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

Sequenced treatment effectiveness for posttraumatic stress (STEPS) trial: A protocol for a pragmatic comparative effectiveness trial with baseline results

BACKGROUND

There have only been two efficacy trials reporting a head-to-head comparison of medications and psychotherapy for PTSD, and neither was conducted in primary care. Therefore, this protocol paper describes a pragmatic trial that compares outcomes of primary care patients randomized to initially receive a brief trauma-focused psychotherapy or a choice of three antidepressants. In addition, because there are few trials examining the effectiveness of subsequent treatments for patients not responding to the initial treatment, this pragmatic trial also compares the outcomes of those switching or augmenting treatments.

METHOD

Patients screening positive for PTSD (n = 700) were recruited from the primary care clinics of 7 Federally Qualified Health Centers (FQHC) and 8 Department of Veterans Affairs (VA) Medical Centers and randomized in the ratio 1:1:2 to one of three treatment sequences: 1) selective serotonin reuptake inhibitor (SSRI) followed by augmentation with Written Exposure Therapy (WET), 2) SSRI followed by a switch to serotonin-norepinephrine reuptake inhibitor (SNRI), or 3) WET followed by a switch to SSRI. Participants complete surveys at baseline, 4 months, and 8 months. The primary outcome is PTSD symptom severity as measured by the PTSD Checklist (PCL-5).

RESULTS

Average PCL-5 scores (M = 52.8, SD = 11.1) indicated considerable severity. The most common bothersome traumatic event for VA enrollees was combat (47.8%), and for FQHC enrollees was other (28.2%), followed by sexual assault (23.4%), and child abuse (19.8%). Only 22.4% were taking an antidepressant at baseline.

CONCLUSION

Results will help healthcare systems and clinicians make decisions about which treatments to offer to patients.

Written exposure therapy for veterans with co-occurring substance use disorders and PTSD: Study design of a randomized clinical trial

There are high rates of posttraumatic stress disorder (PTSD) among treatment-seeking veterans with substance use disorders (SUD). While addiction programs traditionally do not address PTSD, there is evidence that trauma treatments for individuals with this comorbidity have improved PTSD and SUD outcomes. Written exposure therapy (WET), a five-session evidence-based psychotherapy (EBP) for PTSD, has high patient satisfaction, and lower dropout compared to other EBPs for PTSD. WET may be ideally suited for clinical settings that may not have the trauma expertise found in PTSD specialty clinics, given it requires less training time, treatment sessions, preparation time, and therapist involvement than existing EBPs, and no homework assignments. This paper describes the design, methodology, and protocol of a randomized clinical trial to evaluate whether treatment as usual (TAU) plus WET (n = 51) is superior to TAU plus a neutral topic writing condition (n = 51) on both PTSD and addiction outcomes for veterans in SUD treatment. The primary hypothesis is that participants assigned to TAU+WET, compared to those in TAU+ neutral topic writing, will report reduced symptoms of PTSD. The secondary hypothesis is that veterans receiving WET will have greater decreases in number of days of substance use compared to TAU+ neutral topic controls at follow-up. Assessments will take place at baseline, post-treatment, 8-week, and 12-week follow-up. Exploratory aims will examine the association between heart rate variability and treatment outcomes. If results prove promising, they will support WET as an effective brief, easy to disseminate, adjunct to current SUD treatment for veterans with comorbid PTSD. Trial registration: ClinicalTrials.gov ID NCT05327504.

The interactions between patient preferences, expectancies, and stigma contribute to posttraumatic stress disorder treatment outcomes

Cognitive processing therapy (CPT) is an effective treatment for posttraumatic stress disorder (PTSD); however, some patients do not improve to the same extent as others. It is important to understand potential factors that can be modified for better patient outcomes. This clinical trial implemented a three-arm, equipoise-stratified randomization design to allow for the accommodation of patient preference before randomization to one of three CPT treatment modalities: in-home, in-office, or telehealth. This study examined whether satisfaction with the modality, perceived stigma, expectations of therapy, and credibility of the therapist differed between modalities and whether these factors impacted treatment outcomes. We hypothesized that the contributions of these variables would depend upon whether participants opted out of any treatment arms and that these factors would predict treatment outcomes. Participants who endorsed less perceived stigma demonstrated larger reductions in PTSD symptom severity than those with similar levels of perceived stigma in the telehealth and in-office conditions, η2 = .12-.18. Participants who endorsed lower satisfaction with their treatment modality and were assigned to the in-home condition experienced larger PTSD symptom reductions than those with similar dissatisfaction in the telehealth and in-office conditions, η2 = .20. The results show the robustness of evidence-based therapies for PTSD given that dissatisfaction did not impede treatment success. In addition, they demonstrate that it is important for clinicians to address stigma before initiating evidence-based therapies for PTSD. Strategies to address these factors are discussed.

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.

Predicting Reasons for Drinking in a Dually-Diagnosed Sample with PTSD and Substance Use Disorders

Objective: Using the negative reinforcement and common factors frameworks, this work assessed whether and how anxiety sensitivity, distress tolerance, and impulsivity relate to reasons for drinking (RFD) in a residential treatment sample with co-occurring alcohol use disorder and posttraumatic stress disorder (AUD-PTSD). Demographic differences were also examined. Method: Participants were 75 (52.0% male, 78.7% white) adults at a residential substance use treatment facility who met criteria for AUD-PTSD with 98.67% meeting criteria for one or more substance use disorders in addition to AUD. Participants completed measures of anxiety sensitivity, distress tolerance, impulsivity, RFD, and AUD-PTSD symptoms. Univariate and multivariate linear regression was used with and without controlling for demographic variables (i.e., age, race, and sex). Results: The positive and negative urgency facets of impulsivity were positively related to both negative affect and cue/craving response RFD with relations maintained after controlling for demographic variables and including PTSD symptom severity (βs .30-.51). There were no significant relations between impulsivity and social RFD. No facets of anxiety sensitivity or distress tolerance were significantly related to RFD domains. Conclusions: Findings suggest that the urgency facets of impulsivity are crucial in understanding negative affect and cue/craving RFD. However, anxiety sensitivity and distress tolerance are not related to RFD in this dually diagnosed AUD-PTSD sample. Treatment considerations and future directions are discussed.

Implementation of group cognitive processing therapy in correction centers: Anticipated determinants from formative evaluation

Nearly all people in prison have experienced trauma, and many meet the criteria for posttraumatic stress disorder (PTSD). Untreated PTSD increases the risk of substance use problems after release, contributing to a well-documented cycle of trauma, addiction, and incarceration. However, evidence-based, trauma-focused therapy for PTSD is rarely offered in prisons, and there is little research that can guide implementation efforts. In preparation for an effectiveness-implementation hybrid II pilot trial examining group-delivered cognitive processing therapy (CPT) in prisons, we conducted a formative evaluation using interviews structured according to the consolidated framework for implementation research (i.e., CFIR). Participants were correction center leadership, treatment staff, health care staff, and security staff (n = 22) and incarcerated persons (n = 14; 57.1% female). We found that CPT was highly compatible with residents' needs and the centers' available resources, culture, existing programs, and current workflow. CPT was also acceptable to all stakeholders. Potential barriers were the lower relative priority for CPT compared with programs that are reinforced at the system level, limited staff time to deliver CPT, limited staff knowledge about PTSD, and center features that could distract from CPT groups and/or training or be countertherapeutic. Taken together, CPT is a promising trauma-focused therapy for corrections, but these findings underscore the importance of identifying and matching potential barriers to effective implementation strategies a priori and work in the policy arena to promote sustainability.

