A cognitive behavioral therapy for co-occurring substance use and posttraumatic stress disorders

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).

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Examining Internalizing Mental Health Correlates of Addiction Severity in Patients Hospitalized With Medical Complications From Substance Use Disorder

Background:

Comorbidities between Substance Use Disorder (SUD) and mental health disorders are highly prevalent, yet there remains a lack of information regarding how mental health conditions may affect addiction severity. Consequently, this study sought to investigate the relationship between internalizing disorders (anxiety and mood disorders) and addiction severity in patients hospitalized for SUD-related medical complications. Individual difference predictors and history of prior treatment for SUD were also examined.

Methods:

Participants (N = 200) were hospitalized patients who consented to receive peer-based recovery support services for their SUD. To be eligible for the study, participants needed to have a SUD diagnosis due to alcohol, opioids, methamphetamine, cocaine, or a combination of these substances (polysubstance use). Participants completed self-report questionnaires regarding demographics, mental health history, prior SUD treatment, and addiction severity (Drug and Alcohol Screening Test; DAST-10) during their hospitalization.

Results:

Results showed that patients with Generalized Anxiety Disorder (GAD) (M = 6.68, SD = 2.97) had greater addiction severity compared to those without GAD (M = 5.41, SD = 3.34), P = .016. Addiction severity results stratified by SUD type showed that the relationship was significant among patients with Alcohol Use Disorder (P = .014), but not among those with other SUD types (Ps > .27). Major Depressive Disorder (MDD) and Post-Traumatic Stress Disorder (PTSD) were not linked to addiction severity. Among those with GAD, 81.4% had previously been to treatment compared to only 53.1% of those without GAD, P = .010. The only participant characteristic linked with addiction severity was insurance status.

Conclusions:

GAD may represent a risk factor for advanced alcohol addiction trajectories, including greater addiction severity and severe health complications requiring inpatient hospitalization.

What's in a name? A data-driven method to identify optimal psychotherapy classifications to advance treatment research on co-occurring PTSD and substance use disorders

Background/Objective

The present study leveraged the expertise of an international group of posttraumatic stress and substance use disorder (PTSD+SUD) intervention researchers to identify which methods of categorizing interventions which target SUD, PTSD, or PTSD+SUD for populations with both PTSD+SUD may be optimal for advancing future systematic reviews, meta-analyses, and comparative effectiveness studies which strive to compare effects across a broad variety of psychotherapy types.

Method

A two-step process was used to evaluate the categorization terminology. First, we searched the literature for pre-existing categories of PTSD+SUD interventions from PTSD+SUD clinical trials, systematic and literature reviews. Then, we surveyed international trauma and substance use subject matter experts about their opinions on pre-existing intervention categorization and ideal categorization nomenclature.

Results

Mixed method analyses revealed that a proliferation of PTSD+SUD treatment research over the last twenty years brought with it an abundance of ways to characterize the treatments that have been evaluated. Results from our survey of experts (N = 27) revealed that interventions for PTSD+SUD can be classified in many ways that appear to overlap highly with one another. Many experts (11/27; 41%) selected the categories of 'trauma-focused and non-trauma focused' as an optimal way to distinguish treatment types. Although several experts reinforced this point during the subsequent meeting, it became clear that no method of categorizing treatments is without flaws.

Conclusion

One possible categorization (trauma-focused/non-trauma focused) was identified. Revised language and nomenclature for classification of PTSD+SUD treatments are needed in order to accommodate the needs of this advancing field.

The Nature, Timing, and Symptom Trajectories of Dropout From Transdiagnostic and Single-Diagnosis Cognitive-Behavioral Therapy for Anxiety Disorders

Dropout from psychotherapy is common and can have negative effects for patients, providers, and researchers. A better understanding of when and why patients stop treatment early, as well as actionable factors contributing to dropout, has the potential to prevent it. Here, we examined dropout from a large randomized controlled trial of transdiagnostic versus single-diagnosis cognitive-behavioral treatment (CBT) for patients with anxiety disorders (n = 179; Barlow et al., 2017). We aimed to characterize the timing of and reasons for dropout and test whether participants who dropped out had different symptom trajectories than those who completed treatment. Results indicated that overall, the greatest risk of dropout was prior to the first treatment session. In single-diagnosis CBT, dropout risk was particularly elevated before the first session and after other early sessions, whereas in transdiagnostic CBT, dropout risk was low and stable before and during treatment. Participants most often dropped out due to failure to comply with study procedures or dissatisfaction with or desiring alternative treatment. Results from multilevel models showed that trajectories of anxiety symptoms did not significantly differ between dropouts and completers. These findings suggest that there may be specific time windows for targeted and timely interventions to prevent dropout from CBT.

Is disinvestment from alcohol and drug treatment services associated with treatment access, completions and related harm? An analysis of English expenditure and outcomes data

INTRODUCTION

The positive impact of substance use treatment is well-evidenced but there has been substantial disinvestment from publicly funded treatment services in England since 2013/2014. This paper examines whether this disinvestment from adult alcohol and drug treatment provision was associated with changes in treatment and health outcomes, including: treatment access, successful completions from treatment, alcohol-specific hospital admissions, alcohol-specific mortality and drug-related deaths.

METHODS

Annual administrative data from 2013/2014 to 2018/2019 was matched at local government level and multi-level time series analysis using linear mixed-effect modelling conducted for 151 upper-tier local authorities in England.

RESULTS

Between 2013/2014 and 2018/2019, £212.2 million was disinvested from alcohol and drug treatment services, representing a 27% decrease. Concurrently, 11% fewer people accessed, and 21% fewer successfully completed, treatment. On average, controlling for other potential explanatory factors, a £10 000 disinvestment from alcohol and drug treatment services was associated with reductions in all treatment outcomes, including 0.3 fewer adults in treatment (95% confidence interval 0.16-0.45) and 0.21 fewer adults successfully completing treatment (95% % confidence interval 0.12-0.29). A £10 000 disinvestment from alcohol treatment was not significantly associated with changes in alcohol-specific hospital admissions or mortality, nor was disinvestment from drug treatment associated with the rate of drug-related deaths.

DISCUSSION AND CONCLUSIONS

Local authority spending cuts to alcohol and drug treatment services in England were associated with fewer people accessing and successfully completing alcohol and drug treatment but were not associated with changes in related hospital admissions and deaths.

