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McLean CP, Foa EB. State of the Science: Prolonged exposure therapy for the treatment of posttraumatic stress disorder. J Trauma Stress 2024. [PMID: 38652057 DOI: 10.1002/jts.23046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2024] [Revised: 03/06/2024] [Accepted: 03/08/2024] [Indexed: 04/25/2024]
Abstract
Prolonged exposure therapy (PE) is a well-established first-line treatment for posttraumatic stress disorder (PTSD) that is based on emotional processing theory. PE has been rigorously evaluated and tested in a large number of clinical trials in many countries covering a wide range of trauma populations. In this review, we summarize the evidence base supporting the efficacy of PE across populations, including adults with sexual assault-related PTSD and mixed trauma-related PTSD, military populations, and adolescents. We highlight important strengths and gaps in the research on PE with individuals from marginalized communities. We discuss the efficacy of PE on associated psychopathology and in the presence of the most commonly comorbid conditions, either alone or integrated with other treatments. In addition, we provide an overview of research examining strategies to augment PE. Much of this work remains preliminary, but numerous trials have tested PE in combination with other psychological or pharmacological approaches, interventions to facilitate extinction learning, and behavioral approaches, in the hopes of further increasing the efficiency and efficacy of PE. There are now several trials testing PE in novel formats that may have advantages over standard in-person PE, such as lower dropout and increased scalability. We examine this recent work on new models of delivering PE, including massed treatment, telehealth, and brief adaptations for primary care, all of which have the potential to increase access to PE. Finally, we highlight several promising areas for future research.
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Affiliation(s)
- Carmen P McLean
- Dissemination and Training Division, National Center for PTSD, VA Palo Alto Health Care System, Menlo Park, California, USA
- Department of Psychiatry and Behavioral Sciences, School of Medicine, Stanford University, Stanford, California, USA
| | - Edna B Foa
- Department of Psychiatry, Perlman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
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2
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Kline AC, Otis NP, Norman SB, Hunt WM, Walter KH. Dropout in a clinical trial for comorbid PTSD and MDD among US service members: Are pretreatment characteristics predictive? Psychother Res 2024:1-13. [PMID: 38497740 DOI: 10.1080/10503307.2024.2325519] [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: 10/06/2023] [Accepted: 02/26/2024] [Indexed: 03/19/2024] Open
Abstract
OBJECTIVE Despite effective treatment options for posttraumatic stress disorder (PTSD), many patients do not complete therapy. This includes U.S. active duty service members, yet factors linked to attendance in this population remain understudied and dropout remains difficult to predict. Additionally, most studies have not examined samples with PTSD and co-occurring major depressive disorder (MDD) despite high rates of comorbidity. METHOD The current study explored predictors of dropout among service members with comorbid PTSD and MDD (N = 94) randomized to cognitive processing therapy enhanced with behavioral activation (BA + CPT) or CPT as part of a clinical trial. RESULTS Using the Fournier approach, only two predictors were associated with lower dropout risk among over 20 examined: shorter duration between pretreatment assessment and Session 1 (p = .041) and past 3-month PTSD treatment engagement (p = .036). CONCLUSION Results suggest the possible utility of early momentum in starting therapy and leveraging recent treatment to improve attendance. However, this study also highlights the possible limitations of commonly assessed pretreatment factors in predicting attendance and current challenges in measuring dropout risk. Strategies to improve prediction, such as shifting focus to assess modifiable factors and processes more proximal to dropout during treatment, may be needed.Trial registration: ClinicalTrials.gov identifier: NCT02874131.
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Affiliation(s)
- Alexander C Kline
- Psychological Health and Readiness, Naval Health Research Center, San Diego, CA, USA
- Leidos, Inc., San Diego, CA, USA
| | - Nicholas P Otis
- Psychological Health and Readiness, Naval Health Research Center, San Diego, CA, USA
- Leidos, Inc., San Diego, CA, USA
| | - Sonya B Norman
- Department of Psychiatry, University of California San Diego, San Diego, CA, USA
- National Center for PTSD, Executive Division, White River Junction, VT, USA
- VA San Diego Healthcare System, San Diego, CA, USA
| | - W Michael Hunt
- Directorate of Mental Health, Naval Medical Center San Diego, San Diego, CA, USA
| | - Kristen H Walter
- Psychological Health and Readiness, Naval Health Research Center, San Diego, CA, USA
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3
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Watkins LE, Patton SC, Wilcox T, Drexler K, Rauch SAM, Rothbaum BO. Substance Use after Completion of an Intensive Treatment Program with Concurrent Treatment for Posttraumatic Stress Disorder and Substance Use among Veterans: Examining the Role of PTSD Symptoms. J Dual Diagn 2024; 20:16-28. [PMID: 38122816 DOI: 10.1080/15504263.2023.2290167] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2023]
Abstract
OBJECTIVE Substance use disorders (SUDs) and posttraumatic stress disorder (PTSD) are costly and highly co-occurring diagnoses, particularly among veterans, suggesting a need to understand this comorbidity and effectively treat both disorders among this population. METHODS The current study aimed to examine substance use outcomes among post-9/11 veterans and service members (N = 48) who completed a two-week intensive outpatient program with concurrent treatment for and PTSD using Prolonged Exposure and substance use. Substance use was assessed at two weeks and three months posttreatment. RESULTS The intensive program had high completion rates and demonstrated decreases in substance use at two weeks and three months posttreatment. Additionally, lower PTSD symptoms at treatment completion were related to less substance use posttreatment. CONCLUSIONS Concurrent intensive treatment of PTSD and SUDs can lead to symptom improvement in a short period of time. Findings support the self-medication model, such that PTSD symptoms at treatment completion were related to substance use at follow-up.