Treatment of Posttraumatic Stress Disorder Alleviates Tinnitus-Related Distress Among Veterans: A Pilot Study

PURPOSE

Military service personnel are at increased risk for developing tinnitus due to heightened exposure to acoustic trauma. The auditory disorder is the leading service-connected disability among veterans and is highly comorbidly diagnosed with posttraumatic stress disorder (PTSD). The biopsychosocial model illustrates that chronic health conditions are exacerbated or maintained by psychiatric distress. Therefore, alleviation of such psychiatric distress can have beneficial impacts on health conditions, such as tinnitus. The aim of this study was to determine whether individuals with both disorders who receive evidence-based therapy for PTSD will experience decreases in both PTSD and tinnitus-related distress.

METHOD

Veterans with comorbid bothersome tinnitus and PTSD received cognitive processing therapy and were assessed for PTSD, tinnitus-related distress, and depression at baseline and 1 month posttreatment follow-up.

RESULTS

At posttreatment follow-up, participants demonstrated significant decreases in PTSD symptoms compared to their baseline scores. Participants also demonstrated decreased tinnitus-related distress and depression, with high effect sizes.

CONCLUSIONS

This pilot study demonstrated that clinical management addressing psychiatric distress, as associated with PTSD, may simultaneously provide benefit for patients with bothersome tinnitus. Although not statistically significant due to the small sample size, large effect sizes indicate that tinnitus-related distress decreased as a function of receiving evidence-based therapy for PTSD. Future clinical trials should increase sample sizes and compare effects to control conditions.

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).

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.

Cognitive Processing Therapy Versus Medication for the Treatment of Comorbid Substance Use Disorder and Post-Traumatic Stress Disorder in Egyptian patients (Randomized Clinical Trial)

"Earlier research has established that posttraumatic stress disorder (PTSD) and substance use disorder (SUD) frequently coexist. Aims: Cognitive Processing Therapy was compared to Sertraline and a placebo in an RCT for treating patients with comorbid SUD and PTSD. Methods: 150 patients with SUD and PTSD were interviewed by clinicians and asked to fill out the Clinician-Administered PTSD Scale (CAPS-5), Posttraumatic Stress Disorder Checklist (PCL-5), Beck Depression Inventory (BDI-II), Timeline Follow Back Interview (TLFB), and Brief Addiction Monitor (BAM). Patients were randomly assigned to the following conditions: CPT (n=50), Sertraline (n=50), or Placebo (n=50). Pretreatment, posttreatment, six and, twelve-month follow-up assessments were conducted. Results: When compared to the sertraline group, CPT resulted in much higher reductions in CAPS scores at posttreatment assessment (d=0.93, p < .000). When compared to the control group, CPT considerably reduced PTSD symptoms (the effect size, d=1.9, p < .000). Sertraline resulted in many significant decreases in CAPS when compared to control groups (the effect size , d=1.11, p<.000). At posttreatment, SUD and depression severity were significantly reduced in both CPT and Sertraline groups. After six and twelve months of follow-up, these differences persisted. Conclusion: Comparatively to the control group, CPT and Sertraline significantly decreased PTSD, SUD, and depression."

Practical Considerations for Treating Comorbid Posttraumatic Stress Disorder in the Addictions Clinic: Approaches to Clinical Care, Leadership, and Alleviating Shame

A practical, common-sense framework for recognizing and addressing comorbid posttraumatic stress disorder (PTSD) in the substance use disorder (SUD) clinic is outlined. The article focuses on strategies that can help establish trauma-informed care or augment an existing approach. Interventions are organized around the task of ameliorating shame (or shame sensitivity), which represents a transdiagnostic mediator of psychopathology and, potentially, capacity for change. Countershaming strategies can guide a trauma-responsive leadership approach. Considering the striking rate of underdiagnosis of PTSD among patients with SUD, implementing routine systematic PTSD screening likely represents the single most consequential trauma-informed intervention that SUD clinics can adopt.

Disruptive Dizziness Among Post-9/11 Veterans With Deployment-Related Traumatic Brain Injury

OBJECTIVE

To identify disruption due to dizziness symptoms following deployment-related traumatic brain injury (TBI) and factors associated with receiving diagnoses for these symptoms.

SETTING

Administrative medical record data from the Department of Veterans Affairs (VA).

PARTICIPANTS

Post-9/11 veterans with at least 3 years of VA care who reported at least occasional disruption due to dizziness symptoms on the comprehensive TBI evaluation.

DESIGN

A cross-sectional, retrospective, observational study.

MAIN MEASURES

International Classification of Diseases, Ninth Revision, Clinical Modification diagnosis codes of dizziness, vestibular dysfunction, and other postconcussive conditions; neurobehavioral Symptom Inventory.

RESULTS

Increased access to or utilization of specialty care at the VA was significant predictors of dizziness and/or vestibular dysfunction diagnoses in the fully adjusted model. Veterans who identified as Black non-Hispanic and those with substance use disorder diagnoses or care were substantially less likely to receive dizziness and vestibular dysfunction diagnoses.

CONCLUSIONS

Access to specialty care was the single best predictor of dizziness and vestibular dysfunction diagnoses, underscoring the importance of facilitating referrals to and utilization of specialized, comprehensive clinical facilities or experts for veterans who report disruptive dizziness following deployment-related TBI. There is a clear need for an evidence-based pathway to address disruptive symptoms of dizziness, given the substantial variation in audiovestibular tests utilized by US providers by region and clinical specialty. Further, the dearth of diagnoses among Black veterans and those in more rural areas underscores the potential for enhanced cultural competency among providers, telemedicine, and patient education to bridge existing gaps in the care of dizziness.

Gender differences in disorders comorbid with posttraumatic stress disorder among U.S. Sailors and Marines

Psychological comorbidity, the co-occurrence of mental health disorders, is more often the rule than the exception among individuals with posttraumatic stress disorder (PTSD). Research shows that prevalence estimates for specific psychological disorders differ by gender; however, little is known about whether these patterns persist in the presence of a comorbid PTSD diagnosis. This study examined gender differences in prevalence estimates for conditions comorbid with PTSD using medical records for 523,626 active duty U.S. Sailors and Marines who entered the military over an 8-year period. Using chi-square tests of independence, we detected statistically significant gender differences for specific comorbid conditions in the subsample of 9,447 service members with a PTSD diagnosis. Women were more likely than men to have PTSD with comorbid adjustment, OR = 1.35; depressive, OR = 1.71; and generalized anxiety or other anxiety disorders, OR = 1.16, with the largest effects for eating, OR = 12.60, and personality disorders, OR = 2.97. In contrast, women were less likely than men to have a diagnosis of PTSD with comorbid alcohol use, OR = 0.69, and drug use disorders, OR = 0.72, with the largest effects for insomnia, OR = 0.42, and traumatic brain injury, OR = 0.17. No significant gender differences emerged for comorbid bipolar, obsessive-compulsive, panic/phobic, psychotic, or somatoform/dissociative disorders, ps = .029-.314. The results show gender differences in conditions comorbid with PTSD generally align with internalizing and externalizing dimensions. Differences in comorbidities with PTSD between women and men could have implications for treatment development and delivery.