Music Therapy to Regulate Arousal and Attention in Patients With Substance Use Disorder and Posttraumatic Stress Disorder: A Feasibility Study

Patients diagnosed with both substance use disorder (SUD) and posttraumatic stress disorder (PTSD) often experience hypervigilance, increased fear, and difficulties regulating emotions. This dual diagnosis increases treatment complexity. Recently, a short-term music therapy intervention for arousal and attention regulation (the SMAART intervention) was designed based on neurobiological findings. Twelve patients with SUD and PTSD (50% females) in outpatient treatment participated in six weekly one-hour sessions of the SMAART intervention. Six patients completed the study. PTSD symptom severity was evaluated with the Posttraumatic Stress Disorder Symptom Scale Interview for DSM-5 (PSSI-5) pre- and post-intervention, and sustained attention was evaluated with the Bourdon-Wiersma (BW) test. A significant difference in measurements for the PSSI-5 overall symptom severity was found pre- and post-intervention. Furthermore, participants showed significant improvement on subscales of hyperarousal, mood and cognition, and attention. The BW test completion time decreased significantly. Two participants dropped out before the end of the intervention due to craving. Concerning future research, it is recommended to define the role of the music more explicitly and to change the design to a randomized controlled trial. A risk for future larger studies is a high dropout rate (50%). Several limitations of the study are discussed.

Adverse Childhood Experiences Increase Risk for Prescription Opioid Misuse

The United States is in the midst of an opioid overdose epidemic, with a significant portion of the burden associated with prescription opioids. In response, the CDC released a Guideline for Prescribing Opioids for Chronic Pain, which promotes access to treatment for opioid use disorder. Decades of research have linked childhood adversity to negative health and risk behavior outcomes, including substance misuse. Our present study builds upon this work to examine the relationship between adverse childhood experiences (ACEs) and prescription opioid misuse. We compiled data from the Behavioral Risk Factor Surveillance System implemented by Montana and Florida in 2010 and 2011, respectively. Logistic regressions (run in 2017) tested the associations between ACEs and subsequent prescription pain medicine/opioid misuse outcomes in adulthood. ACEs were prevalent, with 62.7% of respondents in Montana and 50% in Florida reporting at least one ACE. The presence of ACEs was positively associated with prescription opioid misuse across both samples. Respondents reporting three or more ACEs had increased odds of taking opioids more than prescribed, without a prescription, and for the feeling they cause. Our results support a strong link between ACEs and prescription opioid misuse. Opportunities to prevent opioid misuse start with assuring safe, stable, nurturing relationships and environments in childhood and across the lifespan to prevent ACEs from occurring, and intervening appropriately when they do occur. Substance use prevention programs for adolescents, appropriate pain management and opioid prescribing protocols, and treatments for opioid use disorder can address ACEs by enhancing treatment safety and effectiveness and can reduce the intergenerational continuity of early adversity.

Denial of Alcohol Treatment Need among Baby Boomers across Time: Implications for Social Work

As baby boomers continue to enter older adulthood in the coming decades, research suggests that this cohort is expected to exhibit changes in alcohol usage and treatment need patterns compared to previous older-adult cohorts. The literature suggests that unmet alcohol treatment need may be related to denial of treatment need among baby boomers who possess a diagnosable alcohol-use disorder (AUD). Therefore, this study explores potential risk and protective factors predicting alcohol-use among baby boomers who d\eny treatment need at two time periods. Data was obtained from the National Survey of Drug and Health (NSDUH). Variable selection procedures were performed at each time period, resulting in two predictive models for baby boomers who denied alcohol treatment need when treatment was indicated by a concurrent diagnosable alcohol-use disorder. The primary findings suggest that generalized, nonspecific alcohol treatment may be ineffective for treating AUD baby boomers who deny alcohol treatment need. Rather, as baby boomers continue to enter older adulthood, individualized specialty treatments may be needed in order to provide effective alcohol treatment for this unprecedentedly large birth cohort.

A meta-analysis of the effect of substance use interventions on emotion outcomes

OBJECTIVE

Emotional distress has been posited as a key underlying mechanism in the development and maintenance of substance use disorder (SUD), and patients seeking SUD treatment are often experiencing high levels of negative emotion and/or low levels of positive emotion. But the extent to which SUD interventions impact emotional outcomes among general SUD populations is yet unquantified. The current meta-analysis aims to fill this gap.

METHOD

A total of 11,754 records were screened for randomized, controlled trials examining the effect of behavioral SUD interventions on emotion outcomes. Our search yielded a total of 138 effect sizes calculated based on data from 5,146 individuals enrolled in 30 independent clinical trials. Random-effects meta-analysis was used to calculate pooled effect sizes, and metaregression analyses examined study-level moderators (e.g., intervention type).

RESULTS

Findings indicated a small but significant effect of SUD interventions on emotion outcomes, d = 0.157, 95% CI [0.052, 0.262] (k = 30). The effect size for negative emotion was nominally bigger, d = 0.162, 95% CI [0.056, 0.269] (k = 30), whereas the effect for positive emotion did not reach statistical significance, d = 0.062, 95% CI [-0.089, 0.213] (k = 7). Studies featuring SUD interventions designed to specifically target emotions (i.e., affect-regulation, mindfulness-based treatments) produced larger reductions in negative emotion compared with studies featuring interventions that did not contain specific emotion modules (e.g., contingency management).

CONCLUSIONS

Findings suggest that SUD interventions-especially mindfulness-based and affect-regulation treatments-indeed significantly reduce negative emotion, although relatively small effect sizes indicate potential room for improvement. Conclusions regarding positive emotion should be considered preliminary because of the limited numbers of samples assessing these outcomes. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Predictors of Adherence to Treatment in Behavioral Health Therapy for Latino Immigrants: The Importance of Trust

A complex array of barriers to care influence patients' adherence to behavioral healthcare services. Understanding barriers to care is critical to ensure sufficient dosage of treatment. This study assessed the influence of perceived barriers on Latino migrants' prospective adherence to treatment for co-occurring mental health and substance use disorders as part of a clinical trial. Eligible participants (18-70 years-old) were recruited from community-based settings and classified according to their intervention session attendance. Baseline assessments included socio-demographic factors, clinical characteristics (i.e., depression, anxiety, post-traumatic stress disorder, substance use), psychosocial and cultural factors (i.e., ethnic identity, health literacy, discrimination), and perceived attitudinal and structural barriers to care. Treatment involved 10-sessions of cognitive-behavioral therapy, psychoeducation, and mindfulness (Integrated Intervention for Dual problems and Early Action) and emphasized participant's engagement in treatment. We used multinomial logistic regression models to examine the association between barriers to care reported at baseline, sociodemographic characteristics, psychosocial and cultural factors, clinical factors, and treatment adherence. Mistrust in previous behavioral health treatment(s) was the reported barrier significantly associated with completion of the program after adjusting for clinical, psychosocial, and cultural factors, with those expressing mistrust in previous treatment(s) showing higher rates of completion compared to those who did not report this barrier. Evidence-based and culturally-tailored interventions provided by ethnically matched providers may overcome cultural mistrust and increase adherence to behavioral health care among Latino immigrants.

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

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

A Cross-Sectional and Longitudinal Study of the Effects of a Mindfulness Meditation Mobile Application Platform on Reducing Stress and Anxiety

Introduction

The development of many lifestyle-related chronic disorders occurs as a result of stress and anxiety. In recent years, in order to overcome lifestyle-related problems, people are increasingly making use of mindfulness meditation mobile applications despite the fact that there is no substantial evidence that this practice has benefits for their health.

