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Medenblik AM, Garner AR, Basting EJ, Sullivan JA, Jensen MC, Shorey RC, Stuart GL. Examining trauma, anxiety, and depression as predictors of dropout from residential treatment for substance use disorders. J Clin Psychol 2024; 80:1767-1779. [PMID: 38662953 DOI: 10.1002/jclp.23692] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2023] [Revised: 02/27/2024] [Accepted: 04/01/2024] [Indexed: 07/05/2024]
Abstract
Substance use disorders (SUDs) are highly prevalent and have deleterious effects on one's health and well-being. Inpatient treatment for SUDs reduces patient relapse, which subsequently ameliorates these negative effects on the individual and society. Additionally, those who complete treatment are less likely to relapse compared to those who do not complete treatment. Thus, maintaining patient engagement in treatment and reducing the rates of those leaving against medical advice (AMA) is particularly important. Examining the factors and comorbidities that may contribute to treatment dropout has the potential to identify at-risk patients in need of additional individualized intervention. The current study aimed to examine comorbid anxiety, depression, and posttraumatic stress disorder (PTSD) symptoms as predictors of dropout AMA in a residential substance use treatment population. Results showed that patients with social anxiety were more likely to leave treatment AMA, while those with PTSD were more likely to complete treatment. Findings suggest that PTSD-specific treatment, as offered in this facility, may help with patient retention, while group focused therapy may be distressing to those with social anxiety. Clinical implications of this research may include incorporating evidence-based practice for social anxiety early during inpatient treatment to reduce anxiety such that patients may better engage with SUDs treatment.
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Affiliation(s)
- Alyssa M Medenblik
- Department of Psychology, University of Tennessee-Knoxville, Knoxville, Tennessee, USA
| | - Alisa R Garner
- Department of Psychology, University of Tennessee-Knoxville, Knoxville, Tennessee, USA
| | - Evan J Basting
- Department of Psychology, University of Tennessee-Knoxville, Knoxville, Tennessee, USA
| | - Jacqueline A Sullivan
- Department of Psychology, University of Tennessee-Knoxville, Knoxville, Tennessee, USA
| | - Mary C Jensen
- Department of Psychology, University of Tennessee-Knoxville, Knoxville, Tennessee, USA
| | - Ryan C Shorey
- Department of Psychology, University of Tennessee-Knoxville, Knoxville, Tennessee, USA
- Department of Psychology, University of Wisconsin-Milwaukee, Milwaukee, Wisconsin, USA
| | - Gregory L Stuart
- Department of Psychology, University of Tennessee-Knoxville, Knoxville, Tennessee, USA
- Residential Addiction Treatment Center, Cornerstone of Recovery, Alcoa, Tennessee, USA
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2
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Gonçalves M, Martinho G, Ghafoori B. Trauma-focused treatments for victims of interpersonal violence: A comparison of treatment interventions and outcomes. Psychother Res 2024:1-14. [PMID: 38805400 DOI: 10.1080/10503307.2024.2353890] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2023] [Accepted: 05/02/2024] [Indexed: 05/30/2024] Open
Abstract
Background: Interpersonal violence represents a critical public health issue globally, with profound psychological impacts on victims. Objective: The main objective of this study was to analyze the effectiveness of different trauma-focused therapies on mental health outcomes of victims of interpersonal violence, at a community mental health clinic. Methods: Employing a secondary data methodology, the research involves 601 participants who reported being victims of sexual assault (49.1%), domestic violence (44.3%) or sexual trafficking (6.7%). The average age of the participants was 35.54 years, with a majority being female (89.8%). Results: Initial assessments revealed distinct symptomatology among the groups; however, by the ninth therapy session, symptom severity converged across the board, surpassing threshold levels for clinical concern. No significant interaction was observed between the type of trauma-focused therapy and the specific trauma encountered, suggesting a beneficial effect of trauma-focused therapies investigated. This uniformity in therapeutic outcomes underscores the potential of trauma-focused therapies to foster psychological healing in victims of diverse forms of interpersonal violence. Conclusions: The findings advocate for the widespread adoption of trauma-focused therapeutic interventions in community settings, emphasizing their role in the recovery of victims, independent of the nature of the trauma or the specific trauma-focused therapeutic model employed.
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Affiliation(s)
- Mariana Gonçalves
- Psychology Research Center, School of Psychology, University of Minho, Braga, Portugal
| | | | - Bita Ghafoori
- Department of Advanced Studies in Education and Counseling, California; State University Long Beach, Long Beach, CA, USA
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3
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Somohano VC, Cameron D, Lewis M, Denneson LM, Lovejoy TI, O'Neil ME. Characterizing and Comparing Evidence-Based Psychotherapy Utilization Among Veterans with Co-occurring PTSD and Substance Use Disorder. Subst Use Misuse 2024; 59:425-431. [PMID: 38111167 DOI: 10.1080/10826084.2023.2275566] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2023]
Abstract
Objective: The current study sought to describe a nationally representative sample of Veterans diagnosed with co-occurring PTSD and substance use disorder (SUD) who initiated and completed evidence-based psychotherapy (EBP) for PTSD, and explored whether completion rates differed by SUD subtype. Methods: Using electronic health record data from the Veterans Health Administration (VHA) Corporate Data Warehouse, Veterans with a dual diagnosis of PTSD and SUD who initiated either Cognitive Processing Therapy (CPT) or Prolonged Exposure (PE) between January 01, 2019 and July 16, 2019 were identified (N = 2,996). Logistic analyses were employed to determine whether there were differences in EBP completion rates among Veterans with an alcohol use disorder (AUD; n = 1,383) versus all other SUDs (n = 1,613). Results: On average, Veterans were 45 years old, and identified as male, White, and non-Hispanic. Logistic regression analyses revealed there was not a significant difference between Veterans with AUD only and other SUDs in the probability of completing EBP treatment, OR = 1.02, 95% CI =0.87, 1.17, p = 0.79. Conclusions: No differences in EBP completion rates were observed between SUD subtypes, indicating that EBPs for PTSD are tolerated well for individuals with various types of SUDs and may be offered as treatment options.