In-office, in-home, and telehealth cognitive processing therapy for posttraumatic stress disorder in veterans: a randomized clinical trial

BACKGROUND

Trauma-focused psychotherapies for combat-related posttraumatic stress disorder (PTSD) in military veterans are efficacious, but there are many barriers to receiving treatment. The objective of this study was to determine if cognitive processing therapy (CPT) for PTSD among active duty military personnel and veterans would result in increased acceptability, fewer dropouts, and better outcomes when delivered In-Home or by Telehealth as compared to In-Office treatment.

METHODS

The trial used an equipoise-stratified randomization design in which participants (N = 120) could decline none or any 1 arm of the study and were then randomized equally to 1 of the remaining arms. Therapists delivered CPT in 12 sessions lasting 60-min each. Self-reported PTSD symptoms on the PTSD Checklist for DSM-5 (PCL-5) served as the primary outcome.

RESULTS

Over half of the participants (57%) declined 1 treatment arm. Telehealth was the most acceptable and least often refused delivery format (17%), followed by In-Office (29%), and In-Home (54%); these differences were significant (p = 0.0008). Significant reductions in PTSD symptoms occurred with all treatment formats (p < .0001). Improvement on the PCL-5 was about twice as large in the In-Home (d = 2.1) and Telehealth (d = 2.0) formats than In-Office (d = 1.3); those differences were statistically large and significant (d = 0.8, 0.7 and p = 0.009, 0.014, respectively). There were no significant differences between In-Home and Telehealth outcomes (p = 0.77, d = -.08). Dropout from treatment was numerically lowest when therapy was delivered In-Home (25%) compared to Telehealth (34%) and In-Office (43%), but these differences were not statistically significant.

CONCLUSIONS

CPT delivered by telehealth is an efficient and effective treatment modality for PTSD, especially considering in-person restrictions resulting from COVID-19.

TRIAL REGISTRATION

ClinicalTrials.gov ID NCT02290847 (Registered 13/08/2014; First Posted Date 14/11/2014).

Moderators for the Relationship between Post-Traumatic Stress Disorder and Opioid Use Disorder

Objective: Post-traumatic stress disorder (PTSD) is a common risk factor for opioid use disorder (OUD). However, not all individuals with PTSD develop OUD when exposed to opioids. As the underlying moderators remain unexplored, this analysis aimed to determine if non-traumatic adverse experiences and stressors prior to the age of 18 moderate the relationship between PTSD and OUD. Methods: In a matched dataset (n = 830) of individuals with or without PTSD who reported lifetime use of opioids, the following non-traumatic adverse experiences and stressors were assessed: emotional abuse, emotional neglect and physical neglect, parents' adverse experiences, and number of days jailed before the age of 18. Using the PROCESS macro in SAS for each factor, the conditional effects were estimated through simple slopes. Moderation was inferred through significant interaction effects. Results: The matched data were similar on age, gender, ethnicity, education, being born in the US, living with, or losing biological parents before age 18, and family history of depression, anxiety, and substance use disorder. Significantly more individuals in the preexisting PTSD group had preexisting psychiatric disorders, and preexisting substance use and schizotypal personality disorder. Childhood emotional abuse and neglect and physical neglect (effect: 0.03; 95%CI: 0.001-0.056; p = .039), and more than one event of adversity experienced by parents (effect: 0.34; 95%CI: 0.07-0.61; p = .013) significantly interacted with PTSD to lead to OUD. Conclusion: The conditional effect of PTSD on the development of OUD after exposure to opioids was dependent on the frequency and severity of childhood non-traumatic adverse experiences. To identify individuals with PTSD who are at a high risk of developing OUD, programs may focus on non-traumatic adverse childhood experiences that are not commonly explored. Future steps may include focusing on educational schemes to mitigate this higher risk of developing OUD in at-risk individuals, for example, by discussing the risks when prescribing opioids.

Economic costs of implementing evidence-based telemedicine outreach for posttraumatic stress disorder in VA

Background

Telemedicine outreach for posttraumatic stress disorder (TOP) is a virtual evidence-based practice (EBP) involving telephone care management and telepsychology that engages rural patients in trauma-focused psychotherapy. This evaluation examined implementation and intervention costs attributable to deploying TOP from a health system perspective.

Methods

Costs were ascertained as part of a stepped wedge cluster randomized trial at five sites within the Veterans Affairs (VA) Healthcare System. All sites initially received a standard implementation strategy, which included internal facilitation, dissemination of an internal facilitators operational guide, funded care manager, care managing training, and technical support. A subset of clinics that failed to meet performance metrics were subsequently randomized to enhanced implementation, which added external facilitation that focused on incorporating TOP clinical processes into existing clinic workflow. We measured site-level implementation activities using project records and structured activity logs tracking personnel-level time devoted to all implementation activities. We monetized time devoted to implementation activities by applying an opportunity cost approach. Intervention costs were measured as accounting-based costs for telepsychiatry/telepsychology and care manager visits, ascertained using VA administrative data. We conducted descriptive analyses of strategy-specific implementation costs across five sites. Descriptive analyses were conducted instead of population-level cost-effectiveness analysis because previous research found enhanced implementation was not more successful than the standard implementation in improving uptake of TOP.

Results

Over the 40-month study period, four of five sites received enhanced implementation. Mean site-level implementation cost per month was $919 (SD = $238) during standard implementation and increased to $1,651 (SD = $460) during enhanced implementation. Mean site-level intervention cost per patient-month was $46 (SD = $28) during standard implementation and $31 (SD = $21) during enhanced implementation.

Conclusions

Project findings inform the expected cost of implementing TOP, which represents one factor health systems should consider in the decision to broadly adopt this EBP. Plain Language Summary: What is already known about the topic: Trauma-focused psychotherapy delivered through telemedicine has been demonstrated as an effective approach for the treatment of post-traumatic stress disorder (PTSD). However, uptake of this evidence-based approach by integrated health systems such as the Veterans Affairs (VA) Health Care System is low. What does this paper add: This paper presents new findings on the costs of two implementation approaches designed to increase adoption telemedicine outreach for PTSD from a health system perspective. What are the implications for practice, research, and policy: Cost estimates from this paper can be used by health systems to inform the relative value of candidate implementation strategies to increase adoption of evidence-based treatments for PTSD or other mental health conditions.

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.