Aim

Testing the effectiveness of this method in reducing stress and anxiety through the development of a mindfulness meditation mobile application was the aim of this project.

Methodology

Two independent studies were conducted. For both the studies, IBM SPSS Statistics 23.0 software was used to perform the statistical analysis. The first study was conducted cross-sectionally between 111 meditators and 111 non-meditators. The use of Depression, Anxiety, Stress Scale (DASS) was employed in assessing the stress and anxiety. It was found out that stress (P < 0.000) and anxiety (P < 0.000) are significantly reduced for meditators in comparison with the non-meditators. A substantial reduction was observed using the cross-sectional study, and a longitudinal study was carried out to affirm the effectiveness of this method in reducing stress and anxiety. 67 users were shortlisted for the study and their stress and anxiety level was measured before and after practicing mindfulness meditation.

Result

The result revealed that there was a substantial reduction in stress (P = 0.01) and anxiety (P = 0.02).

Conclusion

Therefore, mindfulness meditation mobile application can serve as another medium of delivery in addressing the problems of stress and anxiety. However, future research is warranted to determine the biological effects of mindfulness meditation.

Age-Specific Associations Between Violence Exposure and Past 30-Day Marijuana and Alcohol Use

Using data from a cohort study of students at risk for high school dropout, we examined associations between violence exposure and past 30-day alcohol and marijuana use. We used varying-coefficient regression with person-level fixed effects to estimate how those associations changed within-person across ages approximately 14-23. Generally, violence perpetration was most strongly associated with substance use, within-person. Substance use became increasingly associated with both observed violence and violence perpetration during early/middle adolescence; this increase continued longer into development (age 18+) for alcohol use. Across most of the age range studied here, violence victimization was minimally associated with within-person changes in substance use. Results indicate age-specific associations between violence exposure and alcohol and other drug use, which may be useful for informing prevention strategies.

Psychiatric and Substance Use Comorbidity in Treatment-Seeking Injection Opioid Users Referred From Syringe Exchange

OBJECTIVE

The present study evaluated rates of co-occurring current psychiatric and substance use disorders in a sample of opioid-dependent treatment-seeking injection drug users referred from syringe exchange.

METHODS

Participants (N = 208) completed the Structured Clinical Interview for the Diagnostic and Statistical Manual of Mental Disorders (DSM) IV-R to assess current (within the past year) psychiatric and substance use disorders and the two most commonly diagnosed personality disorders (antisocial and borderline personality disorders).

RESULTS

Forty-eight percent of the sample had a current Axis I psychiatric disorder, and 67% had a co-occurring current substance use disorder. Posttraumatic stress disorder (21%), major depression (17%), and bipolar I (12%) were the most prevalent Axis I psychiatric disorders, and cocaine use disorder (53%) was the most commonly co-occurring substance use disorder. Women were more likely to have diagnoses of most anxiety disorders and less likely to have diagnoses of alcohol use disorder or antisocial personality disorder. The presence of a personality disorder was associated with higher rates of cocaine and sedative use disorder.

CONCLUSIONS

Findings suggest the importance of evaluating and treating co-occurring psychiatric and substance use disorders in the treatment of injection drug users with opioid dependence.

A Randomized Controlled Trial for Veterans with PTSD and Substance Use Disorder: Creating Change versus Seeking Safety

BACKGROUND

Posttraumatic stress disorder (PTSD) and substance use disorder (SUD) co-occur in military veterans and other populations.

OBJECTIVE

To conduct a randomized controlled trial to compare a new past-focused treatment (Creating Change; CC), to a well-established, evidence-based present-focused treatment for PTSD/SUD (Seeking Safety; SS), on symptoms of both disorders. CC guides patients to process the past through exploration of PTSD/SUD life themes and memories whereas SS focuses on coping skills in the present.

METHODS

Fifty-two male and female veterans with current PTSD/SUD were randomized (n = 26 per treatment) and assessed at baseline, end-of-treatment and 3-month follow-up. They received 17 individual one-hour sessions.

RESULTS

Intent-to-treat analyses indicated that both conditions improved over time, with no difference between conditions, on PTSD, alcohol use, and drug use (our primary outcomes) as well as mental health symptoms, quality of life, self-efficacy, and SUD cognitions. Effect sizes were medium except for alcohol use, which was large. Change over time reflected improvement from baseline to end-of-treatment, with gains sustained at follow-up, although alcohol use showed continued improvement from end-of-treatment to follow-up. Both treatments evidenced a strong safety profile; and attendance, alliance, and treatment satisfaction were also very strong. Conclusions/importance: CC has promise as a PTSD/SUD therapy with strong public health relevance and the potential to fill important gaps in the field. We used minimal exclusionary criteria to obtain a real-world sample, which was severe-predominantly substance-dependent with chronic PTSD and additional psychiatric diagnoses. Future research is warranted, especially on nonveteran samples and treatment mechanisms of action.

Importance of Behavioral Therapy in Patients Hospitalized for Post-Traumatic Stress Disorder (PTSD) with Opioid Use Disorder

Objective: To analyze differences in demographic pattern and hospitalization outcomes in post-traumatic stress disorder (PTSD) with opioid use disorder (OUD) patients managed with versus without behavioral therapy (BT). Methods: We conducted case-control study using Nationwide Inpatient Sample and identified PTSD and OUD using ICD–9–CM codes. Linear regression model was used to evaluate impact of BT on inpatient stay and cost. Results: We analyzed 1531 inpatient admissions and 786 patients received BT. Females had higher odds of receiving BT during inpatient management for PTSD with OUD (OR 1.210; 95% CI 1.020–1.436). About 63.1% patients receiving BT were benefited by Medicaid. Patients receiving BT had an increase in hospital stay by 1.27 days (P = 0.085) and hospitalization cost by $4734 (P = 0.018). There were no transfers to short term hospitals and lower transfers to skilled nursing facility (3.8% vs. 10.1%) in patients receiving BT. Conclusion: This study aims to reinforce combination management with psychotropic medications and BT in PTSD patients with comorbid OUD during hospitalization as it significantly decreases adverse disposition of the patient and thereby improves the quality of life post-treatment.