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Affiliation(s)
| | | | - Tiffany Wilcox
- Emory University School of Medicine, Atlanta, Georgia, USA
| | - Karen Drexler
- Emory University School of Medicine, Atlanta, Georgia, USA
| | - Sheila A M Rauch
- Atlanta VA Medical Center, Emory University School of Medicine, Atlanta, Georgia, USA
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Lebeaut A, Zegel M, Steinberg L, Zvolensky MJ, Vujanovic AA. The development and initial validation of the Trauma-Related Alcohol Use Coping Measure (TRAC). PSYCHOLOGY OF ADDICTIVE BEHAVIORS 2023:2024-27963-001. [PMID: 38010782 PMCID: PMC11128532 DOI: 10.1037/adb0000974] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2023]
Abstract
OBJECTIVE Posttraumatic stress disorder (PTSD) symptoms and alcohol use commonly co-occur and present a prevalent clinical comorbidity. The self-medication/coping model has been applied most consistently to understand the PTSD-alcohol use association. However, there is a relative paucity of self-report measures designed to assess motivations for alcohol use, specifically for coping with PTSD symptoms. The goals of the present study were to develop and validate a measure that assesses the use of alcohol to cope with specific facets of PTSD symptomatology across two independent samples. METHOD Two samples were evaluated: a university-based sample (N = 617; 77.0% women; Mage = 22.3; SD = 5.20) composed of racially diverse trauma-exposed students and a nationally representative sample (N = 510; 52.5% women; Mage = 39.5; SD = 10.9) of trauma-exposed adults who endorsed PTSD symptoms and past-year hazardous drinking. Both samples completed identical online questionnaire batteries. A Trauma-Related Alcohol Use Coping (TRAC) measure was developed and validated across both samples. RESULTS Confirmatory factor analysis was used to support the latent, hierarchical structure of the TRAC measure (total score; coping with intrusion, avoidance, negative alterations in cognitions and mood, and arousal/reactivity symptoms) and supported an 18-item version of the TRAC measure (university-based sample [N = 617]: RMSEA = 0.047, 90% CI [.04, .05]; SRMR = 0.043; CFI = 0.95; TLI = 0.95; nationally representative sample [N = 510]: RMSEA = 0.045, 90% CI [.04, .05]; SRMR = 0.021; CFI = 0.98; TLI = 0.97). The TRAC measure demonstrated excellent internal consistency, convergent, and discriminant validity with well-established measures of mental health, known-groups validity, and incremental validity relative to non-PTSD coping-motivated drinking. CONCLUSIONS Overall, the TRAC measure can be used to assess the extent to which alcohol use is related to coping with PTSD symptoms. (PsycInfo Database Record (c) 2023 APA, all rights reserved).
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Affiliation(s)
- Antoine Lebeaut
- Department of Psychology, University of Houston, Houston, Texas
| | - Maya Zegel
- Department of Psychology, University of Houston, Houston, Texas
| | - Lynne Steinberg
- Department of Psychology, University of Houston, Houston, Texas
| | - Michael J. Zvolensky
- Department of Psychology, University of Houston, Houston, Texas
- Health Research Institute, University of Houston, Houston, Texas
- Department of Behavioral Science, The University of Texas MD Anderson Cancer Center
| | - Anka A. Vujanovic
- Department of Psychology, University of Houston, Houston, Texas
- Health Research Institute, University of Houston, Houston, Texas
- Department of Psychological and Brain Sciences, Texas A&M University
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5
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Social Factors Predict Treatment Engagement in Veterans with PTSD or SUD. J Behav Health Serv Res 2022; 50:286-300. [PMID: 36456866 DOI: 10.1007/s11414-022-09823-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/18/2022] [Indexed: 12/03/2022]
Abstract
Veterans with PTSD and SUDs often fail to initiate, or prematurely discontinue, mental health treatment in Veteran Affairs Medical Centers (VAMC). While much is known about clinical characteristics and demographic factors impacting treatment engagement in this population, less is known about the role of social factors. This retrospective study examines primary care-based screening assessment and specialty mental healthcare appointment data in a VAMC, to test whether social factors predict treatment initiation and appointment attendance. Findings reveal veterans were more likely to initiate treatment when (a) those with SUDs (n = 235) reported more frequent negative exchanges with others and (b) those with PTSD (n = 2107) reported more perceived support or being partnered. Those with PTSD who were partnered had higher appointment attendance rates. Findings suggest social factors are relevant to treatment initiation among veterans with PTSD and SUDs and that close others may be helpful in facilitating referrals.