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Affiliation(s)
- Vanessa C Somohano
- Center to Improve Veteran Involvement in Care, VA Portland Healthcare System, Portland, Oregon, USA
| | - David Cameron
- Center to Improve Veteran Involvement in Care, VA Portland Healthcare System, Portland, Oregon, USA
- School of Medicine, Oregon Health and Science University, Portland, Oregon, USA
| | - Meaghan Lewis
- Center to Improve Veteran Involvement in Care, VA Portland Healthcare System, Portland, Oregon, USA
| | - Lauren M Denneson
- Center to Improve Veteran Involvement in Care, VA Portland Healthcare System, Portland, Oregon, USA
- School of Medicine, Oregon Health and Science University, Portland, Oregon, USA
| | - Travis I Lovejoy
- Center to Improve Veteran Involvement in Care, VA Portland Healthcare System, Portland, Oregon, USA
- School of Medicine, Oregon Health and Science University, Portland, Oregon, USA
| | - Maya E O'Neil
- Center to Improve Veteran Involvement in Care, VA Portland Healthcare System, Portland, Oregon, USA
- School of Medicine, Oregon Health and Science University, Portland, Oregon, USA
- Department of Medical Informatics and Clinical Epidemiology, Oregon Health and Science University, Portland, OR
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Polizzi CP, Sistad RE, Livingston NA, Brief D, Litwack S, Roy M, Solhan M, Rosenbloom D, Keane TM. Alcohol-Related Problems As Moderators of PTSD Symptom Change During Use of a Web-Based Intervention for Hazardous Drinking and PTSD. J Stud Alcohol Drugs 2024; 85:51-61. [PMID: 37796630 PMCID: PMC10846604 DOI: 10.15288/jsad.23-00094] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2023] [Accepted: 09/14/2023] [Indexed: 10/07/2023] Open
Abstract
OBJECTIVE Alcohol-related problems (e.g., physical, interpersonal, intrapersonal, impulse control, social responsibility) can have an impact on posttraumatic stress disorder (PTSD) symptoms during treatment. Evidence-based online self-help tools exist to target alcohol use and related problems and co-occurring PTSD symptoms. It is unknown to what degree individuals with varying alcohol-related problems respond differently to web-based interventions for hazardous alcohol use and PTSD. The current study evaluated specific alcohol-related problems as potential moderators of PTSD symptom changes during the VetChange online intervention while controlling for average daily alcohol use, gender, race, and age. METHOD We conducted a secondary analysis of a randomized controlled trial that included 600 post-9/11 veterans (518 men and 82 women). Mixed-effects regression models of alcohol-related problems on PTSD severity scores over time were performed separately in an initial intervention group (IIG; n = 404) and a delayed intervention group (DIG; n = 196) that was used as a comparison condition. RESULTS Interpersonal problems emerged as a moderator of PTSD symptom changes in IIG such that veterans endorsing greater interpersonal problems demonstrated larger reductions in PTSD symptoms throughout VetChange. There were no significant moderation effects in DIG. Non-White veterans reported significantly higher PTSD symptoms during VetChange. Post hoc analyses indicated that veterans with higher interpersonal problems were more likely to engage in online intervention content focused on identifying high-risk drinking situations and coping with symptoms. CONCLUSIONS Findings imply that veterans reporting alcohol-related interpersonal problems may benefit the most from, and be more motivated to use, online interventions for hazardous alcohol use and PTSD symptoms.
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Affiliation(s)
- Craig P. Polizzi
- U.S. Department of Veteran Affairs, Veterans Affairs Boston Healthcare System, Boston, Massachusetts
- Department of Psychiatry, Boston University Chobanian & Avedisian School of Medicine, Boston, Massachusetts
| | - Rebecca E. Sistad
- U.S. Department of Veteran Affairs, Veterans Affairs Boston Healthcare System, Boston, Massachusetts
- U.S. Department of Veteran Affairs, Minneapolis Veterans Affairs Healthcare System, Minneapolis, Minnesota
| | - Nicholas A. Livingston
- U.S. Department of Veteran Affairs, Veterans Affairs Boston Healthcare System, Boston, Massachusetts
- Department of Psychiatry, Boston University Chobanian & Avedisian School of Medicine, Boston, Massachusetts
- National Center for PTSD, Behavioral Science Division, Veterans Affairs Boston Healthcare System, Boston, Massachusetts
| | - Deborah Brief
- U.S. Department of Veteran Affairs, Veterans Affairs Boston Healthcare System, Boston, Massachusetts
- Department of Psychiatry, Boston University Chobanian & Avedisian School of Medicine, Boston, Massachusetts
| | - Scott Litwack
- U.S. Department of Veteran Affairs, Veterans Affairs Boston Healthcare System, Boston, Massachusetts
- Department of Psychiatry, Boston University Chobanian & Avedisian School of Medicine, Boston, Massachusetts
| | - Monica Roy
- U.S. Department of Veteran Affairs, Veterans Affairs Boston Healthcare System, Boston, Massachusetts
- Department of Psychiatry, Boston University Chobanian & Avedisian School of Medicine, Boston, Massachusetts
| | - Marika Solhan
- Department of Psychiatry, Boston University Chobanian & Avedisian School of Medicine, Boston, Massachusetts
- U.S. Department of Veterans Affairs, Boston Vet Center, Boston, Massachusetts
| | - David Rosenbloom
- Boston University School of Public Health, Boston, Massachusetts
| | - Terence M. Keane
- U.S. Department of Veteran Affairs, Veterans Affairs Boston Healthcare System, Boston, Massachusetts
- Department of Psychiatry, Boston University Chobanian & Avedisian School of Medicine, Boston, Massachusetts
- National Center for PTSD, Behavioral Science Division, Veterans Affairs Boston Healthcare System, Boston, Massachusetts
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Cooper AA, Kline AC, Baier AL, Feeny NC. Rethinking Research on Prediction and Prevention of Psychotherapy Dropout: A Mechanism-Oriented Approach. Behav Modif 2023; 47:1195-1218. [PMID: 30079755 DOI: 10.1177/0145445518792251] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2023]
Abstract
Dropout is a ubiquitous psychotherapy outcome in clinical practice and treatment research alike, yet it remains a poorly understood problem. Contemporary dropout research is dominated by models of prediction that lack a strong theoretical foundation, often drawing on data from clinical trials that report on dropout in an inconsistent and incomplete fashion. In this article, we assert that dropout is a critical treatment outcome that is worthy of investigation as a mechanistic process. After briefly describing the scope of the dropout problem, we discuss the many factors that limit the field's present understanding of dropout. We then articulate and illustrate a transdiagnostic conceptual framework for examining psychotherapy dropout in contemporary research, concluding with recommendations for future research. With a more comprehensive understanding of the factors affecting retention, research efforts can shift toward investigating key processes underlying treatment dropout, thus, boosting prediction and informing strategies to mitigate dropout in clinical practice.