Binge drinking following residential treatment for posttraumatic stress disorder among veterans with and without alcohol use disorder

Posttraumatic stress disorder (PTSD) is complicated by high rates of problematic drinking and comorbid alcohol use disorder (AUD). This study examined veterans seeking residential PTSD treatment, comparing those with and without AUD, to determine whether trauma type and/or PTSD symptom changes during treatment were associated with binge drinking at 4-month follow-up. Analyses compared characteristics of veterans (N = 758) in residential treatment, as well as associations of demographic, trauma, and alcohol-related variables, with binge drinking episodes at follow-up. Results showed no differences in PTSD symptom improvements based on AUD diagnosis. Among AUD-diagnosed veterans, 21.3% endorsed binge drinking 4 or more (14.3% endorsed 9 or more) days, while 10.8% of veterans without AUD endorsed binge drinking 4 or more (5.2% endorsed 9 or more) days at follow-up. Among AUD-diagnosed veterans, while PTSD symptom improvements were not associated with binge drinking outcomes, drinking days at admission and military sexual trauma (MST) predicted a greater likelihood of binge drinking. Among veterans without AUD, drinking days at admission, PTSD symptom increases, being unmarried, 'other' race, and less education, were associated with a higher likelihood of binge drinking, while MST and combat exposure predicted a lower likelihood of binge drinking. In conclusion, drinking days at admission is a predictor of binge drinking following treatment; thus, alcohol use should be assessed at intake and addressed among those who endorse drinking to reduce the likelihood of alcohol resumption following residential treatment. Furthermore, among AUD-diagnosed veterans, despite PTSD symptom decreases during treatment, MST predicted a greater likelihood of 9 or more binge drinking days at follow-up.

Impact of hazardous alcohol use on intensive PTSD treatment outcomes among veterans

Background: Intensive treatment programmes (ITPs) for posttraumatic stress disorder (PTSD) produce large symptom reductions and have generally higher completion rates compared to traditional weekly care. Although ITPs do not appear to increase substance use, it has yet to be determined whether their effectiveness differs for veterans with and without hazardous alcohol use (HAU). Objective: This study examined the effectiveness of a 3-week Cognitive Processing Therapy-based ITP for 538 veterans with PTSD (66.0% male; mean age = 41.22 years) and with (n = 193) or without HAU (n = 343) for reducing PTSD and depression symptoms. Method: Veterans' PTSD (PCL-5) and depression (PHQ-9) symptoms were assessed at pre-treatment, during treatment, and at post-treatment. HAU (AUDIT-C total score ≥4 for males; ≥3 for females) was measured at intake. Results: Treatment completion rates were high for both individuals who endorsed HAU (92.68%) and those who did not (93.37%), likely due to veterans being housed near the treatment facility. Mixed effects regression models revealed a significant time by alcohol use interaction when predicting both PCL-5 (p < .001) and PHQ-9 (p = .003), suggesting time-trends over the course of the ITP differed based on alcohol use. Veterans who endorsed HAU improved to a statistically significantly lesser extent. However, endpoint differences between groups for both outcomes were small (Cohen's ds between 0.15 and 0.20). Conclusions: Veterans with and without HAU reported significant reductions in PTSD and depression symptoms and completed the ITP at comparably high rates. Findings support the effectiveness of intensive PTSD treatment programmes for individuals with PTSD and HAU. Future studies should utilize controlled designs to evaluate whether intensive PTSD treatment can reduce HAU.

Drinking to Cope with Posttraumatic Stress: A Nationally Representative Study of Men with and without Military Combat Experience

Posttraumatic stress disorder (PTSD) and hazardous alcohol use are prevalent among trauma survivors. Despite higher rates of both PTSD and hazardous alcohol use among military combat veterans than civilians, scant research has examined whether military combat experience is associated with drinking alcohol to cope with PTSD symptoms. This study tested the hypothesis that compared to trauma-exposed men without combat experience, men with military combat experience would be more likely to endorse drinking alcohol to cope with their PTSD symptoms. Methods: Interview data from N = 11,474 men who reported at least one lifetime traumatic experience were drawn from the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC), a face-to-face interview study that recruited a nationally representative sample of adults living in the United States between 2004 and 2005. Results: Among men endorsing lifetime trauma exposure, men with military combat experience (n = 1,386) were more likely than men without combat experience (n = 10,088) to report drinking alcohol to cope (7.22 vs. 2.61% in unweighted analyses, 6.46 vs. 2.37% in weighted analyses). Total number of lifetime trauma types, lifetime PTSD severity, and lifetime alcohol abuse/dependence were significantly associated with drinking to cope in bivariate and multivariate analyses. Military combat experience was significantly associated with drinking to cope in multivariate analyses adjusting for lifetime PTSD diagnosis. Military combat experience was not significantly associated with drinking to cope in multivariate analyses adjusting for lifetime PTSD symptom count. Conclusions: Although military combat experience was significantly associated with drinking to cope in bivariate analyses, multivariate analyses yielded mixed findings: combat experience was significantly associated with drinking to cope in models adjusting for PTSD diagnosis, but not in models adjusting for PTSD symptom count. Findings highlight the importance of assessing and targeting PTSD symptom-related alcohol use, even in the absence of alcohol abuse/dependence. Results from this preliminary study could inform future research on drinking to cope with PTSD symptoms among military combat veterans and other trauma survivors.

The Impact of Hazardous Drinking Among Active Duty Military With Posttraumatic Stress Disorder: Does Cognitive Processing Therapy Format Matter?

This study was a secondary data analysis of clinical trial data collected from 268 active duty U.S. military service members seeking cognitive processing therapy (CPT) for posttraumatic stress disorder (PTSD) at Fort Hood, Texas, related to combat operations following September 11, 2001. Our primary aim was to evaluate changes in PTSD symptom severity and alcohol misuse as a function of baseline hazardous drinking and treatment format (i.e., group or individual). At baseline and posttreatment, PTSD was assessed using the PTSD Symptom Scale-Interview Version and PTSD Checklist for DSM-5. Hazardous drinking was categorically defined as an Alcohol Use Disorder Identification Test total score of 8 or higher. Employing intent-to-treat, mixed-effects regression analysis, all groups reported reduced PTSD symptom severity, Hedges' gs = -0.33 to -1.01, except, unexpectedly, nonhazardous drinkers who were randomized to group CPT, Hedges' g = -0.12. Hazardous drinkers who were randomized to individual therapy had larger reductions in PTSD symptoms than nonhazardous drinkers who were randomized to group CPT, Hedges' g = -0.25. Hazardous drinkers also reported significant reductions in alcohol misuse, regardless of treatment format, Hedges' gs = -0.78 to -0.86. This study builds upon an emerging literature suggesting that individuals with PTSD and co-occurring alcohol use disorder can engage successfully in CPT, which appears to be an appropriate treatment for these individuals whether it is delivered individually or in a group format. However, as a portion of participants remained classified as hazardous drinkers at posttreatment, some individuals may benefit from integrated treatment.

The MET(T)A Protocol: Mindfulness and EMDR Treatment Template for Agencies

Evidence indicating the relationship between trauma and substance use disorders (SUDs), in addition to relapse and treatment retention rates for this population, suggests there is a need for a trauma-focused solution to treat SUDs. Eye movement desensitization and reprocessing (EMDR) therapy has been studied extensively as an effective approach for treating trauma and Posttraumatic Stress Disorder (PTSD). The research evaluating its treatment for other mental health disorders such as SUDs is promising. Merging mindfulness and ethical mindfulness practices with EMDR therapy lends additional evidence-based elements to make the case for this integrative system of treatment to be studied as a trauma-focused primary psychotherapy to treat SUDs. The resulting treatment, the MET(T)A Protocol (Mindfulness and EMDR Treatment Template for Agencies), has been created to address the need for a trauma-focused solution to treat SUDs. Procedures of the MET(T)A Protocol as applied in each of the 8 phases of EMDR therapy are described in detail. Clinical examples are provided to explain the application of the MET(T)A Protocol.