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6
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Bedard-Gilligan M, Lehinger E, Cornell-Maier S, Holloway A, Zoellner L. Effects of Cannabis on PTSD Recovery: Review of the Literature and Clinical Insights. CURRENT ADDICTION REPORTS 2022; 9:203-216. [PMID: 36385902 PMCID: PMC9648847 DOI: 10.1007/s40429-022-00414-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/20/2022] [Indexed: 11/27/2022]
Abstract
Purpose of Review Individuals with posttraumatic stress disorder (PTSD) may use cannabis to reduce symptoms yet are also at risk for developing problematic use. This review outlines theories, summarizes recent empirical studies, and discusses clinical implications of cannabis use and PTSD recovery. Recent Findings Although naturalistic studies and open trials find a relationship between cannabinoids and PTSD symptom reduction, methodological limitations preclude definitive conclusions. The only randomized controlled trial to date found cannabis had no greater effect on PTSD symptoms than placebo. Summary Rigorous studies of the long-term impact of cannabis use on PTSD recovery are needed. Clinicians and researchers must weigh the potential therapeutic effect against the costs and risks associated with long-term cannabis use. Clinicians should consider all available PTSD treatment options, along with client level factors such as the function of cannabis use, motivation to change use, and the potential impact of cannabis on treatment engagement when making clinical recommendations.
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Affiliation(s)
| | - Elizabeth Lehinger
- Department of Psychiatry and Behavioral Sciences, University of Washington
| | | | - Ash Holloway
- Department of Psychology, University of Washington
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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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Examining attendance patterns across integrated therapies for posttraumatic stress disorder and alcohol use disorder. J Anxiety Disord 2022; 85:102498. [PMID: 34823044 DOI: 10.1016/j.janxdis.2021.102498] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2021] [Revised: 09/06/2021] [Accepted: 11/02/2021] [Indexed: 11/23/2022]
Abstract
A substantial body of evidence supports the use of integrated treatments for posttraumatic stress disorder (PTSD) and alcohol use disorder (AUD). Integrated trauma-focused exposure therapies reduce PTSD symptoms more than comparison treatments, including integrated coping skills therapies, but demonstrate lower attendance, raising questions regarding the relationships between attendance, outcomes, and treatment type. We aimed to examine these relationships in a RCT comparing integrated prolonged exposure (Concurrent Treatment for PTSD and Substance Use Disorders Using Prolonged Exposure, COPE; n = 58), to integrated coping skills therapy (Seeking Safety, SS; n = 52) offered in 12 sessions, with an option to extend up to four additional sessions. Participants were categorized based on number of sessions attended (0-4; 5-8; 9-12; 13-16). Multilevel modeling revealed that only when examining therapy attendance segments individually, clinical outcomes were comparable across treatments except in the 9-12 group, with COPE resulting in greater reductions in PTSD symptoms (p < 0.001), but not in alcohol use. Extending past 12 sessions was not associated with additional clinically meaningful symptom improvement for either treatment. These results suggest that attending a complete or near complete course of exposure therapy may enhance PTSD outcomes relative to non-trauma-focused therapies.
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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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10
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Anger and predictors of drop-out from PTSD treatment of veterans and first responders. Behav Cogn Psychother 2021; 50:237-251. [PMID: 34569465 DOI: 10.1017/s1352465821000382] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND Drop-out is an important barrier in treating post-traumatic stress disorder (PTSD) with consequences that negatively impact clients, clinicians and mental health services as a whole. Anger is a common experience in people with PTSD and is more prevalent in military veterans. To date, no research has examined if anger may predict drop-out in military veterans or first responders. AIMS The present study aimed to determine the variables that predict drop-out among individuals receiving residential treatment for PTSD. METHOD Ninety-five military veterans and first responders completed pre-treatment measures of PTSD symptom severity, depression, anxiety, anger, and demographic variables. Logistic regression analyses were used to determine if these variables predicted drop-out from treatment or patterns of attendance. RESULTS Female gender was predictive of drop-out. However, when analysed by occupation female gender was predictive of drop-out among first responders and younger age was predictive of drop-out in military participants. Anger, depression, anxiety and PTSD symptom severity were not predictive of drop-out in any of the analyses. No variables were found to predict attendance patterns (consistent or inconsistent) or early versus late drop-out from the programme. CONCLUSION These results suggest that although anger is a relevant issue for treating PTSD, other factors may be more pertinent to drop-out, particularly in this sample. In contrast with other findings, female gender was predictive of drop-out in this study. This may indicate that in this sample, there are unique characteristics and possible interacting variables that warrant exploration in future research.
