safe interventions for use with Indigenous Peoples. This scoping review illuminates gaps in the literature and highlights a need for research reporting on trauma-informed interventions for substance use with Indigenous Peoples.

Culturally adapted evidence-based treatments for adults with substance use problems: A systematic review and meta-analysis

BACKGROUND

This systematic review/meta-analysis aimed to synthesize empirical evidence from randomized controlled trials on the efficacy of culturally adapted interventions (CAIs) for substance use and related consequences for adults of color.

METHODS

Six electronic databases were searched to identify eligible studies. Two reviewers independently screened studies, extracted data, and assessed risks of bias. We used robust variance estimation in meta-regression to synthesize effect size estimates and conduct moderator analyses.

RESULTS

Twenty-two studies met the inclusion criteria and were included in the review. The overall effect size was 0.23 (95 % Confidence Interval [CI] = 0.12, 0.35). The subgroup effect sizes for comparing CAIs with inactive controls and with active controls were 0.31 (CI = 0.14, 0.48) and 0.14 (CI=-0.02, 0.29), respectively. The effect sizes for alcohol use, illicit drug use, unspecified substance use outcomes, and substance use related consequences were 0.25 (CI = 0.08, 0.43), 0.35 (CI =-0.30, 1.00), 0.22 (CI=-0.17, 0.62), and 0.02 (CI=-0.11, 0.16), respectively. Moderator analysis showed that CAIs' effects might not vary significantly by treatment model, dose, country, follow-up assessment timing, participant age, or gender/sex.

CONCLUSIONS

Research on substance use interventions that are culturally adapted for people of color is growing, and more high-quality studies are needed to draw definitive conclusions about CAIs' treatment effects. Our study found CAIs to be a promising approach for reducing substance use and related consequences. We call for more efficacy/effectiveness and implementation research to further advance the development and testing of evidence-based CAIs that meet the unique needs and sociocultural preferences of diverse populations.

Intervening for HIV prevention and mental health: a review of global literature

INTRODUCTION

Numerous effective HIV prevention options exist, including behaviour change interventions, condom promotion and biomedical interventions, like voluntary medical male circumcision and pre-exposure prophylaxis. However, populations at risk of HIV also face overlapping vulnerabilities to common mental disorders and severe mental illness. Mental health status can affect engagement in HIV risk behaviours and HIV prevention programmes. We conducted a narrative review of the literature on HIV prevention among key populations and other groups vulnerable to HIV infection to understand the relationship between mental health conditions and HIV prevention outcomes and summarize existing evidence on integrated approaches to HIV prevention and mental healthcare.

METHODS

We searched five databases for studies published from January 2015 to August 2020, focused on HIV prevention and mental health conditions among key populations and individuals with serious mental illness. Studies were included if they evaluated an HIV prevention intervention or assessed correlates of HIV risk reduction and included assessment of mental health conditions or a mental health intervention.

RESULTS AND DISCUSSION

We identified 50 studies meeting our inclusion criteria, of which 26 were randomized controlled trials or other experimental designs of an HIV prevention intervention with or without a mental health component. Behaviour change interventions were the most common HIV prevention approach. A majority of studies recruited men who have sex with men and adolescents. Two studies provided distinct approaches to integrated HIV prevention and mental health service delivery. Overall, a majority of included studies showed that symptoms of mental disorder or distress are associated with HIV prevention outcomes (e.g. increased risky sexual behaviour, poor engagement in HIV prevention behaviours). In addition, several studies conducted among groups at high risk of poor mental health found that integrating a mental health component into a behaviour change intervention or linking mental health services to combination prevention activities significantly reduced risk behaviour and mental distress and improved access to mental healthcare.

CONCLUSIONS

Evidence suggests that mental health conditions are associated with poorer HIV prevention outcomes, and tailored integrated approaches are urgently needed to address overlapping vulnerabilities among key populations and other individuals at risk.