Cognitive behavioral social rhythm group therapy versus present centered group therapy for veterans with posttraumatic stress disorder and major depressive disorder: A randomized controlled pilot trial

BACKGROUND

Cognitive Behavioral Social Rhythm Group Therapy (CBSRT) is a chronobiologically-informed group therapy designed to stabilize social rhythms in veterans with comorbid combat-related PTSD and major depressive disorder (MDD). This randomized controlled pilot trial is the first to examine feasibility and preliminary efficacy of group CBSRT as compared to group Present Centered Therapy (PCT), a well-characterized active attention, psychotherapy condition.

METHODS

A total of 43 male veterans with combat-related PTSD, MDD, and disruptions in sleep or daily routine were randomly assigned to CBSRT or PCT. Therapy was provided weekly in a group modality for 12 weeks. Follow-up feasibility and gold-standard PTSD, MDD, and subjective/objective sleep assessments were conducted at post-treatment, 3 months, and 6 months post-treatment.

RESULTS

Feasibility results demonstrated that veterans assigned to CBSRT had higher rates of attendance than veterans assigned to PCT. Both CBSRT and PCT were associated with improvements in PTSD and MDD symptoms, sleep efficiency, and number of awakenings; there were no differences between group therapies on these indices. Veterans in the CBSRT group had a greater reduction in the number of nightmares than veterans in the PCT group.

LIMITATIONS

Preliminary results must be qualified by the small sample size.

CONCLUSIONS

Group CBSRT may be more feasible for veterans than PCT. Both CBSRT and PCT were associated with improvements in psychiatric symptoms with few differences between conditions. CBSRT is a promising new group therapy that may help address the high-rate of PTSD therapy attrition in combat veterans.

CLINICAL TRIAL REGISTRATION

NCT00984698.

Parallel process modeling of posttraumatic stress disorder symptoms and alcohol use severity in returning veterans

Posttraumatic stress disorder (PTSD) is associated with higher levels of alcohol use among returning veterans. Persistent PTSD symptoms can predict alcohol use over the span of hours, days, weeks, and months; however, knowledge of the strength of these associations beyond 1 year remains limited. In this study, we examined the 6-year course of co-occurring PTSD and alcohol use to explicate the directional and possible enduring effects of PTSD on alcohol use severity over time. Our study included 1,649 returning veterans (M age = 37.49; SD = 9.88) who completed 4 waves of data collection between 2010 and 2016. We used parallel process modeling to evaluate temporal associations between PTSD symptoms and alcohol use severity across 4 (T1-T4) waves of data collection. PTSD and alcohol use both decreased significantly between T1 and T4 and in tandem with one another. That is, decreases in one were associated with decreases in the other. Further, individuals with higher levels of PTSD symptom severity at T1 reported accelerated rates of change regarding PTSD symptoms and alcohol use over time. Conversely, baseline alcohol use severity did not predict the rate of change in PTSD symptom severity. Our findings provide evidence of a prospective association between PTSD symptoms and alcohol use and highlight the potential for reciprocal associations between them over the span of years. Importantly, our demonstration of the natural course of co-occurring PTSD symptoms and alcohol use suggests further trauma-focused and combined intervention strategies are needed to disrupt this enduring and reciprocal pattern among returning veterans. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

Cortisol as a Biomarker of Alcohol Use in Combat Veterans: A Literature Review and Framework for Future Research

Objective: Alcohol use and alcohol use disorders (AUDs) are an increasing concern among veterans, particularly those from recent conflicts in Iraq and Afghanistan. The study of biomarkers in alcohol use and AUD has moved to enhancing the understanding of the development and maintenance of AUDs, as well as investigating its association with clinical severity and potential predictors of treatment response. Cortisol, a glucocorticoid known as a stress hormone, has been linked with both stress and trauma, as well as increased alcohol suppression effects. Method/Results: The present review summarizes existing literature and presents suggestions for future research to evaluate whether cortisol may be a possible biomarker of alcohol use disorder risk in combat veterans. Specifically, aspects of combat deployments and high levels of PTSD, coupled with the stress of reintegration may dysregulate cortisol and increase risk to AUD. There may also be bidirectional impacts, such that alcohol is used as a coping mechanism and can dysregulate hypothalamic pituitary adrenal (HPA) axis functioning and cortisol. Conclusions: In the context of this framework, cortisol may serve as a biomarker for the development of AUD, as well as a biomarker of risk or relapse. This review ends with both theoretical and clinical implications, as well as directions for future research.

Zonisamide as an Adjunctive Treatment to Cognitive Processing Therapy for Veterans With Posttraumatic Stress Disorder and Comorbid Alcohol Use Disorder: A Pilot Study

BACKGROUND AND OBJECTIVES

There are high rates of comorbid alcohol use disorder (AUD) among those who have posttraumatic stress disorder (PTSD). Ideally, treatment for comorbidity should address both disorders simultaneously. Zonisamide, an anticonvulsant, may be effective in decreasing alcohol use and may attenuate symptoms of PTSD. Treatment strategies can include medication in combination with a proven evidence-based psychotherapy designed to treat PTSD, such as cognitive processing therapy (CPT).

METHODS

This 12-week pilot study was designed to test feasibility, acceptability, and preliminary efficacy of zonisamide (400 mg) as an adjunct to CPT for veterans with PTSD and comorbid AUD. Veterans (n = 24) with PTSD and current alcohol dependence were randomized in a 3:1 ratio to receive zonisamide or placebo in a double-blind fashion. All subjects received CPT enhanced to include sessions addressing drinking behavior.

RESULTS

Subjects overall reported a significant decrease in drinking outcomes, craving, and symptoms of PTSD. Zonisamide was well-tolerated and easily administered with CPT, which was also well-tolerated. Exploratory analysis of comparison of groups suggests there was no advantage of zonisamide vs placebo in drinking or PTSD outcomes. There was a numeric but nonsignificant higher rate of abstinence with zonisamide (50%) vs placebo (33%).

CONCLUSION AND SCIENTIFIC SIGNIFICANCE

The interpretation of the results is limited by the pilot nature of this study. The combination of psychosocial treatment with medication management mimics real-world treatment. In order to isolate the individual contributions of medication vs psychotherapy a much larger study would need to be conducted. (Am J Addict 2020;29:515-524).