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11
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Pandey S, Bolstad I, Lien L, Bramness JG. Antisocial Personality Disorder Among Patients in Treatment for Alcohol Use Disorder (AUD): Characteristics and Predictors of Early Relapse or Drop-Out. Subst Abuse Rehabil 2021; 12:11-22. [PMID: 33907489 PMCID: PMC8064678 DOI: 10.2147/sar.s296526] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2020] [Accepted: 03/15/2021] [Indexed: 12/18/2022] Open
Abstract
Background Patients with alcohol use disorders (AUD) vary significantly in many clinically important characteristics making them a heterogenous group. AUD patients with comorbid antisocial personality disorder (ASPD) form an important sub-group, and studies indicate that these patients may have poorer treatment outcomes. Therefore, we aimed to investigate the characteristics of AUD inpatients with comorbid ASPD and identify predictors of early relapse or treatment drop-out in these patients. Methods In a longitudinal study of AUD patients (n = 113; 30 females; aged 27 to 72 years) in treatment at three residential rehabilitation clinics in Norway, we used interviews and self-report questionnaires to collect data on alcohol use, mental health, and trauma experience. In addition, we assessed biochemical parameters. The patients were followed up at 6 weeks to identify early relapse or drop-out. Results Prevalence of ASPD among AUD patients was 15%. AUD patients with comorbid ASPD were exclusively male, of younger age, and reported more childhood trauma, and adult attention-deficit-hyperactivity-disorder symptoms. They reported more hazardous drinking behavior and more often had dependence on substances in addition to alcohol. The presence of ASPD did not predict early relapse or drop-out. However, early relapse or drop-out in ASPD patients was associated with childhood and adult trauma, younger age of drinking debut, and higher baseline prolactin levels. Conclusion AUD patients with ASPD had different clinical characteristics to other AUD patients and they had specific predictors of early relapse or drop-out. Our findings indicate that the early relapse or drop-out among AUD patients with ASPD may be attributed to environmental and possibly biological vulnerability. However, further studies with larger sample size are warranted to confirm these preliminary associations.
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Affiliation(s)
- Susmita Pandey
- Norwegian National Advisory Unit on Concurrent Substance Abuse and Mental Health Disorders, Innlandet Hospital Trust, Brumunddal, Norway.,Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Ingeborg Bolstad
- Norwegian National Advisory Unit on Concurrent Substance Abuse and Mental Health Disorders, Innlandet Hospital Trust, Brumunddal, Norway
| | - Lars Lien
- Norwegian National Advisory Unit on Concurrent Substance Abuse and Mental Health Disorders, Innlandet Hospital Trust, Brumunddal, Norway.,Department of Health and Social Science, Innlandet University of Applied Science, Elverum, Norway
| | - Jørgen G Bramness
- Norwegian National Advisory Unit on Concurrent Substance Abuse and Mental Health Disorders, Innlandet Hospital Trust, Brumunddal, Norway.,Department of Clinical Medicine, UiT - Norway's Arctic University, Tromsø, Norway.,Norwegian Institute of Public Health, Oslo, Norway
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12
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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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13
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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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14
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Smink WAC, Sools AM, Postel MG, Tjong Kim Sang E, Elfrink A, Libbertz-Mohr LB, Veldkamp BP, Westerhof GJ. Analysis of the Emails From the Dutch Web-Based Intervention "Alcohol de Baas": Assessment of Early Indications of Drop-Out in an Online Alcohol Abuse Intervention. Front Psychiatry 2021; 12:575931. [PMID: 34975551 PMCID: PMC8714780 DOI: 10.3389/fpsyt.2021.575931] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2020] [Accepted: 10/18/2021] [Indexed: 12/02/2022] Open
Abstract
Nowadays, traditional forms of psychotherapy are increasingly complemented by online interactions between client and counselor. In (some) web-based psychotherapeutic interventions, meetings are exclusively online through asynchronous messages. As the active ingredients of therapy are included in the exchange of several emails, this verbal exchange contains a wealth of information about the psychotherapeutic change process. Unfortunately, drop-out-related issues are exacerbated online. We employed several machine learning models to find (early) signs of drop-out in the email data from the "Alcohol de Baas" intervention by Tactus. Our analyses indicate that the email texts contain information about drop-out, but as drop-out is a multidimensional construct, it remains a complex task to accurately predict who will drop out. Nevertheless, by taking this approach, we present insight into the possibilities of working with email data and present some preliminary findings (which stress the importance of a good working alliance between client and counselor, distinguish between formal and informal language, and highlight the importance of Tactus' internet forum).