Alcohol, cannabis, and other drug use: Engagement and outcome in PTSD treatment

The co-occurrence of posttraumatic stress disorder (PTSD) and substance use is related to poorer outcome and increased dropout from trauma-focused treatment. Investigating PTSD and substance use can inform the intervention approaches. Exploring cannabis use in particular is especially important because rates of cannabis use have been increasing with recent legalization trends. A better understanding of how substance use is associated with treatment processes and outcome for individuals with PTSD is needed to enhance care. In this study, both lifetime diagnoses of alcohol and drug use disorders and current alcohol and drug use severity were examined in 200 men and women with chronic PTSD who received either prolonged exposure (PE) or sertraline. No lifetime or current alcohol use variables predicted dropout, adherence, or poorer outcome. However, lifetime diagnosis of both an alcohol and drug disorder (OR = 3.42) and recent cannabis use (OR = 3.38) strongly predicted higher dropout. Recent cannabis use and drug use severity predicted poorer adherence to PE (β = -.22 to -.29) but not to sertraline. Drug use severity (β = -.22) also predicted worse treatment outcome, as did lifetime diagnosis of an alcohol and drug disorder (β = -.48). Overall, patients with drug use improved with treatment but had less treatment retention, adherence, and symptom reduction. Strategies to increase engagement and retention may be indicated for these patients. Individuals who are using cannabis or other drugs may be at higher risk for not completing PTSD treatment, potentially prolonging the cycle of PTSD and substance use. (PsycINFO Database Record

A Novel, Integrated Cognitive-Behavioral Therapy for Co-Occurring Posttraumatic Stress and Substance Use Disorders: A Case Study

Posttraumatic stress disorder (PTSD) and substance use disorders (SUD) are complex psychiatric conditions that commonly co-occur. No preferred, evidence-based treatments for PTSD/SUD comorbidity are presently available. Promising integrated treatments have combined prolonged exposure therapy with cognitive-behavioral relapse prevention therapy for SUD. We describe a case study that showcases a novel, integrated cognitive-behavioral treatment approach for PTSD/SUD, entitled Treatment of Integrated Posttraumatic Stress and Substance Use (TIPSS). The TIPSS program integrates cognitive processing therapy with cognitive-behavioral therapy for SUD for the treatment of co-occurring PTSD/SUD. The present case report, based upon a woman with PTSD comorbid with both cocaine and alcohol dependence, demonstrates that TIPSS has the potential to effectively reduce PTSD symptoms as well as substance use.

What Therapies are Favored in the Treatment of the Psychological Sequelae of Trauma in Human Trafficking Victims?

Human trafficking is a major public health concern that brings about deleterious psychological consequences and sequelae. Although a number of risk and protective factors for the health consequences of human trafficking victims have been identified, there is a dearth of information in the area of treatment. Specifically, we found no articles comparing the different components of prevailing trauma treatment strategies, and the potential usefulness of these strategies in the treatment of human trafficking victims. To this end, we compared and contrasted the different therapeutic treatments typically implemented with victims of trauma (including domestic violence victims and torture victims), and discussed how the different components of these treatments may or may not be helpful for human trafficking victims. We assessed the impact of these treatments on the psychological consequences of trauma and, in particular on posttraumatic stress disorder. We also assessed the potential usefulness of these treatments with co-occurring problems such as substance use, psychosis, dissociation, and other mood and anxiety disorders. On the basis of the prevailing research, we highlighted cognitive therapies as being preferred in addressing the needs of human trafficking victims. Mental health providers who work with human trafficking victims should become aware of and practiced in the use of cognitive therapeutic approaches in treating this population. Efficacy and effectiveness studies are needed to validate our recommendations.

A treatment development study of a cognitive and mindfulness-based therapy for adolescents with co-occurring post-traumatic stress and substance use disorder

OBJECTIVE

Substance use is common among adolescents with post-traumatic stress disorder (PTSD). We aimed to develop and study an integrated treatment for adolescents with co-occurring disorders.

DESIGN

This is a therapy development and open pilot trial study of a manualized therapy for adolescents with post-traumatic stress, depression, and substance use that uses a combination of cognitive therapy (CT) and mindfulness.

METHODS

Descriptive statistics and paired sample t-tests were calculated to assess for changes in PTSD symptoms, depression, and substance use frequency from baseline to end of treatment using standardized measures and validated by urine drug screens. We also examined for safety, predictors of clinical outcomes, and treatment retention.

RESULTS

Thirty-seven adolescents participated in the study; 62% were study completers as defined by retention for at least 6 weeks of treatment. There were significant improvements in PTSD and depression symptoms from baseline to end of treatment, reflecting medium effect sizes, and which was associated with changes in trauma-associated cognitions. There was a reduction in cannabis use, which was the most commonly used substance.

CONCLUSIONS

Preliminary results suggest feasibility, safety, and potential clinical effectiveness of an integrated therapy for adolescents with PTSD, depression, and substance use. Retention was comparable to other therapy clinical trial studies of adolescents despite the high risk for poor treatment retention and poor clinical outcomes among adolescents with PTSD and co-occurring disorders. We discuss the rationale for continued research of this mindfulness-based CT for adolescents with co-occurring disorders.

PRACTITIONER POINTS

Adolescents with co-occurring PTSD and substance use achieved meaningful improvement in PTSD and depression symptom severity after receiving a CT and mindfulness dual diagnosis approach. An integrated manualized therapy for dual diagnosis shows promise for reducing cannabis use in adolescents with PTSD. Changes in trauma-related cognitions have the potential to improve PTSD and depression symptoms in adolescents with substance use problems.

Development of a novel, integrated cognitive-behavioral therapy for co-occurring posttraumatic stress and substance use disorders: A pilot randomized clinical trial

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.

Behavioral Treatments for Alcohol Use Disorder and Post-Traumatic Stress Disorder

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.

Racial/Ethnic Differences in Contemporaneous Use of Mental Health and Substance Use Treatment Among Individuals Experiencing Both Mental Illness and Substance Use Disorders

This study examined whether the well-established racial/ethnic differences in mental health service utilization among individuals with mental illness are reflected in the treatment utilization patterns of individuals experiencing both mental illness and substance use disorders, particularly in regards to the use of contemporaneous mental health and substance abuse treatment. Using pooled data from the National Survey on Drug Use and Health (2009-2013), the patterns of mental health and substance use treatment utilization of 8748 White, Black, or Latino individuals experiencing both mental illness and substance use disorders were analyzed. Multinomial logistic regression was conducted to test the relationships among racial/ethnic groups and the receipt of contemporaneous treatment, mental health treatment alone, and substance use treatment alone as compared with no treatment utilization. Results indicated that Black and Latino respondents were less likely to receive contemporaneous treatment than Whites respondents. Also, significantly associated with outcomes were several interactions between race/ethnicity and predisposing, need and enabling factors known to be associated with service utilization. The findings suggest that an underlying mechanism of racial/ethnic differences among individuals with co-occurring mental illness and substance use disorders in the treatment utilization may differ by the specific types of treatment and between Blacks and Latinos. Therefore, efforts to reduce these disparities should consider specialty in each treatment settings and heterogeneity within diverse racial/ethnic groups.

Neurobiology of comorbid post-traumatic stress disorder and alcohol-use disorder

Post-traumatic stress disorder (PTSD) and alcohol-use disorder (AUD) are highly comorbid in humans. Although we have some understanding of the structural and functional brain changes that define each of these disorders, and how those changes contribute to the behavioral symptoms that define them, little is known about the neurobiology of comorbid PTSD and AUD, which may be due in part to a scarcity of adequate animal models for examining this research question. The goal of this review is to summarize the current state-of-the-science on comorbid PTSD and AUD. We summarize epidemiological data documenting the prevalence of this comorbidity, review what is known about the potential neurobiological basis for the frequent co-occurrence of PTSD and AUD and discuss successes and failures of past and current treatment strategies. We also review animal models that aim to examine comorbid PTSD and AUD, highlighting where the models parallel the human condition, and we discuss the strengths and weaknesses of each model. We conclude by discussing key gaps in our knowledge and strategies for addressing them: in particular, we (1) highlight the need for better animal models of the comorbid condition and better clinical trial design, (2) emphasize the need for examination of subpopulation effects and individual differences and (3) urge cross-talk between basic and clinical researchers that is reflected in collaborative work with forward and reverse translational impact.