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Lee BK, Ofori Dei SM, Brown MMR, Awosoga OA, Shi Y, Greenshaw AJ. Congruence couple therapy for alcohol use and gambling disorders with comorbidities (part I): Outcomes from a randomized controlled trial. FAMILY PROCESS 2023; 62:124-159. [PMID: 36217243 DOI: 10.1111/famp.12813] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/11/2021] [Revised: 07/08/2022] [Accepted: 07/20/2022] [Indexed: 06/16/2023]
Abstract
A nonblinded randomized trial was conducted at two Canadian provincial outpatient addiction clinics that tested the effectiveness of a systemic congruence couple therapy (CCT) versus individual-based treatment-as-usual (TAU) on nine clinical outcomes: (1) primary outcomes-alcohol use and gambling, psychiatric symptoms, and couple adjustment; (2) secondary outcomes-emotion regulation, substance use, depression, post-traumatic stress symptoms, and life stress. Data of primary clients and partners (N = 46) were analyzed longitudinally across baseline, posttreatment (5 months), and follow-up (8 months). Alcohol use disorder (95%) and gambling disorder (5%) were in the severe range at baseline, and co-addiction was 27%. Psychiatric comorbidity was 100%, and 18% of couples were jointly addicted. Between-group comparison favored CCT in primary outcomes with medium-to-large effect sizes (Cohen's h = 0.74-1.44). Secondary outcomes were also significantly stronger for CCT (Cohen's h = 0.27-1.53). Within-group, for all primary outcomes, a significant proportion of symptomatic CCT clients and partners improved, converging with ANOVA results of large effect sizes (0.14-0.29). All secondary outcomes improved significantly in CCT with large effect sizes (0.14-0.50). TAU showed significant within-group improvement in alcohol use, other substance use, and life stress with large effect sizes (0.16-0.40). Primary clients and partners made largely equivalent improvement within CCT and within TAU. Results were triangulated with clients' satisfaction ratings and counselors' reports. Overall, significant within-group effects were detected for CCT both clinically and statistically and between-group difference favored CCT. Future trials are required to validate these promising findings.
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Affiliation(s)
- Bonnie K Lee
- Faculty of Health Sciences, University of Lethbridge, Lethbridge, Alberta, Canada
| | - Samuel M Ofori Dei
- Faculty of Health Sciences, University of Lethbridge, Lethbridge, Alberta, Canada
| | - Matthew M R Brown
- Department of Psychiatry, University of Alberta, Edmonton, Alberta, Canada
| | - Olu A Awosoga
- Faculty of Health Sciences, University of Lethbridge, Lethbridge, Alberta, Canada
| | - Yanjun Shi
- Faculty of Health Sciences, University of Lethbridge, Lethbridge, Alberta, Canada
| | - Andrew J Greenshaw
- Department of Psychiatry, University of Alberta, Edmonton, Alberta, Canada
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Killeen TK, Wen CC, Neelon B, Baker N. Predictors of Treatment Completion among Women Receiving Integrated Treatment for Comorbid Posttraumatic Stress and Substance Use Disorders. Subst Use Misuse 2023; 58:500-511. [PMID: 36705433 DOI: 10.1080/10826084.2023.2170183] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
Background: Retention in treatment for individuals with comorbid posttraumatic stress disorder (PTSD) and substance use disorders (SUD) is an area of concern in treatment outcome studies. The current study explores key variables related to retention in a group of women with comorbid PTSD and SUD enrolled in community SUD treatment randomized to eight weekly sessions of a trauma adapted mindfulness-based relapse prevention (TA-MBRP) or an integrated coping skills (ICS) group intervention. Methods: Two unadjusted and adjusted logistic discrete failure time (DFT) models were fit to examine associations between participants and the time (in weeks) to treatment completion status. Key covariates of interest, including time-varying PTSD Symptom Scale-Self Report (PSS) total score, time-varying Five Factors Mindfulness Questionnaire (FFMQ) total score, group assignment, baseline endorsements of substance use and demographics such as age, race and employment status were fit into the model. Results: In the adjusted PSS model, increased levels of PTSD symptom severity (PSS) scores at week 5 and 7 (PSS OR: 1:06: OR 1.13, respectively) were associated with higher odds of non-completion. In the FFMQ model, increased levels of FFMQ scores at week 6 (OR: 0:92) were associated with lower odds of non-completion. In both models, assignment to the ICS control group and unemployment were associated with lower odds of completion and baseline use of cocaine and sedatives were associated with higher odds of completion. Conclusion: Monitoring PTSD symptom severity and measures of mindfulness can inform providers on strategies to enhance retention early in treatment for individuals with comorbid PTSD/SUD.ClinicalTrials.gov # NCT02755103.