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Affiliation(s)
- Wouter A C Smink
- Department of Psychology, Health Technology, University of Twente, Enschede, Netherlands.,Department of Research Methodology, Measurement Data Analysis, University of Twente, Enschede, Netherlands
| | - Anneke M Sools
- Department of Psychology, Health Technology, University of Twente, Enschede, Netherlands
| | - Marloes G Postel
- Department of Psychology, Health Technology, University of Twente, Enschede, Netherlands.,Tactus Addiction Treatment, Enschede, Netherlands
| | | | - Auke Elfrink
- Department of Psychology, Health Technology, University of Twente, Enschede, Netherlands
| | - Lukas B Libbertz-Mohr
- Department of Psychology, Health Technology, University of Twente, Enschede, Netherlands
| | - Bernard P Veldkamp
- Department of Research Methodology, Measurement Data Analysis, University of Twente, Enschede, Netherlands
| | - Gerben J Westerhof
- Department of Psychology, Health Technology, University of Twente, Enschede, Netherlands
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15
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Allan NP, López-Castro T, Hien DA, Papini S, Killeen TK, Gros DF, Ruglass LM, Barrett E, Back SE. Response-to-Treatment for Comorbid Post-Traumatic Stress and Substance Use Disorders: The Value of Combining Person- and Variable-Centered Approaches. JOURNAL OF PSYCHOPATHOLOGY AND BEHAVIORAL ASSESSMENT 2020; 42:725-738. [PMID: 33239837 PMCID: PMC7682732 DOI: 10.1007/s10862-020-09803-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Optimizing treatment for co-occurring post-traumatic stress disorder and substance use disorder (PTSD+SUD) is critically important. Whereas treatments have been designed that target PTSD+SUD with some success, these treatments do not benefit all. Data-driven approaches that combine person- and variable-centered methods, such as parallel process latent class growth analysis (PP-LCGA) can be used to identify response-to-treatment trajectories across both PTSD symptoms and substance use. The current study employed PP-LCGA separately in two randomized clinical trials (study 1 n = 81, Mean age = 40.4 years, SD = 10.7; study 2 n = 59, Mean age = 44.7 years, SD = 9.4) to examine PTSD symptom response and percentage of days using substances across treatment trials comparing Concurrent Treatment of PTSD and SUD using Prolonged Exposure and Relapse Prevention. Results revealed four PTSD+SUD profiles for study one and three PTSD+SUD profiles for study two. For PTSD symptoms, response trajectories could be broadly classified into treatment responders and non-responders across both studies. For substance use, response trajectories could be broadly classified into declining, moderately stable, and abstaining profiles. When considering PTSD symptoms and substance use trajectories together, profiles emerged that would have been missed had these treatment outcomes been considered separately.
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Affiliation(s)
| | | | - Denise A. Hien
- Gordon F. Derner Institute of Advanced Psychological Studies, Adelphi, Garden City, NY
| | | | - Therese K. Killeen
- Department of Psychiatry & Behavioral Sciences, Medical University of South Carolina, Charleston, SC
| | - Daniel F. Gros
- Department of Psychiatry & Behavioral Sciences, Medical University of South Carolina, Charleston, SC
- Mental Health Service Line, Ralph H. Johnson Veterans Affairs Medical Center, Charleston, SC
| | - Lesia M. Ruglass
- Department of Psychology, The City College of New York, New York, NY
| | - Emma Barrett
- Department of Psychiatry & Behavioral Sciences, Medical University of South Carolina, Charleston, SC
| | - Sudie E. Back
- Department of Psychiatry & Behavioral Sciences, Medical University of South Carolina, Charleston, SC
- Mental Health Service Line, Ralph H. Johnson Veterans Affairs Medical Center, Charleston, SC
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16
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Brown DG, Flanagan JC, Jarnecke A, Killeen TK, Back SE. Ethnoracial differences in treatment-seeking veterans with substance use disorders and co-occurring PTSD: Presenting characteristics and response to integrated exposure-based treatment. J Ethn Subst Abuse 2020; 21:1141-1164. [PMID: 33111647 DOI: 10.1080/15332640.2020.1836699] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
OBJECTIVE Substance use disorders (SUD) and posttraumatic stress disorder (PTSD) frequently co-occur. While previous research has examined ethnoracial differences among individuals with either SUD or PTSD, little research to date has focused on individuals with co-occurring SUD/PTSD. The current study addresses this gap in the literature. METHOD Participants were 79 military veterans (91% male; 38% African American [AA] and 62% White) with current SUD/PTSD who were randomized to receive Concurrent Treatment of PTSD and Substance Use Disorders using Prolonged Exposure (COPE) or Relapse Prevention (RP). Primary outcomes included substance use and self-reported and clinician-rated PTSD symptoms. RESULTS At baseline, AA participants were significantly older, reported greater substance and alcohol use, and tended to report higher PTSD severity than White participants. AA participants evidenced greater decreases in substance and alcohol use during treatment, but greater increases in substance and alcohol use during follow-up as compared to White participants. All participants decreased alcohol consumption during treatment; however, AA participants in the COPE condition and White participants in the RP condition evidenced the steepest decreases in average number of drinks per drinking day (DDD) during treatment. Additionally, White participants receiving RP reported greater increases in DDD during follow-up compared to AA participants. CONCLUSION Overall, integrated treatment for co-occurring SUD/PTSD was effective for both AA and White participants; however, some important differences emerged by ethnoracial group. Findings suggest that greater attention to race and ethnicity is warranted to better understand the needs of diverse patients with SUD/PTSD and to optimize treatment outcomes.