A pilot study of the trauma recovery group for veterans with post traumatic stress disorder and co-occurring serious mental illness

BACKGROUND

Many Veterans may not benefit from gold-standard evidence-based treatments for post-traumatic stress disorder (PTSD) because they suffer from co-occurring serious mental illness (SMI).

AIMS

This pilot study is the first to evaluate the feasibility and preliminary effectiveness of the Trauma Recovery Group in a sample of Veterans with PTSD and SMI.

METHODS

Fourteen Veterans with PTSD and SMI were enrolled in a 21-session group-based cognitive behavioral therapy program targeting PTSD. The PTSD Checklist was the primary outcome measure; secondary outcomes included the Participant Health Questionnaire, the Post Traumatic Cognitions Inventory, and the Beck Cognitive Insight Scale.

RESULTS

Seventy-one percent of participants completed the trial. The intervention was associated with a significant reduction of PTSD symptoms and a trend-level reduction of maladaptive post-traumatic cognitions. There was a significant positive correlation between change in PTSD symptoms and change in post-traumatic cognitions.

CONCLUSIONS

The findings support the feasibility and preliminary effectiveness of the Trauma Recovery Group for Veterans with co-occurring PTSD and SMI, and suggest that controlled research on the program is warranted.

A systematic review of technology-based interventions for co-occurring substance use and trauma symptoms

Introduction

Technology-based mental health interventions are becoming increasingly common, and several have begun to target multiple outcomes in a single intervention. Recent developments in the treatment of co-occurring posttraumatic stress disorder and substance use disorder has led to the development and testing of technology-based interventions for these disorders. The current systematic review examined technology-based interventions designed to improve mental health outcomes among patients with co-occurring trauma symptoms and substance use.

Methods

Of 601 articles reviewed, 14 included a technology-based intervention for patients with these co-occurring problems.

Results

Seven of these studies provided preliminary evidence that technology-based interventions are likely to be efficacious in reducing either trauma symptoms or substance use. The seven remaining studies demonstrated that technology-based interventions for co-occurring trauma symptoms and substance use are feasible.

Discussion

This review suggests that technology-based interventions for co-occurring trauma symptoms and substance use are feasible, but more work is needed to assess efficacy using scientifically rigorous studies.

Concurrent Treatment of Substance Use and PTSD

Substance use disorders (SUD) and posttraumatic stress disorder (PTSD) are chronic, debilitating conditions that frequently co-occur. Individuals with co-occurring SUD and PTSD suffer a more complicated course of treatment and less favorable treatment outcomes compared to individuals with either disorder alone. The development of effective psychosocial and pharmacological interventions for co-occurring SUD and PTSD is an active and critically important area of investigation. Several integrated psychosocial treatments for co-occurring SUD and PTSD have demonstrated promising outcomes. While recent studies examining medications to treat co-occurring SUD and PTSD have yielded encouraging findings, there remain substantial gaps in the evidence base regarding the treatment of co-occurring SUD and PTSD. This review will summarize the findings from clinical trials targeting a reduction in SUD and PTSD symptoms simultaneously. These results may improve our knowledge base and subsequently enhance our ability to develop effective interventions for this complex comorbid condition.

Predictors of dropout in concurrent treatment of posttraumatic stress disorder and alcohol dependence: Rate of improvement matters

OBJECTIVE

The present study examined predictors and moderators of dropout among 165 adults meeting DSM-IV criteria for posttraumatic stress disorder (PTSD) and alcohol dependence (AD). Participants were randomized to 24 weeks of naltrexone (NAL), NAL and prolonged exposure (PE), pill placebo, or pill placebo and PE. All participants received supportive AD counseling (the BRENDA manualized model).

METHOD

Logistic regression using the Fournier approach was conducted to investigate baseline predictors of dropout across the entire study sample. Rates of PTSD and AD symptom improvement were included to evaluate the impact of symptom change on dropout.

RESULTS

Trauma type and rates of PTSD and AD improvement significantly predicted dropout, accounting for 76% of the variance in dropout. Accidents and "other" trauma were associated with the highest dropout, and physical assault was associated with the lowest dropout. For participants with low baseline PTSD severity, faster PTSD improvement predicted higher dropout. For those with high baseline severity, both very fast and very slow rates of PTSD improvement were associated with higher dropout. Faster rates of drinking improvement predicted higher dropout among participants who received PE.

CONCLUSIONS

The current study highlights the influence of symptom trajectory on dropout risk. Clinicians may improve retention in PTSD-AD treatments by monitoring symptom change at regular intervals, and eliciting patient feedback on these changes.

The impact of treatment condition and the lagged effects of PTSD symptom severity and alcohol use on changes in alcohol craving

Given the high rates of comorbidity between posttraumatic stress disorder (PTSD) and substance use disorder (SUD), we investigated an integrated treatment for these disorders. Individuals with comorbid PTSD and alcohol dependence were randomized to receive naltrexone or placebo, with or without prolonged exposure (PE). All participants also received BRENDA (supportive counseling). The naltrexone plus PE group showed a greater decline in alcohol craving symptoms than those in the placebo with no PE group. The PE plus placebo and the naltrexone without PE groups did not differ significantly from the placebo with no PE group in terms of alcohol craving. No treatment group differences were found for percentage of drinking days. Alcohol craving was moderated by PTSD severity, with those with higher PTSD symptoms showing faster decreases in alcohol craving. Both PTSD and alcohol use had a lagged effect on alcohol craving, with changes in PTSD symptoms and percentage of days drinking being associated with subsequent changes in craving. These results support the relationship between greater PTSD symptoms leading to greater alcohol craving and suggest that reducing PTSD symptoms may be beneficial to reducing craving in those with co-occurring PTSD/SUD.

Posttraumatic Stress Disorder, Health Problems, and Depression Among African American Women in Residential Substance Use Treatment

BACKGROUND

Rates of posttraumatic stress disorder (PTSD) are high among women seeking treatment for substance use disorders (SUDs). Minority women, in particular, experience high rates of trauma and may be less likely to disclose trauma history. This article identifies items from pre-existing screening measures that can be used across settings to sensitively but noninvasively identify women with likely PTSD.