The impact of substance use disorders on treatment engagement among justice-involved veterans with posttraumatic stress disorder

Veterans involved with the criminal justice system represent a particularly vulnerable population who experience high rates of both posttraumatic stress disorder (PTSD) and substance use disorders (SUD). This study sought to investigate whether having co-occurring SUD is a barrier to PTSD treatment. This is a retrospective observational study of a national sample of justice-involved veterans served by the Veterans Health Administration Veterans Justice Outreach program who had a diagnosis of PTSD (N = 27,857). Mixed effects logistic regression models with a random effect for facility (N = 141 medical centers) were utilized to estimate the odds of receiving each type of PTSD treatment as a function of having a SUD diagnosis. Results indicate that a majority of veterans with PTSD served by the Veterans Justice Outreach program have an SUD diagnosis (73%), and having a co-occurring SUD was associated with higher odds of receiving PTSD treatment, after adjusting for demographic differences. Although not without limitations, these results suggest that among justice-involved veterans enrolled in the Veterans Health Administration with PTSD, having an SUD comorbidity is not a barrier to PTSD treatment and may in fact facilitate access to PTSD treatment. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Efficacy of Integrated Exposure Therapy vs Integrated Coping Skills Therapy for Comorbid Posttraumatic Stress Disorder and Alcohol Use Disorder: A Randomized Clinical Trial

IMPORTANCE

Co-occurrence of posttraumatic stress disorder (PTSD) and alcohol use disorder (AUD) is common and associated with psychiatric and functional problems. Understanding whether exposure therapy is tolerable and efficacious for treating PTSD and AUD is critical to ensure that best practice treatments are available.

OBJECTIVE

To compare the efficacy of integrated (ie, targeting both PTSD and alcohol use) prolonged exposure (I-PE) therapy with present-centered integrated coping skills (I-CS) therapy, a more commonly available treatment, in reducing PTSD symptoms and alcohol use.

DESIGN, SETTING, AND PARTICIPANTS

This prospective randomized clinical trial with masked assessments considered 186 veterans seeking Veterans Affairs mental health services. A total of 119 veterans with PTSD and AUD were randomized. Data were collected from February 1, 2013, to May 31, 2017, before treatment, after treatment, and at 3- and 6-month follow-ups. Intention-to-treat analyses were performed.

INTERVENTIONS

Veterans underwent I-PE (Concurrent Treatment of PTSD and Substance Use Disorder Using Prolonged Exposure) or I-CS (Seeking Safety) therapy.

MAIN OUTCOMES AND MEASURES

A priori planned outcomes were PTSD symptoms (Clinician Administered PTSD Scale for DSM-5) and percentage of heavy drinking days (Timeline Follow-Back) before treatment, after treatment, and at 3- and 6-month follow-ups.

RESULTS

A total of 119 veterans (mean [SD] age, 41.6 [12.6] years; 107 [89.9%] male) were randomized. Linear mixture models found that PTSD symptoms decreased in both conditions, with a significantly greater decrease for I-PE treatment compared with I-CS treatment (treatment × time interaction, -2.83; F3,233.1 = 4.92; Cohen d = 0.41; P = .002). The percentage of heavy drinking days improved in both conditions but was not statistically different between I-PE and I-CS treatment (treatment × time interaction, 1.8%; F3,209.9 = 0.18; Cohen d = 0.04; P = .91).

CONCLUSIONS AND RELEVANCE

The I-PE arm had a greater reduction in PTSD symptoms than the I-CS arm and comparable drinking decreases. The study provides evidence that exposure therapy is more efficacious in treating PTSD than a more commonly available integrated treatment without exposure for comorbid PTSD and AUD.

TRIAL REGISTRATION

ClinicalTrials.gov identifier: NCT01601067.

Provider fidelity and modifications to cognitive processing therapy in a diverse community health clinic: Associations with clinical change

OBJECTIVE

The purpose of this study is to examine associations between therapist adherence, competence, and modifications of an evidence-based protocol (EBP) delivered in routine clinical care and client outcomes.

METHOD

Data were derived from a NIMH-funded implementation-effectiveness hybrid study of Cognitive Processing Therapy (CPT) for PTSD in a diverse community health center. Providers (n = 19) treated clients (n = 58) as part of their routine clinical care. Clients completed the PCL-S and PHQ-9 at baseline, after each CPT session, and posttreatment. CPT sessions were rated for treatment fidelity and therapist modifications.

RESULTS

Overall, therapist adherence was high, although it decreased across sessions suggesting potential drift. Therapist competence ratings varied widely. Therapists made on average 1.6 fidelity-consistent and 0.4 fidelity-inconsistent modifications per session. Results show that higher numbers of fidelity-consistent modifications were associated with larger reductions in posttraumatic stress and depressive symptoms. High adherence ratings were associated with greater reductions in depressive symptoms, whereas higher competence ratings were associated with greater reduction in posttraumatic stress symptoms.

CONCLUSIONS

The results highlight the importance of differentially assessing therapist adherence, competence, and modifications to EBP in usual care settings. The findings also suggest that effective EBP delivery in routine care may require minor adaptations to meet client needs, consistent with previous studies. Greater attention to fidelity and adaptation can enhance training so providers can tailor while retaining core components of the intervention. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Conceptualization, Assessment, and Treatment of Traumatic Stress in First Responders: A Review of Critical Issues

First responders are regularly confronted with exposure to traumatic events, including potentially life-threatening situations as well as the grave injuries and deaths of colleagues and civilians. Evidence indicates that the prevalence of posttraumatic stress disorder (PTSD) is substantially higher among first responders than the general population. This article provides information about the outpatient trauma services at McLean Hospital's LEADER (Law Enforcement, Active Duty, Emergency Responder) program to assist clinicians who encounter these first responders in their practices or who are specifically interested in working with this patient population. We begin by synthesizing the literature on the prevalence of PTSD in first responders following work-related exposure to traumatic stress, and by addressing the occupation-specific risk factors and the third-variable risk factors that may contribute to potentiated risk. We then discuss assessment strategies and treatment options used in our program, which is tailored for individuals who are dealing with mental health issues stemming from occupation-specific traumatic-stress exposure. We also address the unique challenges of treating traumatized first responders with more complex issues such as traumatic stress exposure across the lifespan and safety issues, including acute suicidality. We conclude by discussing notable gaps in the literature, including the need to investigate why and how women present with different PTSD symptoms than men and how these differences need to be taken into account in determining appropriate treatment for women.

Examination of Treatment Effects on Hazardous Drinking Among Service Members With Posttraumatic Stress Disorder

Posttraumatic stress disorder (PTSD) and alcohol use disorder are frequently comorbid and present significant treatment challenges. Unfortunately, since the September 11, 2001, terrorist attacks in the United States, the rates of PTSD and hazardous drinking among active duty service members have increased significantly. Previous research on PTSD has typically excluded participants with current substance abuse. However, there is some research examining independent treatments for PTSD and substance abuse provided consecutively, concurrently, or as enhancements to other treatment. The current study examined the association between current hazardous drinking and PTSD treatment among 108 active duty service members with PTSD in a randomized controlled trial of group cognitive processing therapy and group present-centered therapy. Total scores above 8 on the Alcohol Use Disorders Identification Test defined hazardous alcohol use. At baseline, 25.0% of the sample was categorized as hazardous drinkers, and the hazardous and nonhazardous drinking groups did not differ in PTSD symptom severity, F(1, 106) = 0.08, p = .777, d = 0.06. Over the course of treatment, the two groups also did not differ significantly in PTSD symptom severity change on the PTSD Checklist, F(1, 106) = 1.20, p = .280, d = 0.33. Treatment for PTSD did not exacerbate hazardous drinking, and the hazardous drinking group showed significant reductions in drinking following PTSD treatment. Limitations and implications for treatment considerations are discussed.