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Affiliation(s)
- Delisa G Brown
- Medical University of South Carolina, Charleston, South Carolina
| | - Julianne C Flanagan
- Medical University of South Carolina, Charleston, South Carolina.,Ralph H. Johnson VAMC, Charleston, South Carolina
| | - Amber Jarnecke
- Medical University of South Carolina, Charleston, South Carolina
| | | | - Sudie E Back
- Medical University of South Carolina, Charleston, South Carolina.,Ralph H. Johnson VAMC, Charleston, South Carolina
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17
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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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18
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Alpert E, Hayes AM, Barnes JB, Sloan DM. Predictors of Dropout in Cognitive Processing Therapy for PTSD: An Examination of Trauma Narrative Content. Behav Ther 2020; 51:774-788. [PMID: 32800305 PMCID: PMC7431675 DOI: 10.1016/j.beth.2019.11.003] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2019] [Revised: 11/07/2019] [Accepted: 11/09/2019] [Indexed: 12/30/2022]
Abstract
Dropout rates in trauma-focused treatments for adult posttraumatic stress disorder (PTSD) are high. Most research has focused on demographic and pretreatment predictors of dropout, but findings have been inconsistent. We examined predictors of dropout in cognitive processing therapy (CPT) by coding the content of trauma narratives written in early sessions of CPT. Data are from a randomized controlled noninferiority trial of CPT and written exposure therapy (WET) in which CPT showed significantly higher dropout rates than WET (39.7% CPT vs. 6.4% WET). Participants were 51 adults with a primary diagnosis of PTSD who were receiving CPT and completed at least one of three narratives in the early sessions of CPT. Sixteen (31%) in this subsample were classified as dropouts and 35 as completers. An additional 9 participants dropped out but could not be included because they did not complete any narratives. Of the 11 participants who provided a reason for dropout, 82% reported that CPT was too distressing. The CHANGE coding system was used to code narratives for pathological trauma responses (cognitions, emotions, physiological responses) and maladaptive modes of processing (avoidance, ruminative processing, overgeneralization), each on a scale from 0 (absent) to 3 (high). Binary logistic regressions showed that, averaging across all available narratives, more negative emotions described during or around the time of the trauma predicted less dropout. More ruminative processing in the present time frame predicted lower rates of dropout, whereas more overgeneralized beliefs predicted higher rates. In the first impact statement alone, more negative emotions in the present time frame predicted lower dropout rates, but when emotional reactions had a physiological impact, dropout was higher. These findings suggest clinicians might attend to clients' written trauma narratives in CPT in order to identify indicators of dropout risk and to help increase engagement.
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Affiliation(s)
| | - Adele M. Hayes
- University of Delaware, Department of Psychological and Brain Sciences
| | - J. Ben Barnes
- University of Delaware, Department of Psychological and Brain Sciences
| | - Denise M. Sloan
- VA Boston Healthcare System, National Center for PTSD,Boston University School of Medicine
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19
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Lewis C, Roberts NP, Gibson S, Bisson JI. Dropout from psychological therapies for post-traumatic stress disorder (PTSD) in adults: systematic review and meta-analysis. Eur J Psychotraumatol 2020; 11:1709709. [PMID: 32284816 PMCID: PMC7144189 DOI: 10.1080/20008198.2019.1709709] [Citation(s) in RCA: 113] [Impact Index Per Article: 28.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2019] [Revised: 10/27/2019] [Accepted: 10/29/2019] [Indexed: 02/01/2023] Open
Abstract
Background: Despite the established efficacy of psychological therapies for post-traumatic stress disorder (PTSD) there has been little systematic exploration of dropout rates. Objective: To ascertain rates of dropout across different modalities of psychological therapy for PTSD and to explore potential sources of heterogeneity. Method: A systematic review of dropout rates from randomized controlled trials (RCTs) of psychological therapies was conducted. The pooled rate of dropout from psychological therapies was estimated and reasons for heterogeneity explored using meta-regression. Results:: The pooled rate of dropout from RCTs of psychological therapies for PTSD was 16% (95% CI 14-18%). There was evidence of substantial heterogeneity across studies. We found evidence that psychological therapies with a trauma-focus were significantly associated with greater dropout. There was no evidence of greater dropout from therapies delivered in a group format; from studies that recruited participants from clinical services rather than via advertisements; that included only military personnel/veterans; that were limited to participants traumatized by sexual traumas; that included a higher proportion of female participants; or from studies with a lower proportion of participants who were university educated. Conclusions: Dropout rates from recommended psychological therapies for PTSD are high and this appears to be particularly true of interventions with a trauma focus. There is a need to further explore the reasons for dropout and to look at ways of increasing treatment retention.