METHOD

For a sample of 104 African American women in residential SUD treatment who provided informed consent as a part of a larger randomized clinical trial, the prevalence of trauma and PTSD, as well as the relationships between trauma, health, depression, and distress, was examined. Measures included Posttraumatic Stress Diagnostic Scale (PDS), Center for Epidemiologic Studies-Depression Scale (CES-D), Pennebaker Inventory of Limbic Languidness (PILL), and Brief Symptom Inventory (BSI). Additional analyses were undertaken to determine if a subset of noninvasive items could serve to identify the presence of a probable PTSD diagnosis.

RESULTS

Most women (94.2%) reported at least one lifetime trauma, with over half (51.0%) meeting DSM-IV criteria for PTSD. Women with greater trauma symptom severity reported more health problems and higher levels of depression and distress. Five BSI items and one CES-D item were significantly associated with a probable PTSD diagnosis with a sensitivity of 88.7%, a specificity of 66.7%, a positive predictive value of 73.4%, a negative predictive value of 85.0%, and an accuracy of 77.9%.

CONCLUSION

Findings affirm that African American women with SUDs present for residential treatment with comorbid psychiatric and emotional conditions that warrant assessment and treatment. Results highlight potential benefits of brief screening with routine measures and coordinated access to ancillary psychiatric and medical services, in conjunction with substance treatment, such as in residential or primary care.

Nature and Treatment of Comorbid Alcohol Problems and Post Traumatic Stress Disorder Among American Military Personnel and Veterans

Many service members and veterans seeking treatment for alcohol problems also have post-traumatic stress disorder (PTSD). This article considers the effectiveness of treating alcohol problems and PTSD simultaneously. The authors begin by summarizing the extent of excessive alcohol use among military service members and veterans. They then explore the relationship between combat exposure and subsequent alcohol use; identify and briefly describe evidence-based treatments for alcohol problems and PTSD, separately; and review research on the effects of single treatments for both PTSD symptoms and alcohol use.

Treatment Access Barriers and Disparities Among Individuals with Co-Occurring Mental Health and Substance Use Disorders: An Integrative Literature Review

The purpose of this integrative review is to examine and synthesize extant literature pertaining to barriers to substance abuse and mental health treatment for persons with co-occurring substance use and mental health disorders (COD). Electronic searches were conducted using ten scholarly databases. Thirty-six articles met inclusion criteria and were examined for this review. Narrative review of these articles resulted in the identification of two primary barriers to treatment access for individuals with COD: personal characteristics barriers and structural barriers. Clinical implications and directions for future research are discussed. In particular, additional studies on marginalized sub-populations are needed, specifically those that examine barriers to treatment access among older, non-White, non-heterosexual populations.

Adherence and competence in two manual-guided therapies for co-occurring substance use and posttraumatic stress disorders: clinician factors and patient outcomes

BACKGROUND

The challenges of implementing and sustaining evidence-based therapies into routine practice have been well-documented.

OBJECTIVES

This study examines the relationship among clinician factors, quality of therapy delivery, and patient outcomes.

METHODS

Within a randomized controlled trial, 121 patients with current co-occurring substance use and posttraumatic stress disorders were allocated to receive either manualized Integrated Cognitive Behavioral Therapy (ICBT) or Individual Addiction Counseling (IAC). Twenty-two clinicians from seven addiction treatment programs were trained and supervised to deliver both therapies. Clinician characteristics were assessed at baseline; clinician adherence and competence were assessed over the course of delivering both therapies; and patient outcomes were measured at baseline and 6-month follow-up.

RESULTS

Although ICBT was delivered at acceptable levels, clinicians were significantly more adherent to IAC (p < 0.05). At session 1, clinical female gender (p < 0.05) and lower education level (p < 0.05) were predictive of increased clinician adherence and competence across both therapies. Adherence and competence at session 1 in either therapy were significantly predictive of positive patient outcomes. ICBT adherence (p < 0.05) and competence (p < 0.01) were predictive of PTSD symptom reduction, whereas IAC adherence (p < 0.01) and competence (p < 0.01) were associated with decreased drug problem severity.

CONCLUSIONS

The differential impact of adherence and competence for both therapy types is consistent with their purported primary target: ICBT for PTSD and IAC for substance use. These findings also suggest the benefits of considering clinician factors when implementing manual-guided therapies. Future research should focus on diverse clinician samples, randomization of clinicians to therapy type, and prospective designs to evaluate models of supervision and quality monitoring.

A randomized controlled trial of treatments for co-occurring substance use disorders and post-traumatic stress disorder

BACKGROUND AND AIMS

Post-traumatic stress disorder (PTSD) is common among people with substance use disorders, and the comorbidity is associated with negative outcomes. We report on a randomized controlled trial comparing the effect of integrated cognitive-behavioral therapy (ICBT) plus standard care, individual addiction counseling plus standard care and standard care alone on substance use and PTSD symptoms.

DESIGN

Three-group, multi-site randomized controlled trial.

SETTING

Seven addiction treatment programs in Vermont and New Hampshire, USA.

PARTICIPANTS/CASES

Recruitment took place between December 2010 and January 2013. In this single-blind study, 221 participants were randomized to one of three conditions: ICBT plus standard care (SC) (n = 73), individual addiction counseling (IAC) plus SC (n = 75) or SC only (n = 73). One hundred and seventy-two patients were assessed at 6-month follow-up (58 ICBT; 61 IAC; 53 SC). Intervention and comparators: ICBT is a manual-guided therapy focused on PTSD and substance use symptom reduction with three main components: patient education, mindful relaxation and flexible thinking. IAC is a manual-guided therapy focused exclusively on substance use and recovery with modules organized in a stage-based approach: treatment initiation, early abstinence, maintaining abstinence and recovery. SC are intensive out-patient program services that include 9-12 hours of face-to-face contact per week over 2-4 days of group and individual therapies plus medication management.

MEASUREMENTS

Primary outcomes were PTSD severity and substance use severity at 6 months. Secondary outcomes were therapy retention.

FINDINGS

PTSD symptoms reduced in all conditions with no difference between them. In analyses of covariance, ICBT produced more favorable outcomes on toxicology than IAC or SC [comparison with IAC, parameter estimate: 1.10; confidence interval (CI) = 0.17-2.04; comparison with SC, parameter estimate: 1.13; CI = 0.18-2.08] and had a greater reduction in reported drug use than SC (parameter estimate: -9.92; CI = -18.14 to -1.70). ICBT patients had better therapy continuation versus IAC (P<0.001). There were no unexpected or study-related adverse events.

CONCLUSIONS

Integrated cognitive behavioral therapy may improve drug-related outcomes in post-traumatic stress disorder sufferers with substance use disorder more than drug-focused counseling, but probably not by reducing post-traumatic stress disorder symptoms to a greater extent.