Tailoring Cognitive Behavioral Therapy for Trauma-Exposed Persons Living With HIV

This Treatment Development Report describes the need for evidence-based psychosocial trauma-focused treatment for people living with comorbid posttraumatic stress disorder (PTSD) and HIV. Individuals with HIV have higher rates of exposure to traumatic events and PTSD than the general public, and they also experience additional consequences of PTSD on the management of their chronic disease (e.g., established link between PTSD symptoms and lack of adherence to antiretroviral therapy [ART]). We used the empirically-supported ADAPT-ITT approach to consider the initial steps in adapting evidence-based Cognitive Processing Therapy (CPT) for individuals with PTSD and HIV. This paper reviews a case example that involved various clinical issues that may arise when providing trauma-focused treatment for people living with HIV including HIV-stigma, disease management, and the need for making multicultural adaptations to psychotherapy. This case example illustrates how trauma-focused treatment may benefit from enhancement to address additional barriers that may arise over the course of PTSD treatment in this population. Feasibility of engaging and delivering a "full dose" of evidence-based PTSD treatment among individuals living with HIV is discussed. While evidence-based treatments can reduce PTSD symptom severity, issues related to chronic disease coping and HIV-related stigma management could be integrated to augment the efficacy of treatment for individuals with HIV. Adaptive intervention research targeting PTSD in persons living with HIV warrants further attention, especially given the association between PTSD and adherence to ART.

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

An overlooked sequela of HIV risk is trauma exposure, yet few HIV interventions address trauma exposure, mental health, and substance misuse. In a two-arm randomized controlled trial 73 Native American women were randomized to a culturally-adapted Cognitive Processing Therapy (CPT) or 6-weeks waitlist. Outcomes assessed: PTSD symptom severity, alcohol use frequency, substance abuse or dependence diagnosis, and high-risk sexual behavior defined as vaginal/anal intercourse (a) under the influence of alcohol and/or illicit substances, (b) with a partner who was concurrently sexually active with someone else, and/or (c) with more than one partner in the past 6 weeks. Among immediate intervention participants, compared to waitlist participants, there were large reductions in PTSD symptom severity, high-risk sexual behavior, and a medium-to-large reduction in the frequency of alcohol use. CPT appears to improve mental health and risk behaviors, suggesting that addressing PTSD may be one way of improving HIV-risk related outcomes.

Substance use disorders and PTSD: Examining substance use, PTSD symptoms, and dropout following imaginal exposure

Integrated exposure-based interventions to treat substance use disorders (SUD) and posttraumatic stress disorder (PTSD) may not be widely utilized, in part, because of clinician concerns that such interventions will worsen symptomatology and lead to treatment dropout. In order to address this question, the current pilot study examined whether participants' ratings of craving and distress following imaginal exposure predicted increased substance use, PTSD severity, and treatment dropout. Participants (N = 46) were U.S. military Veterans who met criteria for current SUD and PTSD. Subjective ratings of craving and distress, and past-week substance use and PTSD symptom severity were assessed at each treatment session. Multilevel modeling tested whether lagged ratings of craving and distress predicted the following week's frequency of substance use and PTSD severity. Discrete time survival analysis, using proportional odds Cox ratio, examined whether craving and distress ratings predicted treatment dropout. The findings revealed that neither craving nor distress following imaginal exposure were associated with the following week's substance use or PTSD severity. However, participants with higher craving and distress were more likely to drop out before completing treatment. Future research is needed to develop strategies to increase treatment retention for individuals at-risk for treatment dropout and identify mechanisms that account for the association between in-session ratings of craving and distress and dropout.

Effects of Psychoeducation and Stress Coping Techniques on Posttraumatic Stress Disorder Symptoms

This study examined the effects of psychoeducation and stress management techniques on Posttraumatic Stress Disorder (PTSD) symptoms in Libya. The 41 Libyan patients who volunteered to take part in the study were first assessed using the PTSD Checklist. They attended workshops on PTSD symptoms, stress management techniques, and communication skills on three successive days after which they were asked to answer the Coping Inventory for Stressful Situations two weeks after they completed the workshops. Among the 39% of the participants who were diagnosed with PTSD prior to the intervention, 15% met the diagnostic criteria for PTSD after the intervention. The preintervention scores were consistently higher than the postintervention scores, and there were significant differences in the PTSD Checklist total score and the re-experiencing, avoidance, and hyperarousal symptom scores. This study concluded that in mass-trauma events such as war and natural disasters, PTSD education can reduce the PTSD symptoms of those affected. Whether the benefits of psychoeducation on the participants are long term or short term is recommended for further study due to the limitations imposed by the willingness of the participants to participate, the amount of time they are willing to stay with the program, and the duration of the psychoeducation program itself.

Trauma treatment for veterans in buprenorphine maintenance treatment for opioid use disorder

INTRODUCTION

Opioid use disorder (OUD) rates are high among veterans. PTSD is also prevalent among veterans; those with comorbidity have worse outcomes than those without comorbidity. This study assessed buprenorphine retention rates in veterans initiating OUD treatment, comparing veterans without PTSD to veterans with PTSD who were receiving versus not receiving concurrent trauma treatment.

METHODS

This retrospective chart review examined consecutive referrals to buprenorphine maintenance (N = 140). PTSD diagnosis was identified by chart review and retention was defined as continuous buprenorphine maintenance 6-months post-admission. Logistic regression analyses compared buprenorphine retention for veterans without PTSD and PTSD-diagnosed veterans who received concurrent trauma treatment to a reference group of PTSD-diagnosed veterans who did not receive trauma treatment. Models adjusted for opioid type, age, and service-connected status.

RESULTS

Sixty-seven (47.9%) buprenorphine-seeking veterans carried a PTSD diagnosis; only 31.3% (n = 21) received trauma treatment while in buprenorphine maintenance, with 11.9% (n = 8) receiving evidence-based psychotherapy for PTSD. Among PTSD-diagnosed veterans who received trauma treatment, 90.5% (n = 19/21) were in buprenorphine maintenance at 6-months, compared to 23.9% (n = 11/46) of PTSD-diagnosed veterans without trauma treatment, and 46.6% (n = 34/73) of veterans without PTSD. In the full model, veterans with trauma treatment had 43.36 times greater odds of remaining in buprenorphine treatment than the reference group.

CONCLUSIONS

Most PTSD-diagnosed veterans in buprenorphine treatment were not receiving trauma treatment. Those receiving concurrent trauma treatment had better retention, suggesting OUD and trauma can be simultaneously addressed. Future clinical trials should investigate trauma-focused treatment for veterans with comorbid PTSD who are seeking buprenorphine for OUD.