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Affiliation(s)
- Catrin Lewis
- National Centre for Mental Health (NCMH), Division of Psychological Medicine and Clinical Neurosciences, Cardiff University School of Medicine, Cardiff, UK
| | - Neil P Roberts
- National Centre for Mental Health (NCMH), Division of Psychological Medicine and Clinical Neurosciences, Cardiff University School of Medicine, Cardiff, UK.,Psychology and Psychological Therapies, Cardiff & Vale University Health Board, Cardiff, UK.,Cardiff University Traumatic Stress Service, Cardiff & Vale University Health Board, Cardiff, UK
| | - Samuel Gibson
- National Centre for Mental Health (NCMH), Division of Psychological Medicine and Clinical Neurosciences, Cardiff University School of Medicine, Cardiff, UK
| | - Jonathan I Bisson
- National Centre for Mental Health (NCMH), Division of Psychological Medicine and Clinical Neurosciences, Cardiff University School of Medicine, Cardiff, UK
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20
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Zang Y, Su YJ, McLean CP, Foa EB. Predictors for Excellent Versus Partial Response to Prolonged Exposure Therapy: Who Needs Additional Sessions? J Trauma Stress 2019; 32:577-585. [PMID: 31265187 DOI: 10.1002/jts.22412] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2018] [Revised: 01/20/2019] [Accepted: 01/30/2019] [Indexed: 11/09/2022]
Abstract
In practice, the duration of psychotherapy is determined by the patient's response to treatment. Identifying predictors for treatment responses is of great clinical utility to guide clinicians in their treatment planning. Demographic characteristics, trauma history, comorbidity, and early reduction of posttraumatic stress disorder (PTSD) symptoms were examined as predictors of excellent versus partial response to prolonged exposure therapy (PE) for PTSD. Participants were 96 female assault survivors with chronic PTSD who received at least eight PE sessions with or without cognitive restructuring. Participants were classified as excellent responders (n = 27) or partial responders (n = 69) based on whether they achieved at least 70% improvement in self-reported PTSD severity on the PTSD Symptom Scale-Self-Report at the end of Session 8. Excellent responders terminated therapy after Session 9, and partial responders were offered up to three additional sessions. Logistic regression was conducted to investigate predictors of response to PE. Results showed that prior interpersonal violence and comorbid alcohol use disorder were associated with partial response. Comorbid depressive disorder and early PTSD symptom reduction were associated with excellent response. Being treated by a cognitive behavioral therapy expert predicted higher excellent response for patients with a history of prior interpersonal violence. The model accounted for 56.6% of the variance in treatment response and correctly predicted responder status for 83.3% of the sample. These findings contribute to the field's understanding of factors that predict or moderate response to PE and have implications for treatment planning.