Implementation and effectiveness of integrated trauma and addiction treatment for incarcerated men

A controlled trial of Seeking Safety (SS) and Male-Trauma Recovery Empowerment Model (M-TREM) examined implementation and effectiveness of integrated group therapy for comorbid post-traumatic stress disorder (PTSD) and substance use disorder (SUD) on PTSD and mental health symptoms plus self-esteem and efficacy for incarcerated men. The study sample (n=230) was male inmates 18 years or older who were primarily non-white, high school graduates or equivalents, had childhood trauma histories, committed violent crimes, had serious mental illnesses, and resided in a maximum security prison. Incarcerated men, who screened positive for PTSD and SUD, were assigned randomly (n=142) or by preference (n=88) to receive SS or M-TREM, with a waitlist group of (n=93). Manualized interventions were group-administered for 14 weeks. Primary outcomes were PTSD and other mental health symptoms. Secondary outcomes were self-esteem, coping, and self-efficacy. SUD outcomes cannot be measured in a correctional setting. Implementation feasibility was exhibited by the ability to recruit, screen, assign, and retain participants. Effectiveness findings depended on sample, design, and method for analysis. Using a waitlist control group and no follow-up period, we found no aggregate effect of treatment on PTSD symptoms, although, when disaggregated, M-TREM was found to improve PTSD severity and SS improved general mental health symptoms and psychological functioning. Using intent-to-treat and completer analyses, no significant differences were found in the relative performance between SS and M-TREM on primary or secondary outcomes. When longitudinal data were maximized and modeled in ways that reflect the hierarchical nature of the data, we found that SS and M-TREM performed better than no treatment on PTSD severity and secondary outcomes, and that treatment benefits endured. Findings cautiously support implementing either Seeking Safety or M-TREM to treat incarcerated men with co-morbid PTSD and addiction problems.

Integrated Cognitive Behavioral Therapy (ICBT) For PTSD and Substance Use in Iraq and Afghanistan Veterans: A Feasibility Study

Co-occurring posttraumatic stress disorder (PTSD) and substance use disorder (SUD) is prevalent in military Veterans and is associated with poorer outcomes than either disorder alone. The current pilot study examines the feasibility of delivering integrated cognitive behavioral therapy (ICBT) for co-occurring PTSD-SUD to Veterans who served in Iraq and Afghanistan. Our primary aims were testing the feasibility of engaging and retaining Veterans with a complex clinical presentation in a 12-week structured therapy. We focused on two feasibility outcomes: 1) acceptability; and 2) tolerability. We also examined clinically meaningful change in PTSD and depressive symptoms as a secondary aim. Over the course of the study, we recruited 12 eligible Veterans, 6 of whom completed ICBT. We encountered challenges related to engaging and retaining Veterans in treatment and discuss adaptations and refinements of ICBT or other integrated treatments for returning Veterans with co-occurring PTSD-SUD to increase feasibility with military Veterans.

Treatment of co-occurring anxiety disorders and substance use disorders

Anxiety disorders commonly co-occur with substance use disorders both in the general population and in treatment-seeking samples. This co-occurrence is associated with greater symptom severity, higher levels of disability, and poorer course of illness relative to either disorder alone. Little research has been conducted, however, on the treatment of these co-occurring disorders. This gap may not only leave anxiety untreated or undertreated but also increase the risk for relapse and poor substance use outcomes. The aim of this article is to review the current state of the literature on treating co-occurring anxiety and substance use disorders. In addition to presenting a brief overview of the epidemiology of this co-occurrence, the article discusses the challenges in assessing anxiety in the context of a substance use disorder, the evidence for various treatment approaches, and recent advances and future directions in this understudied area. Also highlighted is the need for future research to identify optimal behavioral and pharmacologic treatments for co-occurring anxiety and substance use disorders.

Indirect effects of 12-session seeking safety on substance use outcomes: overall and attendance class-specific effects

OBJECTIVES

This study examined in- and post-treatment mediation effects of a 12-session dose of Seeking Safety (SS)-an integrative cognitive behavioral treatment for comorbid PTSD and SUDs-on alcohol and cocaine outcomes in comparison to Women's Health Education (WHE) in a seven-site randomized controlled effectiveness trial.

METHODS

Women (n = 353) enrolled in outpatient substance abuse treatment, who had experienced multiple traumas in childhood and/or adulthood and who had comorbid PTSD, were randomly assigned to receive SS or WHE delivered in open enrollment groups for 12 sessions in 6 weeks (unlike the full 25-topic SS protocol). Data were analyzed under two forms of longitudinal mediation analysis, each accounting for changes over time in group membership and group context, respectively.

RESULTS

Women in SS, compared to WHE, showed significantly steeper decreases in PTSD frequency and severity, which in turn, showed significant impact in reducing both cocaine and alcohol use. This pattern was strongest for those who completed most of the treatment sessions, which was the majority of patients in the trial; these patterns only emerged during the in-treatment phase.

CONCLUSIONS

Use of an integrated approach to PTSD/SUD such as SS can be helpful to more rapidly reduce PTSD, which consequently reduce SUD symptoms, particularly for those who attend most of the available treatment sessions.

SCIENTIFIC SIGNIFICANCE

This is one of the first studies to illustrate such effects in treating comorbid PTSD and SUD in the context of a highly impaired population delivered by community-based providers. (Am J Addict 2014;23:218-225).

Cognitive processing therapy for veterans with comorbid PTSD and alcohol use disorders

Posttraumatic stress disorder (PTSD) and alcohol-use disorders (AUD) frequently present comorbidity in veteran populations. Traditionally those with alcohol dependence have been excluded from PTSD treatment outcome studies, thus we do not know how those with alcohol dependence may tolerate or respond to PTSD-specific interventions; no studies to date have examined the extent to which cognitive PTSD interventions are tolerated or effective for those with comorbid PTSD/AUD. The present study examines the extent to which CPT is tolerated by and effective in treating PTSD symptoms for veterans with PTSD and AUD, as compared to veterans with PTSD only in an outpatient treatment setting. Data were obtained through chart review of 536 veterans diagnosed with PTSD who had received at least 1 session of CPT at a Midwestern US Veterans Affairs hospital. Nearly half (n=264, 49.3%) of the veterans in the study exhibited a current or past AUD diagnosis. Participants were grouped into the following diagnostic groups: current AUD (past 12 months), past AUD (prior to 12 months), and no AUD. Participants completed an average of 9 sessions of CPT with no significant difference between AUD diagnostic groups on the number of CPT sessions completed. Individuals with past AUD had higher initial symptoms of self-reported PTSD symptoms than those with no AUD. All groups reported significant reductions in PTSD symptoms and depression over time. Overall, the results suggest that CPT appears well tolerated among veterans with comorbid AUD and is associated with significant reductions in symptoms of PTSD and depression in an outpatient treatment setting.

Substance use disorders and PTSD: an exploratory study of treatment preferences among military veterans

BACKGROUND

Substance use disorders (SUDs) and Post Traumatic Stress Disorder (PTSD) frequently co-occur among Veterans and are associated with poor treatment outcomes. Historically, treatments for SUDs and PTSD have been delivered sequentially and independently. More recently, however, integrated treatments have shown promise. This study investigated Veterans' perceptions of the interrelationship between SUDs and PTSD, as well as treatment preferences.