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Affiliation(s)
- Therese K Killeen
- Department of Psychiatry and Behavioral Sciences, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Chun-Che Wen
- Department of Public Health Sciences, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Brian Neelon
- Department of Public Health Sciences, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Nathanial Baker
- Department of Public Health Sciences, Medical University of South Carolina, Charleston, South Carolina, USA
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Watkins LE, Patton SC, Drexler K, A. M. Rauch S, Rothbaum BO. Clinical Effectiveness of an Intensive Outpatient Program for Integrated Treatment of Comorbid Substance Abuse and Mental Health Disorders. COGNITIVE AND BEHAVIORAL PRACTICE 2022. [DOI: 10.1016/j.cbpra.2022.05.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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9
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Failure in psychotherapy: a qualitative comparative study from the perspective of patients diagnosed with depression. COUNSELLING PSYCHOLOGY QUARTERLY 2022. [DOI: 10.1080/09515070.2022.2047614] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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Roberts NP, Lotzin A, Schäfer I. A systematic review and meta-analysis of psychological interventions for comorbid post-traumatic stress disorder and substance use disorder. Eur J Psychotraumatol 2022; 13:2041831. [PMID: 35558682 PMCID: PMC9090345 DOI: 10.1080/20008198.2022.2041831] [Citation(s) in RCA: 24] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND The psychological treatment of comorbid post-traumatic stress disorder (PTSD) and substance use disorder (SUD) is clinically challenging, and outcomes are often poor. OBJECTIVE This paper describes a systematic review and meta-analysis which sought to establish the current efficacy for a number of established psychological approaches for adults and adolescents, in comparison to interventions for SUD alone, or other active approaches, following a pre-registered protocol. METHOD This review followed PRISMA and Cochrane Collaboration guidelines. Data extraction and risk of bias judgements using Cochrane criteria were undertaken by all authors. Primary outcomes were PTSD severity and substance use post-treatment. The quality of findings was assessed using GRADE. Following a comprehensive search, conducted to 13 September 2021, 27 studies were included. RESULTS We found a relatively high level of dropout across studies. In our main comparisons, we found no benefits for present-focused treatment approaches aimed at improving coping skills beyond those for SUD-only interventions. We found modest benefits for trauma-focused intervention plus SUD intervention post-treatment for PTSD (standardized mean difference (SMD) = -0.36, 95% confidence interval (CI) -0.64, -0.08), and at 6-13 months for PTSD (SMD = -0.48, 95% CI -0.81, -0.15) and alcohol use (SMD = -0.23, 95% CI -0.44, -0.02). There were no benefits for cognitive restructuring interventions as a group, but we found a modest effect for integrated cognitive behavioural therapy (ICBT) for PTSD post-treatment (SMD = -0.33, 95% CI -0.62, -0.04). There was evidence of some benefit for trauma-focused intervention over present-focused intervention for PTSD from a single study and for reduction in dropout for incentivized attendance for trauma-focused intervention from another single study. Most findings were of very low quality. CONCLUSION There is evidence that trauma-focused therapy and ICBT can improve PTSD for some individuals, but many patients do not fully engage with treatment and average treatment effects are modest. HIGHLIGHTS For PTSD, evidence was strongest for trauma-focused CBT-based approaches, but effects were modest.There was little evidence of any added benefit on substance use, beyond that of standard addiction treatments, for any included intervention.Dropout from treatment was high.
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Affiliation(s)
- Neil P Roberts
- Cardiff & Vale University Health Board, Cardiff, UK.,Division of Psychological Medicine and Clinical Neurosciences, Cardiff University, Cardiff, UK
| | - Annett Lotzin
- Department of Psychiatry and Psychotherapy, Center for Interdisciplinary Addiction Research, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Ingo Schäfer
- Department of Psychiatry and Psychotherapy, Center for Interdisciplinary Addiction Research, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
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Kline AC, Panza KE, Harlé KM, Angkaw AC, Trim RS, Back SE, Norman SB. Within-treatment clinical markers of dropout risk in integrated treatments for comorbid PTSD and alcohol use disorder. Drug Alcohol Depend 2021; 221:108592. [PMID: 33618193 DOI: 10.1016/j.drugalcdep.2021.108592] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2020] [Revised: 01/15/2021] [Accepted: 01/19/2021] [Indexed: 10/22/2022]
Abstract
BACKGROUND Integrated interventions for comorbid posttraumatic stress disorder (PTSD) and alcohol use disorder (AUD) are effective, but many patients prematurely drop out from treatment. Little is known about within-treatment risk factors for dropout, limiting the ability during therapy to identify patients at risk for attrition. METHODS We examined measures assessing PTSD (PTSD Checklist for DSM-5; PCL-5), alcohol use (Substance Use Inventory; SUI), and patient satisfaction (Client Satisfaction Questionnaire; CSQ-8) as potential within-treatment markers of dropout risk, administered to 110 veterans in a randomized clinical trial of integrated exposure therapy versus integrated coping skills therapy for comorbid PTSD + AUD. Hierarchical Cox proportional hazard models with dropout status as the endpoint assessed effects of PCL-5, SUI, and CSQ-8 on dropout risk, and whether effects differed by treatment modality. RESULTS A significant interaction between treatment and changes in alcohol use was observed (HR = 2.86, p = .007), where between-session alcohol use was positively associated with dropout hazard rate for those receiving integrated exposure therapy (HR = 2.34, p = .004), but not coping skills therapy (HR = 0.73, p = .19). Specifically, an increase of one drink consumed per day in the interval since last assessment (typically 2-3 weeks) was associated with a 5-fold increase in dropout hazard rate. CONCLUSIONS The findings provide preliminary evidence of detectable within-treatment markers of dropout during integrated treatment for PTSD + AUD. Study of within-treatment indicators proximal to dropout may help identify at-risk patients and inform timely strategies to boost retention.
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Affiliation(s)
- Alexander C Kline
- VA San Diego Healthcare System, 3350 La Jolla Village Dr, San Diego, CA, 92161, USA; Department of Psychiatry, University of California San Diego, 9500 Gilman Dr, La Jolla, CA, 92093, USA.
| | - Kaitlyn E Panza
- VA San Diego Healthcare System, 3350 La Jolla Village Dr, San Diego, CA, 92161, USA; Department of Psychiatry, University of California San Diego, 9500 Gilman Dr, La Jolla, CA, 92093, USA
| | - Katia M Harlé
- VA San Diego Healthcare System, 3350 La Jolla Village Dr, San Diego, CA, 92161, USA; Department of Psychiatry, University of California San Diego, 9500 Gilman Dr, La Jolla, CA, 92093, USA
| | - Abigail C Angkaw
- VA San Diego Healthcare System, 3350 La Jolla Village Dr, San Diego, CA, 92161, USA; Department of Psychiatry, University of California San Diego, 9500 Gilman Dr, La Jolla, CA, 92093, USA; National Center for Posttraumatic Stress Disorder, 163 Veterans Dr, White River Junction, VT, 05009, USA
| | - Ryan S Trim
- VA San Diego Healthcare System, 3350 La Jolla Village Dr, San Diego, CA, 92161, USA; Department of Psychiatry, University of California San Diego, 9500 Gilman Dr, La Jolla, CA, 92093, USA
| | - Sudie E Back
- Department of Psychiatry and Behavioral Sciences, Medical University of South Carolina, 171 Ashley Ave, Charleston, SC, 29425, USA; Ralph H. Johnson Veteran Affairs Medical Center, 109 Bee St, Charleston, SC, 29401, USA
| | - Sonya B Norman
- Department of Psychiatry, University of California San Diego, 9500 Gilman Dr, La Jolla, CA, 92093, USA; National Center for Posttraumatic Stress Disorder, 163 Veterans Dr, White River Junction, VT, 05009, USA
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12
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Resick PA, Wachen JS, Dondanville KA, LoSavio ST, Young-McCaughan S, Yarvis JS, Pruiksma KE, Blankenship A, Jacoby V, Peterson AL, Mintz J. Variable-length Cognitive Processing Therapy for posttraumatic stress disorder in active duty military: Outcomes and predictors. Behav Res Ther 2021; 141:103846. [PMID: 33894644 DOI: 10.1016/j.brat.2021.103846] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2020] [Revised: 03/04/2021] [Accepted: 03/15/2021] [Indexed: 11/28/2022]
Abstract
Cognitive Processing Therapy (CPT) is an evidence-based therapy recommended for posttraumatic stress disorder (PTSD). However, rates of improvement and remission are lower in veterans and active duty military compared to civilians. Although CPT was developed as a 12-session therapy, varying the number of sessions based on patient response has improved outcomes in a civilian study. This paper describes outcomes of a clinical trial of variable-length CPT among an active duty sample. Aims were to determine if service members would benefit from varying the dose of treatment and identify predictors of treatment length needed to reach good end-state (PTSD Checklist-5 ≤ 19). This was a within-subjects trial in which all participants received CPT (N = 127). Predictor variables included demographic, symptom, and trauma-related variables; internalizing/externalizing personality traits; and readiness for change. Varying treatment length resulted in more patients achieving good end-state. Best predictors of nonresponse or needing longer treatment were pretreatment depression and PTSD severity, internalizing temperament, being in precontemplation stage of readiness for change, and African American race. Controlling for differences in demographics and initial PTSD symptom severity, the outcomes using a variable-length CPT protocol were superior to the outcomes of a prior study using a fixed, 12-session CPT protocol. CLINICALTRIALS.GOV IDENTIFIER: NCT023818.