"There Is a Lot of Practice in Not Thinking about That": Structural, Interpersonal, and Individual-Level Barriers to HIV/STI Prevention among Reservation Based American Indians

American Indians (AI) face significant disparities in HIV/STI morbidity and mortality, and historical, structural, interpersonal, and individual level barriers stymie prevention efforts. The objective of this paper is to examine barriers to HIV/STI prevention among reservation-based AI. We conducted face-to-face qualitative interviews with 17 reservation-based AI community leaders and community members in Southern California on HIV/STI knowledge and attitudes and barriers to prevention. The disruption of traditional coping mechanisms and healing processes were compromised by historical trauma, and this allowed stigmas to exist where they did not exist before. This impacted access to healthcare services and trust in medicine, and is linked to individuals adopting negative coping behaviors that confer risk for HIV/STI transmission (e.g., substance use and sexual behaviors). Most of the participants reported that HIV/STIs were not discussed in their reservation-based communities, and many participants had a misperception of transmission risk. Stigma was also linked to a lack of knowledge and awareness of HIV/STI's. Limited available services, remoteness of communities, perceived lack of privacy, and low cultural competency among providers further hindered the access and use of HIV/STI prevention services. These findings highlight the need to address the historical, structural, and interpersonal factors impacting individual-level behaviors that can increase HIV/STI transmission among reservation-based AIs. Prevention work should build on community strengths to increase HIV/STI knowledge, reduce stigma, and increase access to preventative care while using culturally grounded methodologies.

A randomized comparison trial of culturally adapted HIV prevention approaches for Native Americans reducing trauma symptoms versus substance misuse: The Healing Seasons protocol

Native Americans (NA) experience interrelated risks of trauma exposure, substance use, and HIV risk behaviors that put them at increased risk for HIV infection. Despite these known risk factors, there are very few published randomized trials testing interventions to reduce trauma-related symptoms and substance misuse among NA.

METHODS

The Healing Seasons study is a randomized comparsion trial of two counseling strategies, Narrative Exposure Therapy (NET) addressing PTSD or Motivational interviewing with cognitive behavioral therapy skills training (MIST) addressing substance misuse as a means to prevent HIV among NA. Using a community-based participatory research approach, we adapted both evidence-based interventions to be specific to the risk contexts and realities of NA and to include psychoeducational and skill-building components that include cultural-specific stories, virtues, and traditional treatment strategies. Participants, 16 years and older, were recruited from a Pacific Northwest tribal community, screened over the phone, enrolled in person, and randomized in equal numbers to NET or MIST. We stratified by age (16-29 years and 30 or older) and gender (male or female identified) to ensure balance between treatment arms. The primary outcomes were number of sex partners and frequency of sexual acts (with and without condoms), sex under the influence of substances, frequency of substance use, and PTSD severity.

DISCUSSION

Behavioral interventions for NA are needed to prevent HIV risk behaviors when faced with trauma symptoms and substance misuse. This study will provide evidence to determine feasibility and efficacy of addressing related risk factors as part of counseling-based HIV prevention intervention to reduce sexual risk among this population.

TRIAL REGISTRATION

ClinicalTrials.gov number, NCT03112369, registered April 12, 2017.

Global estimate of the prevalence of post-traumatic stress disorder among adults living with HIV: a systematic review and meta-analysis

OBJECTIVES

Although people living with HIV (PLWH) have been disproportionately affected by post-traumatic stress disorder (PTSD), the global prevalence of PTSD among PLWH is unknown. This study aimed to systematically review the prevalence of PTSD among PLWH worldwide and explore variation in prevalence across sociodemographic and methodological factors.

DESIGN

A meta-analysis using a random-effects model was conducted to pool the prevalence estimated from individual studies, and subgroup analyses were used to analyse heterogeneities.

SETTING, PARTICIPANTS AND MEASURES

Observational studies providing PTSD prevalence data in an adult HIV population were searched from January 2000 to November 2019. Measurements were not restricted, although the definition of PTSD had to align with the Diagnostic and Statistical Manual of Mental Disorders or the International Classification of Diseases diagnostic criteria.

RESULTS

A total of 38 articles were included among 2406 records identified initially. The estimated global prevalence of PTSD in PLWH was 28% (95% CI 24% to 33%). Significant heterogeneity was detected in the proportion of PLWH who reported PTSD across studies, which was partially explained by geographic area, population group, measurement and sampling method (p<0.05).

CONCLUSION

PTSD among PLWH is common worldwide. This review highlights that PTSD should be routinely screened for and that more effective prevention strategies and treatment packages targeting PTSD are needed in PLWH.