A cognitive processing therapy-based treatment program for veterans diagnosed with co-occurring posttraumatic stress disorder and substance use disorder: The relationship between trauma-related cognitions and outcomes of a 6-week treatment program

Dysfunctional trauma-related cognitions are important in the emergence and maintenance of posttraumatic stress disorder (PTSD) and the modification of such cognitions is a proposed mechanism of trauma treatment. However, the authors are not aware of any research examining trauma-related cognitions as a treatment mechanism in a sample of individuals with comorbid PTSD and substance use disorder (SUD). Accordingly, the present study sought to address this gap in the literature and examined the relationship between trauma-related cognitions and treatment outcomes within a sample of seventy-two veterans diagnosed with PTSD and SUD. Veterans completed a 6-week day CPT-based treatment program that included cognitive processing therapy as a central component. Measures of trauma-related cognitions, PTSD symptoms, depressive symptoms, and trauma-cued substance craving were completed at pre- and post-treatment. As expected, trauma-related cognitions were associated with several PTSD-related variables prior to treatment. Furthermore, results of a within-subjects mediational analysis indicated that maladaptive trauma-related cognitions decreased during the treatment program and accounted for a significant portion of the variance in the reduction of PTSD and depressive symptoms at post-treatment. This study provides support for the position that attempts to modify dysfunctional trauma-related cognitions among veterans with co-occurring PTSD and SUD can lead to desirable treatment outcomes.

Posttraumatic stress disorder symptoms improve after an integrated brief alcohol intervention for OEF/OIF/OND veterans

OBJECTIVE

Although brief alcohol interventions (BAIs) that incorporate personalized feedback demonstrate efficacy for reducing the frequency and quantity of alcohol consumption in veteran samples, little research has explored the influence of BAIs in reducing symptoms of posttraumatic stress disorder (PTSD). The goal of this investigation was to understand whether PTSD symptom severity and diagnostic status changed after exposure to an intervention that targeted alcohol misuse and integrated feedback on PTSD.

METHOD

Sixty-eight combat veterans (8.8% female; 27.9% African American) who screened positive for hazardous drinking were recruited from a Veterans Affairs Medical Center. Participants received a 1-session brief intervention that primarily targeted alcohol misuse but also included personalized feedback and psychoeducation on PTSD symptoms and coping. Participants were randomized to receive personalized written feedback either with or without a motivational interview.

RESULTS

A mixed-model repeated measures analysis revealed that PTSD symptom severity was significantly lower at the 6-week (M = 41.47, SD = 28.94) and 6-month (M = 35.56 SD = 26.99) follow-up appointments relative to baseline (M = 51.22, SD = 26.67), F(2, 127.24) = 38.32, p < .001. Regression analyses demonstrate that the percent change in alcohol use was related to the change in PTSD severity. Further, results indicated that a motivational-interviewing-style counseling session accompanying the feedback was not significantly more efficacious than receiving feedback only.

CONCLUSION

A brief alcohol intervention that integrates information on PTSD has the potential to reduce PTSD severity. Personalized alcohol and PTSD feedback may be useful as an opportunistic intervention for OEF/OIF veterans. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

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.

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.

Co-Occurring Post-Traumatic Stress Disorder and Alcohol Use Disorder in U.S. Military and Veteran Populations

Co-occurring post-traumatic stress disorder (PTSD) and alcohol use disorder (AUD) are costly and consequential public health problems that negatively affect the health and well-being of U.S. military service members and veterans. The disproportionate burden of comorbid PTSD and AUD among U.S. military service members and veterans may be due to unique factors associated with military service, such as aspects of military culture, deployment, and trauma exposure. This review addresses the prevalence of co-occurring PTSD and AUD in military and veteran populations, population-specific factors that contribute to development of the comorbid conditions, and evidence-based treatments that have promise for addressing these conditions in military and veteran populations. Future directions for research and practice relevant to military and veteran populations are discussed.

Empirical Examinations of Modifications and Adaptations to Evidence-Based Psychotherapies: Methodologies, Impact, and Future Directions

This review describes methods used to examine the modifications and adaptations to evidence-based psychological treatments (EBPTs), assesses what is known about the impact of modifications and adaptations to EBPTs, and makes recommendations for future research and clinical care. One hundred eight primary studies and three meta-analyses were identified. All studies examined planned adaptations, and many simultaneously investigated multiple types of adaptations. With the exception of studies on adding or removing specific EBPT elements, few studies compared adapted EBPTs to the original protocols. There was little evidence that adaptations in the studies were detrimental, but there was also limited consistent evidence that adapted protocols outperformed the original protocols, with the exception of adding components to EBPTs. Implications for EBPT delivery and future research are discussed.

An examination of alcohol risk profiles and co-occurring mental health symptoms among OEF/OIF veterans

INTRODUCTION

Compared to the general population, veterans of the wars in Afghanistan and Iraq (OEF/OIF) are more likely to engage in hazardous alcohol use and meet criteria for mental health disorders including Posttraumatic Stress Disorder (PTSD) and Major Depressive Disorder. Less is known how distinct profiles of alcohol use behavior relate to mental health symptoms.

METHOD

The current study examined the extent that indicators of alcohol use (i.e., drinks per week, peak blood alcohol concentration, and alcohol-related problems) are categorized into different alcohol risk profiles utilizing a person-centered approach. We also examined how mental health symptoms (i.e., PTSD, depression, and anxiety-related symptoms) were associated with the alcohol risk profiles. Participants were 252 Veterans who reported consuming alcohol within the past month.

RESULTS

Latent profile analysis indicated a four-class solution yielded the best-fitting model, and profiles were named based on their respective levels and patterns of alcohol use. Mental health symptoms were significantly different among the four profiles. Profiles of veterans who endorsed more alcohol-related problems (i.e., the "Severe alcohol behavior" and "Steady drinkers with functional impairment") also reported comorbid clinical symptoms of PTSD, depression, and anxiety. The "Binge drinkers with no functional impairment" and "Mild alcohol behavior" profiles reported the lowest levels of mental health symptoms.

DISCUSSION

Findings highlight the unique relationship between distinct alcohol risk profiles and mental health outcomes. Targeted interventions and treatment options based on unique alcohol risk profiles may be helpful in tailoring prevention and intervention efforts in detecting co-occurring mental health symptoms among OEF/OIF veterans.

Trauma-Related Pain, Reexperiencing Symptoms, and Treatment of Posttraumatic Stress Disorder: A Longitudinal Study of Veterans

Research has demonstrated a strong positive association between posttraumatic stress disorder (PTSD) symptoms and physical pain. However, few studies have explored the impact of pain problems on the symptoms and treatment of PTSD, and results remain inconsistent. This longitudinal study examined whether trauma-related and trauma-unrelated pain differentially and uniquely predicted reexperiencing symptoms. We also examined whether levels of reexperiencing symptoms mediated the relationship between pain intensity and posttreatment symptoms of avoidance, numbing, and hyperarousal (ANH). Analyses were conducted using archival data from 99 treatment-seeking veterans who reported the etiology and intensity of their pain and severity of PTSD symptoms pre- and posttreatment. Among veterans with trauma-related pain, pain intensity (a) uniquely corresponded to greater posttreatment reexperiencing symptoms (b = 1.09), and (b) was indirectly predictive of ANH symptoms via the reexperiencing symptoms (b = 1.93). However, veterans with trauma-unrelated pain evidenced no associations between pain intensity and reexperiencing (b = 0.04) or ANH symptoms (b = 0.06). We thus found that trauma-related pain was indirectly related to poor PTSD treatment outcomes via reexperiencing symptoms. These findings offer additional insight into factors that may influence PTSD treatment outcomes for pain-suffering trauma survivors.