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Affiliation(s)
- Patricia A Resick
- Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, Durham, NC, USA.
| | - Jennifer Schuster Wachen
- National Center for PTSD, VA Boston Healthcare System, Boston, MA, USA; Department of Psychiatry, Boston University School of Medicine, Boston, MA, USA.
| | - Katherine A Dondanville
- Department of Psychiatry and Behavioral Sciences, University of Texas Health Science Center at San Antonio, San Antonio, TX, USA.
| | - Stefanie T LoSavio
- Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, Durham, NC, USA.
| | - Stacey Young-McCaughan
- Department of Psychiatry and Behavioral Sciences, University of Texas Health Science Center at San Antonio, San Antonio, TX, USA.
| | | | - Kristi E Pruiksma
- Department of Psychiatry and Behavioral Sciences, University of Texas Health Science Center at San Antonio, San Antonio, TX, USA.
| | - Abby Blankenship
- Department of Psychiatry and Behavioral Sciences, University of Texas Health Science Center at San Antonio, San Antonio, TX, USA.
| | - Vanessa Jacoby
- Department of Psychiatry and Behavioral Sciences, University of Texas Health Science Center at San Antonio, San Antonio, TX, USA.
| | - Alan L Peterson
- Department of Psychiatry and Behavioral Sciences, University of Texas Health Science Center at San Antonio, San Antonio, TX, USA; Research and Development Service, South Texas Veterans Health Care System, San Antonio, TX, USA; Department of Psychology, University of Texas at San Antonio, San Antonio, TX, USA.
| | - Jim Mintz
- Department of Psychiatry and Behavioral Sciences, University of Texas Health Science Center at San Antonio, San Antonio, TX, USA.
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Substance use predictors of attendance among veterans in integrated PTSD and alcohol use disorder treatment. J Subst Abuse Treat 2021; 124:108278. [PMID: 33771279 DOI: 10.1016/j.jsat.2021.108278] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2020] [Revised: 11/12/2020] [Accepted: 01/03/2021] [Indexed: 10/22/2022]
Abstract
Comorbid post-traumatic stress disorder (PTSD) and alcohol use disorder (AUD) is common, defined by greater severity and impairment than either disorder alone, and associated with poor treatment attendance. Exposure therapies are effective in treating PTSD+AUD, yet substance use is still cited as a potential contraindication for exposure. This study examined substance use-related predictors of session attendance among veterans (N = 119) randomized to receive integrated exposure therapy (Concurrent Treatment of PTSD and Substance Use Disorders using Prolonged Exposure [COPE]; Back et al., 2015) or integrated coping skills therapy (Seeking Safety [SS]; Najavits, 2002) in a clinical trial for comorbid PTSD+AUD (Norman et al., 2019). At baseline, greater percentage of heavy drinking days (β = -0.23, p = .011) and greater AUD severity per structured clinical interview for DSM-IV-TR (β = -0.21, p = .019) predicted fewer sessions across both treatments. Treatment type did not moderate the relationship between predictors and attendance, except for a trend for craving (p = .057), where greater craving predicted fewer sessions in SS (β = -0.31, p = .02) but not COPE (β = 0.14, p = .28). Percentage of abstinence days, AUD duration, and living in a controlled environment (e.g., recovery home) at the start of therapy were not associated with attendance in either treatment condition. Only a subset of substance use characteristics predicted attendance. Findings did not support the notion that alcohol use leads to lower attendance in exposure therapy compared to nonexposure therapy.