METHODS

Participants were 35 Veterans of recent military conflicts in Iraq and Afghanistan, and prior operations, who completed the Treatment Preferences Questionnaire as well as an in-depth interview.

RESULTS

The majority (94.3%) perceived a relationship between their SUD and PTSD symptoms. Veterans reported that PTSD symptom exacerbation was typically (85.3%) associated with an increase in substance use, and PTSD symptom improvement was typically (61.8%) followed by a decrease in substance use (p<.01). Approximately 66% preferred an integrated treatment approach.

CONCLUSIONS

Although preliminary, the findings provide clinically-relevant information that can be used to enhance the development and provision of care for Veterans with SUDs and PTSD.

Trends in smoking among adults with mental illness and association between mental health treatment and smoking cessation

IMPORTANCE

Significant progress has been made in reducing the prevalence of tobacco use in the United States. However, tobacco cessation efforts have focused on the general population rather than individuals with mental illness, who demonstrate greater rates of tobacco use and nicotine dependence.

OBJECTIVES

To assess whether declines in tobacco use have been realized among individuals with mental illness and examine the association between mental health treatment and smoking cessation.

DESIGN, SETTING, AND PARTICIPANTS

Use of nationally representative surveys of noninstitutionalized US residents to compare trends in smoking rates between adults with and without mental illness and across multiple disorders (2004-2011 Medical Expenditure Panel Survey [MEPS]) and to compare rates of smoking cessation among adults with mental illness who did and did not receive mental health treatment (2009-2011 National Survey of Drug Use and Health [NSDUH]).The MEPS sample included 32,156 respondents with mental illness (operationalized as reporting severe psychological distress, probable depression, or receiving treatment for mental illness) and 133,113 without mental illness. The NSDUH sample included 14,057 lifetime smokers with mental illness.

MAIN OUTCOMES AND MEASURES

Current smoking status (primary analysis; MEPS sample) and smoking cessation, operationalized as a lifetime smoker who did not smoke in the last 30 days (secondary analysis; NSDUH sample).

RESULTS

Adjusted smoking rates declined significantly among individuals without mental illness (19.2% [95% CI, 18.7-19.7%] to 16.5% [95% CI, 16.0%-17.0%]; P < .001) but changed only slightly among those with mental illness (25.3% [95% CI, 24.2%-26.3%] to 24.9% [95% CI, 23.8%- 26.0%]; P = .50), a significant difference in difference of 2.3% (95% CI, 0.7%-3.9%) (P = .005). Individuals with mental illness who received mental health treatment within the previous year were more likely to have quit smoking (37.2% [95% CI, 35.1%-39.4%]) than those not receiving treatment (33.1% [95% CI, 31.5%-34.7%]) (P = .005).

CONCLUSIONS AND RELEVANCE

Between 2004 and 2011, the decline in smoking among individuals with mental illness was significantly less than among those without mental illness, although quit rates were greater among those receiving mental health treatment. This suggests that tobacco control policies and cessation interventions targeting the general population have not worked as effectively for persons with mental illness.

Helping vulnerable populations: a comprehensive review of the treatment outcome literature on substance use disorder and PTSD

We review treatment studies for comorbid substance use disorder (SUD) and posttraumatic stress disorder (PTSD). Results show positive outcomes on multiple domains. Most models had more effect on PTSD than SUD, suggesting SUD is harder to treat. Seeking Safety (SS) is the most studied model. It shows positive outcomes, and is the only treatment outperforming a control on both PTSD and SUD. Partial-dose SS had more mixed results than the full dose. This first-generation of PTSD/SUD research addresses complex samples excluded from "gold standard" PTSD-alone literature. Treatments for PTSD/SUD are generally longer than PTSD-alone treatments and present-focused, emphasizing stabilization and coping. The few models with past-focused (exposure-based) components also incorporated present-focused approaches for these vulnerable clients. We discuss public health perspectives to advance the field.

Synergy between seeking safety and twelve-step affiliation on substance use outcomes for women

OBJECTIVE

The Recovery Management paradigm provides a conceptual framework for the examination of joint impact of a focal treatment and post-treatment service utilization on substance abuse treatment outcomes. We test this framework by examining the interactive effects of a treatment for comorbid PTSD and substance use, Seeking Safety, and post-treatment Twelve-Step Affiliation (TSA) on alcohol and cocaine use.

METHOD

Data from 353 women in a six-site, randomized controlled effectiveness trial within the NIDA Clinical Trials Network were analyzed under latent class pattern mixture modeling. LCPMM was used to model variation in Seeking Safety by TSA interaction effects on alcohol and cocaine use.

RESULTS

Significant reductions in alcohol use among women in Seeking Safety (compared to health education) were observed; women in the Seeking Safety condition who followed up with TSA had the greatest reductions over time in alcohol use. Reductions in cocaine use over time were also observed but did not differ between treatment conditions nor were there interactions with post-treatment TSA.

CONCLUSIONS

Findings advance understanding of the complexities for treatment and continuing recovery processes for women with PTSD and SUDs, and further support the chronic disease model of addiction.

Trauma-focused treatment for posttraumatic stress disorder combined with CBT for severe substance use disorder: a randomized controlled trial

BACKGROUND

This randomized controlled trial (RCT) investigated the effectiveness of a combined treatment for co-morbid Posttraumatic Stress Disorder (PTSD) and severe Substance Use Disorder (SUD).

METHODS

Structured Writing Therapy for PTSD (SWT), an evidence-based traumafocused intervention, was added on to Treatment As Usual (TAU), consisting of an intensive cognitive behavioral inpatient or day group treatment for SUD. The outcomes of the combined treatment (TAU + SWT) were compared to TAU alone in a sample of 34 patients.

RESULTS

Results showed a general reduction of SUD symptoms for both TAU + SWT and TAU. Treatment superiority of TAU + SWT was neither confirmed by interaction effects (time x condition) for SUD or PTSD symptoms, nor by a group difference for SUD diagnostic status at post-treatment. However, planned contrasts revealed that improvements for PTSD severity over time were only significant within the TAU + SWT group. In addition, within the TAU + SWT group the remission of PTSD diagnoses after treatment was significant, which was not the case for TAU. Finally, at post-treatment a trend was noticed for between group differences for the number of PTSD diagnoses favoring TAU + SWT above TAU.

CONCLUSIONS

In sum, the current study provides preliminary evidence that adding a trauma-focused treatment on to standard SUD treatment may be beneficial.

Social workers and delivery of evidence-based psychosocial treatments for substance use disorders

Social workers encounter individuals with substance use disorders (SUDs) in a variety of settings. With changes in health care policy and a movement toward integration of health and behavioral health services, social workers will play an increased role vis-á-vis SUD. As direct service providers, administrators, care managers, and policy makers, they will select, deliver, or advocate for delivery of evidence-based SUD treatment practices. This article provides an overview of effective psychosocial SUD treatment approaches. In addition to describing the treatments, the article discusses empirical support, populations for whom the treatments are known to be efficacious, and implementation issues.