A Randomized Controlled Pilot Trial of Primary Care Treatment Integrating Motivation and Exposure Treatment (PC-TIME) in Veterans With PTSD and Harmful Alcohol Use

State of the Science: Treatment of comorbid posttraumatic stress disorder and substance use disorders

Posttraumatic stress disorder (PTSD) and substance use disorders (SUDs) co-occur at high rates, with research showing that up to nearly 60% of individuals with PTSD also suffer from an alcohol and/or drug use disorder. PTSD/SUD is complex; associated with adverse health, social, and economic outcomes; and can be challenging to treat. Over the past decade, the landscape of treatment research addressing PTSD/SUD has significantly expanded. Ongoing efforts aimed at developing and evaluating novel treatments for PTSD/SUD, encompassing both psychotherapy and pharmacotherapy approaches, are steadily advancing. As such, this State of the Science paper reviews the literature on the latest scientific advances in treating PTSD/SUD. Clinical practice guidelines for the treatment of PTSD/SUD are discussed, along with evidence-based psychotherapies and emerging interventions. Rigorously conducted clinical trials demonstrate that individual, manualized, trauma-focused treatments are the most efficacious psychotherapies to use among individuals with PTSD/SUD. Moreover, patients do not need to be abstinent to initiate or benefit from evidence-based PTSD treatment. To date, no medications have been established for this comorbidity. We highlight ongoing research on novel treatments for PTSD/SUD, such as new forms of integrated trauma-focused psychotherapies, pharmacological augmentation strategies, and technology-based enhancements. Finally, promising future directions for the field are discussed.

Examining the Temporal Relation between Posttraumatic Stress Symptoms and Heavy Drinking among Veterans Receiving Mental Health Treatment in Primary Care

OBJECTIVE

Evidence for the use of integrated treatments targeting co-occurring posttraumatic stress disorder (PTSD) and alcohol use disorders is steadily growing. However, limited work has evaluated the temporal association between posttraumatic stress symptoms (PTSS) and alcohol misuse over the course of integrated treatment, with no studies examining such interventions in primary care (PC). The current study examined temporal changes in PTSS and heavy drinking among individuals who received a brief treatment for co-occurring PTSD and alcohol misuse in PC (Primary Care Treatment Integrating Motivation and Exposure; PC-TIME) compared with those who received PC treatment as usual (PC-TAU).

METHOD

A total of 63 veterans (33 randomized to PC-TIME and 30 randomized to PC-TAU) presenting to PC with co-occurring PTSD and alcohol misuse were included in this study. PTSS and heavy drinking were examined at each treatment session for those in PC-TIME. Veterans in both conditions provided reports of PTSS and heavy drinking at baseline, 8-weeks (post-treatment), 14-weeks, and 20-week follow-ups.

RESULTS

Session-by-session findings for PC-TIME demonstrated that PTSS at Session 1 predicted a greater decrease in heavy drinking from Session 1 to Session 2. Moreover, heavy drinking at baseline predicted greater decreases in PTSS at 8-weeks for those in PC-TIME, whereas the reverse association was found for those randomized to PC-TAU. Additionally, heavy drinking at 8-weeks predicted decreased PTSS at 14-weeks for those randomized to PC-TAU.

CONCLUSIONS

The current study evidenced mixed support for the temporal precedence of PTSS and alcohol misuse. Relations between PTSS and heavy drinking appeared to be linked to treatment targets within PC-TIME and varied between treatment condition (PC-TIME versus PC-TAU). Notably, those with greater than average heavy drinking at the initiation of integrated treatment appeared to have greater reductions in PTSS at post-treatment. Results suggest a mutual maintenance model may best characterize the association between co-occurring PTSS and heavy drinking among treatment-seeking individuals.