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Grundmann J, Lotzin A, Sehner S, Verthein U, Hiller P, Hiersemann R, Lincoln TM, Hillemacher T, Schneider B, Driessen M, Scherbaum N, Dotten AC, Schäfer I. Predictors of attendance in outpatient group treatment for women with posttraumatic stress disorder and substance use disorder. Psychother Res 2020; 31:632-643. [DOI: 10.1080/10503307.2020.1817604] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Affiliation(s)
- Johanna Grundmann
- Center for Interdisciplinary Addiction Research of Hamburg University, Department of Psychiatry and Psychotherapy, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Annett Lotzin
- Center for Interdisciplinary Addiction Research of Hamburg University, Department of Psychiatry and Psychotherapy, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Susanne Sehner
- Institute of Medical Biometry and Epidemiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Uwe Verthein
- Center for Interdisciplinary Addiction Research of Hamburg University, Department of Psychiatry and Psychotherapy, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Philipp Hiller
- Center for Interdisciplinary Addiction Research of Hamburg University, Department of Psychiatry and Psychotherapy, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Rena Hiersemann
- Center for Interdisciplinary Addiction Research of Hamburg University, Department of Psychiatry and Psychotherapy, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Tania M. Lincoln
- Clinical Psychology and Psychotherapy, Institute of Psychology, Faculty of Psychology and Movement Sciences, Universität Hamburg, Hamburg, Germany
| | - Thomas Hillemacher
- Department of Psychiatry and Psychotherapy, Paracelsus Medical University, Nuremberg, Germany
- Department of Psychiatry, Socialpsychiatry and Psychotherapy, Hannover Medical School, Hannover, Germany
| | - Barbara Schneider
- Department of Addictive Disorders, Psychiatry and Psychotherapy, LVR-Klinik Cologne, Cologne, Germany
| | - Martin Driessen
- Clinic of Psychiatry and Psychotherapy, Ev. Klinikum Bielefeld, Bielefeld, Germany
| | - Norbert Scherbaum
- LVR-Hospital Essen, Department of Psychiatry and Psychotherapy, Medical Faculty, University of Duisburg-Essen, Essen, Germany
| | - André C. Dotten
- Department of Psychiatry, Psychotherapy, Psychosomatic and Addiction Medicine, Kliniken Essen-Mitte, Essen, Germany
| | - Ingo Schäfer
- Center for Interdisciplinary Addiction Research of Hamburg University, Department of Psychiatry and Psychotherapy, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
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Geraci JC, Mobbs M, Edwards ER, Doerries B, Armstrong N, Porcarelli R, Duffy E, Loos CM, Kilby D, Juanamarga J, Cantor G, Sutton L, Sokol Y, Goodman M. Expanded Roles and Recommendations for Stakeholders to Successfully Reintegrate Modern Warriors and Mitigate Suicide Risk. Front Psychol 2020; 11:1907. [PMID: 32973608 PMCID: PMC7471060 DOI: 10.3389/fpsyg.2020.01907] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2020] [Accepted: 07/10/2020] [Indexed: 11/13/2022] Open
Abstract
This article draws upon the legends of warriors from ancient Greece and other traditions to illuminate the journey of Modern Warriors (MWs) who have served in the United States military over the last century. It then turns to stakeholders that can assist current MWs in their reintegration to civilian life and mitigate suicide risk. Until this point, without an existing and coordinated local, federal, non-profit, and private system, rates of suicide for post-9/11 MWs after leaving the military have greatly increased, especially for young and women MWs. This is due in part to the military satisfying many of MWs’ needs by providing units, leaders, and a mission during the Departure and Initiation stages of the MW journey. However, as MWs exit the military and face the difficult task of reintegration, the absence of units, leaders, and mission leads to deteriorating psychological health and increasing suicide risk. Written primarily by post-9/11 MWs, this article proposes recommendations for stakeholders to better reintegrate MWs and mitigate suicide risk. The authors strive to develop a system that satisfies MWs’ reintegration needs and enables MWs to be well positioned to continue their next ‘mission’ – to serve and improve society.
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Affiliation(s)
- Joseph C Geraci
- Transitioning Servicemember/Veteran and Suicide Prevention Center, VISN 2 Mental Illness Research, Education and Clinical Center, James J. Peters VA Medical Center, The Bronx, NY, United States.,Resilience Center for Veterans and Families, Teachers College, Columbia University, New York City, NY, United States.,Institute for Veterans and Military Families, Syracuse University, Syracuse, NY, United States
| | - Meaghan Mobbs
- Resilience Center for Veterans and Families, Teachers College, Columbia University, New York City, NY, United States
| | - Emily R Edwards
- Transitioning Servicemember/Veteran and Suicide Prevention Center, VISN 2 Mental Illness Research, Education and Clinical Center, James J. Peters VA Medical Center, The Bronx, NY, United States
| | - Bryan Doerries
- Theater of War Productions, New York City, NY, United States
| | - Nicholas Armstrong
- Institute for Veterans and Military Families, Syracuse University, Syracuse, NY, United States
| | | | - Elana Duffy
- Pathfinder.vet, New York City, NY, United States
| | | | - Daniel Kilby
- Transitioning Servicemember/Veteran and Suicide Prevention Center, VISN 2 Mental Illness Research, Education and Clinical Center, James J. Peters VA Medical Center, The Bronx, NY, United States.,Resilience Center for Veterans and Families, Teachers College, Columbia University, New York City, NY, United States
| | - Josephine Juanamarga
- Resilience Center for Veterans and Families, Teachers College, Columbia University, New York City, NY, United States
| | - Gilly Cantor
- Institute for Veterans and Military Families, Syracuse University, Syracuse, NY, United States
| | - Loree Sutton
- NYC Department of Veterans' Services, New York City, NY, United States
| | - Yosef Sokol
- Transitioning Servicemember/Veteran and Suicide Prevention Center, VISN 2 Mental Illness Research, Education and Clinical Center, James J. Peters VA Medical Center, The Bronx, NY, United States
| | - Marianne Goodman
- Transitioning Servicemember/Veteran and Suicide Prevention Center, VISN 2 Mental Illness Research, Education and Clinical Center, James J. Peters VA Medical Center, The Bronx, NY, United States
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16
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Dagan Y, Yager J. Cannabis and Complex Posttraumatic Stress Disorder: A Narrative Review With Considerations of Benefits and Harms. J Nerv Ment Dis 2020; 208:619-627. [PMID: 32433200 DOI: 10.1097/nmd.0000000000001172] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Despite substantial controversies concerning patients' reports of benefits from cannabis for posttraumatic stress disorder (PTSD) and inconsistent research findings regarding its efficacy and adverse risks, some states have already recognized PTSD as a qualifying condition for medical cannabis. Consequently, medical cannabis can also be provided for patients with complex PTSD who experience additional posttraumatic symptoms of affective dysregulation, negative perception of the self, and difficulties in relationships due to a history of repetitive trauma. In this article, we explore cannabis use in relation to benefits versus harms that might occur relative to specific complex PTSD symptoms and comorbidities. Whereas some symptoms related to PTSD per se (e.g., anxiety, insomnia, nightmares) may be benefited, others that are more characteristic of complex PTSD (e.g., dissociation, reckless behavior, and substance abuse associated with dysregulated affect) may be aggravated. Therefore, clinicians treating patients with complex PTSD who use or seek cannabis should carefully assess patients' motivations and the impacts of particular use patterns on specific symptoms. Clinicians and patients should be aware of and fully discuss the significant number of potential adverse effects of cannabis use, several of which might impede patients' participation in beneficial psychotherapeutic, social, and medical interventions.
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Affiliation(s)
- Yael Dagan
- Jerusalem Mental Health Center, Kfar Shaul Psychiatric Hospital affiliated with The Hebrew University-Hadassah School of Medicine, Jerusalem, Israel
| | - Joel Yager
- Department of Psychiatry, University of Colorado School of Medicine, Aurora, Colorado
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17
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Peirce JM, Schacht RL, Brooner RK. The Effects of Prolonged Exposure on Substance Use in Patients With Posttraumatic Stress Disorder and Substance Use Disorders. J Trauma Stress 2020; 33:465-476. [PMID: 32598569 DOI: 10.1002/jts.22546] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/23/2018] [Revised: 01/13/2020] [Accepted: 01/20/2020] [Indexed: 01/10/2023]
Abstract
Despite research demonstrating the benefit of exposure-based therapy for posttraumatic stress disorder (PTSD) in patients with co-occurring substance use disorders, there remains a strong clinical expectation that this treatment will exacerbate substance use or other psychiatric symptoms. The present study evaluated within-session and session-to-session changes in (a) craving and use of substances for a range of drug classes and (b) symptoms of PTSD and other psychiatric distress in a sample of 44 SUD patients who received prolonged exposure (PE) therapy for PTSD. Visual analog scales showed no within-session increases in craving, except for cocaine, within Session 8. Across sessions, craving scores dropped for heroin, methadone, benzodiazepines, and cocaine; no increases in craving were found. Past-week substance use reported at each session did not differ. The severity of PTSD symptoms and self-reported serious emotional problems decreased from Session 1 to subsequent sessions, with no increases or decreases in other psychiatric, social, or medical problems. Finally, PTSD severity was unrelated to substance use reported 1 or 2 weeks later. Substance use during the past week was associated with higher PTSD severity scores at the next session, B = 6.86 (SE = 2.87), p = .018, but was not associated 2 weeks later. These findings indicate that the concern that exposure therapy for PTSD will increase SUD patients' substance use or other psychiatric symptoms may be unwarranted, and, thus, SUD patients, including those who are actively using, should have access to effective treatments for PTSD, like PE.
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Affiliation(s)
- Jessica M Peirce
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Rebecca L Schacht
- Department of Psychology, University of Maryland, Baltimore County, Baltimore, Maryland, USA
| | - Robert K Brooner
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
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18
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Hakvoort L, de Jong S, van de Ree M, Kok T, Macfarlane C, de Haan H. Music Therapy to Regulate Arousal and Attention in Patients With Substance Use Disorder and Posttraumatic Stress Disorder: A Feasibility Study. J Music Ther 2020; 57:353-378. [PMID: 32651585 DOI: 10.1093/jmt/thaa007] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
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.
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Affiliation(s)
| | - Sirik de Jong
- ArtEZ University of the Artsm, Enschede, The Netherlands
| | - Maartje van de Ree
- ArtEZ University of the Artsm, Enschede, The Netherlands.,Tactus, Addiction Care Twente, Enschede, The Netherlands
| | - Tim Kok
- Tactus, Addiction Care Twente, Enschede, The Netherlands
| | - Clare Macfarlane
- Penitentiary Psychiatric Center Institution Vught & Vrije Universiteit, Amsterdam, The Netherlands
| | - Hein de Haan
- Tactus, Addiction Care Twente, Enschede, The Netherlands
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19
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Botero G, Rivera NI, Calloway SC, Ortiz PL, Edwards E, Chae J, Geraci JC. A lifeline in the dark: Breaking through the stigma of veteran mental health and treating America's combat veterans. J Clin Psychol 2020; 76:831-840. [DOI: 10.1002/jclp.22918] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Affiliation(s)
- Gabriel Botero
- Readjustment Counseling Service/Vet CentersU.S. Department of Veterans Affairs Washington District of Columbia
| | - Nilsa I. Rivera
- Readjustment Counseling Service/Vet CentersU.S. Department of Veterans Affairs Washington District of Columbia
| | - Shakeya C. Calloway
- Readjustment Counseling Service/Vet CentersU.S. Department of Veterans Affairs Washington District of Columbia
| | - Pedro L. Ortiz
- Readjustment Counseling Service/Vet CentersU.S. Department of Veterans Affairs Washington District of Columbia
| | - Emily Edwards
- VISN 2 Mental Illness Research, Education and Clinical CenterU.S. Department of Veterans Affairs Washington District of Columbia
| | - John Chae
- VISN 2 Mental Illness Research, Education and Clinical CenterU.S. Department of Veterans Affairs Washington District of Columbia
- Resilience Center for Veterans and Families, Teachers CollegeColumbia University New York New York
| | - Joseph C. Geraci
- VISN 2 Mental Illness Research, Education and Clinical CenterU.S. Department of Veterans Affairs Washington District of Columbia
- Resilience Center for Veterans and Families, Teachers CollegeColumbia University New York New York
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20
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Jarnecke AM, Allan NP, Badour CL, Flanagan JC, Killeen TK, Back SE. Substance use disorders and PTSD: Examining substance use, PTSD symptoms, and dropout following imaginal exposure. Addict Behav 2019; 90:35-39. [PMID: 30355535 DOI: 10.1016/j.addbeh.2018.10.020] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2018] [Revised: 10/12/2018] [Accepted: 10/15/2018] [Indexed: 12/26/2022]
Abstract
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.
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Affiliation(s)
- Amber M Jarnecke
- Medical University of South Carolina, Charleston, SC, United States.
| | | | | | | | | | - Sudie E Back
- Medical University of South Carolina, Charleston, SC, United States; Ralph H. Johnson VAMC, Charleston, SC, United States
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21
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Back SE, Killeen T, Badour CL, Flanagan JC, Allan NP, Ana ES, Lozano B, Korte KJ, Foa EB, Brady KT. Concurrent treatment of substance use disorders and PTSD using prolonged exposure: A randomized clinical trial in military veterans. Addict Behav 2019; 90:369-377. [PMID: 30529244 DOI: 10.1016/j.addbeh.2018.11.032] [Citation(s) in RCA: 103] [Impact Index Per Article: 20.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2018] [Revised: 11/17/2018] [Accepted: 11/22/2018] [Indexed: 12/25/2022]
Abstract
OBJECTIVE A substantial amount of individuals with substance use disorders (SUD) also meet criteria for posttraumatic stress disorder (PTSD). Prolonged Exposure (PE) is an effective, evidence-based treatment for PTSD, but there is limited data on its use among individuals with current alcohol or drug use disorders. This study evaluated the efficacy of an integrated treatment that incorporates PE (Concurrent Treatment of PTSD and Substance Use Disorders Using Prolonged Exposure or COPE) among veterans. METHOD Military veterans (N = 81, 90.1% male) with current SUD and PTSD were randomized to 12 sessions of COPE or Relapse Prevention (RP). Primary outcomes included the Clinician Administered PTSD Scale (CAPS), PTSD Checklist-Military version (PCL-M), and the Timeline Follow-back (TLFB). RESULTS On average, participants attended 8 out of 12 sessions and there were no group differences in retention. Intent-to-treat analyses revealed that COPE, in comparison to RP, resulted in significantly greater reductions in CAPS (d = 1.4, p < .001) and PCL-M scores (d = 1.3, p = .01), as well as higher rates of PTSD diagnostic remission (OR = 5.3, p < .01). Both groups evidenced significant and comparable reductions in SUD severity during treatment. At 6-months follow-up, participants in COPE evidenced significantly fewer drinks per drinking day than participants in RP (p = .05). CONCLUSIONS This study is the first to report on the use of an integrated, exposure-based treatment for co-occurring SUD and PTSD in a veteran sample. The findings demonstrate that integrated, exposure-based treatments are feasible and effective for military veterans with SUD and PTSD. Implications for clinical practice are discussed.
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Affiliation(s)
- Sudie E Back
- Department of Psychiatry & Behavioral Sciences, Medical University of South Carolina, Charleston, SC, USA; Ralph H. Johnson Veterans Affairs Medical Center, Charleston, SC, USA.
| | - Therese Killeen
- Department of Psychiatry & Behavioral Sciences, Medical University of South Carolina, Charleston, SC, USA
| | - Christal L Badour
- Department of Psychology, University of Kentucky, Lexington, KY, USA
| | - Julianne C Flanagan
- Department of Psychiatry & Behavioral Sciences, Medical University of South Carolina, Charleston, SC, USA
| | | | - Elizabeth Santa Ana
- Department of Psychiatry & Behavioral Sciences, Medical University of South Carolina, Charleston, SC, USA; Ralph H. Johnson Veterans Affairs Medical Center, Charleston, SC, USA
| | - Brian Lozano
- Department of Psychiatry & Behavioral Sciences, Medical University of South Carolina, Charleston, SC, USA; Ralph H. Johnson Veterans Affairs Medical Center, Charleston, SC, USA
| | - Kristina J Korte
- Psychiatry Department, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Edna B Foa
- Department of Psychiatry, University of Pennsylvania, Philadelphia, PA, USA
| | - Kathleen T Brady
- Department of Psychiatry & Behavioral Sciences, Medical University of South Carolina, Charleston, SC, USA; Ralph H. Johnson Veterans Affairs Medical Center, Charleston, SC, USA
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22
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Szafranski DD, Gros DF, Acierno R, Brady KT, Killeen TK, Back SE. Heterogeneity of treatment dropout: PTSD, depression, and alcohol use disorder reductions in PTSD and AUD/SUD treatment noncompleters. Clin Psychol Psychother 2018; 26:218-226. [DOI: 10.1002/cpp.2344] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2017] [Revised: 10/11/2018] [Accepted: 10/11/2018] [Indexed: 11/06/2022]
Affiliation(s)
- Derek D. Szafranski
- Ralph H. Johnson Veterans Affairs Medical CenterMental Health Service 116, General Mental Health 109 Bee Street Charleston SC 29401 USA
- Department of Psychiatry and Behavioral SciencesMedical University of South Carolina Charleston South Carolina USA
| | - Daniel F. Gros
- Ralph H. Johnson Veterans Affairs Medical CenterMental Health Service 116, General Mental Health 109 Bee Street Charleston SC 29401 USA
- Department of Psychiatry and Behavioral SciencesMedical University of South Carolina Charleston South Carolina USA
| | - Ron Acierno
- Ralph H. Johnson Veterans Affairs Medical CenterMental Health Service 116, General Mental Health 109 Bee Street Charleston SC 29401 USA
- College of NursingMedical University of South Carolina Charleston South Carolina USA
| | - Kathleen T. Brady
- Ralph H. Johnson Veterans Affairs Medical CenterMental Health Service 116, General Mental Health 109 Bee Street Charleston SC 29401 USA
- Department of Psychiatry and Behavioral SciencesMedical University of South Carolina Charleston South Carolina USA
| | - Therese K. Killeen
- Department of Psychiatry and Behavioral SciencesMedical University of South Carolina Charleston South Carolina USA
| | - Sudie E. Back
- Ralph H. Johnson Veterans Affairs Medical CenterMental Health Service 116, General Mental Health 109 Bee Street Charleston SC 29401 USA
- Department of Psychiatry and Behavioral SciencesMedical University of South Carolina Charleston South Carolina USA
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Is Integrated CBT Effective in Reducing PTSD Symptoms and Substance Use in Iraq and Afghanistan Veterans? Results from a Randomized Clinical Trial. COGNITIVE THERAPY AND RESEARCH 2018. [DOI: 10.1007/s10608-018-9931-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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Snow R, Wynn ST. Managing Opioid Use Disorder and Co-Occurring Posttraumatic Stress Disorder Among Veterans. J Psychosoc Nurs Ment Health Serv 2018; 56:36-42. [DOI: 10.3928/02793695-20180212-03] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2017] [Accepted: 12/19/2017] [Indexed: 11/20/2022]
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Abstract
Chronic and life-threatening illnesses, such as multiple sclerosis (MS), have been identified as significant stressors potentially triggering posttraumatic stress disorder (PTSD). The study aims to investigate the prevalence of PTSD according to Diagnostic and Statistical Manual of Mental Disorders, 4th Edition, Text Revision (DSM-IV-TR) criteria in a large sample of patients with MS. A total of 988 patients with MS were screened with the Impact of Event Scale-Revised, and then assessed with the PTSD module of the Structured Clinical Interview for DSM-IV and with the Clinician-Administered PTSD Scale to confirm PTSD diagnosis. Posttraumatic symptoms were reported by 25.5% of the sample. A confirmed diagnosis of PTSD was found in 5.7% of patients, but prevalence could reach 8.5%, including also dropout patients. Further studies are needed to evaluate if adjustment disorder could better encompass the frequently encountered subthreshold posttraumatic stress symptoms and how clinicians can deal with these symptoms with appropriate interventions.
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