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Affiliation(s)
- Yinyin Zang
- Department of Psychiatry, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Yi-Jen Su
- Department of Psychiatry, University of Pennsylvania, Philadelphia, Pennsylvania, USA.,Graduate Institute of Behavioral Sciences, Chang Gung University, Taoyuan, Taiwan, ROC.,Department of Psychiatry, Linkou Chang Gung Memorial Hospital, Taoyuan, Taiwan, ROC
| | - Carmen P McLean
- Department of Psychiatry, University of Pennsylvania, Philadelphia, Pennsylvania, USA.,VA Palo Alto Health Care System, Palo Alto, California, USA
| | - Edna B Foa
- Department of Psychiatry, University of Pennsylvania, Philadelphia, Pennsylvania, USA
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21
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Predictors of attendance and dropout in three randomized controlled trials of PTSD treatment for active duty service members. Behav Res Ther 2019; 118:7-17. [DOI: 10.1016/j.brat.2019.03.003] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2018] [Revised: 02/12/2019] [Accepted: 03/04/2019] [Indexed: 11/18/2022]
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22
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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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23
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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: 101] [Impact Index Per Article: 20.2] [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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24
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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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25
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Boffa JW, Short NA, Gibby BA, Stentz LA, Schmidt NB. Distress tolerance as a mechanism of PTSD symptom change: Evidence for mediation in a treatment-seeking sample. Psychiatry Res 2018; 267:400-408. [PMID: 29960937 PMCID: PMC6434692 DOI: 10.1016/j.psychres.2018.03.085] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2017] [Revised: 03/26/2018] [Accepted: 03/29/2018] [Indexed: 11/30/2022]
Abstract
Low distress tolerance, the perceived or actual inability to tolerate negative emotional states, is a transdiagnostic risk marker associated with greater PTSD symptoms and poorer treatment outcomes. However, the role of distress tolerance in PTSD symptom trajectories has not yet been explored. This study examined the mediating role of distress tolerance in PTSD symptom change among outpatients participating in a trial of computerized interventions for anxiety-related and mood-related risk factors. It was hypothesized that pre- to post-intervention change in distress tolerance would predict PTSD symptoms at three- and six-month follow-up, and mediate the effect of condition on PTSD symptoms above and beyond the effects of a competing mediator, anxiety sensitivity. Although condition differences in distress tolerance change were non-significant, distress tolerance change predicted month-three PTSD symptoms and mediated the direct effect of condition on month-three PTSD symptoms. After accounting for the direct effect of condition on month-six PTSD symptoms, distress tolerance change did not predict month-six PTSD symptoms. Findings suggest distress tolerance does play a longitudinal role in PTSD symptom change, and distress tolerance interventions may benefit certain samples who may otherwise not be able to immediately access, or remain in PTSD treatments.
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Affiliation(s)
| | | | | | | | - Norman B. Schmidt
- Correspondence concerning this article should be addressed to Norman B. Schmidt, Department of Psychology, Florida State University, Tallahassee, FL, 32306. ; Telephone: (850) 644-1707; Fax: (850) 644-1707
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26
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Treatment processes and demographic variables as predictors of dropout from trauma-focused cognitive behavioral therapy (TF-CBT) for youth. Behav Res Ther 2018; 107:10-18. [DOI: 10.1016/j.brat.2018.05.008] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2017] [Revised: 03/15/2018] [Accepted: 05/14/2018] [Indexed: 11/22/2022]
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27
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Vujanovic AA, Farris SG, Bartlett BA, Lyons RC, Haller M, Colvonen PJ, Norman SB. Anxiety sensitivity in the association between posttraumatic stress and substance use disorders: A systematic review. Clin Psychol Rev 2018; 62:37-55. [PMID: 29778929 DOI: 10.1016/j.cpr.2018.05.003] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2018] [Revised: 05/08/2018] [Accepted: 05/09/2018] [Indexed: 11/19/2022]
Abstract
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. Thus, it is imperative to better understand cognitive-affective mechanisms, targetable via cognitive-behavioral intervention (i.e., malleable), that may be related to both disorders in order to improve the theory and treatment of PTSD/SUD. Anxiety sensitivity is a malleable cognitive-affective factor with relevance to both PTSD and SUD. This systematic review focused on the published literature on anxiety sensitivity and trauma/PTSD and substance use/SUD from 1966 - May 1, 2018, and includes a total of 35 manuscripts. The state of the literature, limitations, and future research directions are discussed.
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Affiliation(s)
- Anka A Vujanovic
- University of Houston, Department of Psychology, Houston, TX, USA.
| | - Samantha G Farris
- The Warren Alpert Medical School of Brown University, Department of Psychiatry and Human Behavior, Providence, RI, USA; The Miriam Hospital, Centers for Behavioral and Preventative Medicine, Providence, RI, USA; Butler Hospital, Behavioral Medicine and Addictions Research Unit, Providence, RI, USA; Rutgers, The State University of New Jersey, Department of Psychology, Piscataway, NJ, USA
| | | | - Robert C Lyons
- Veterans Affairs San Diego Healthcare System, San Diego, CA, USA; University of California, San Diego School of Medicine, Department of Psychiatry, San Diego, CA, USA
| | - Moira Haller
- Veterans Affairs San Diego Healthcare System, San Diego, CA, USA; University of California, San Diego School of Medicine, Department of Psychiatry, San Diego, CA, USA
| | - Peter J Colvonen
- Veterans Affairs San Diego Healthcare System, San Diego, CA, USA; University of California, San Diego School of Medicine, Department of Psychiatry, San Diego, CA, USA; Veterans Affairs Center of Excellence for Stress and Mental Health, San Diego, CA, USA
| | - Sonya B Norman
- Veterans Affairs San Diego Healthcare System, San Diego, CA, USA; University of California, San Diego School of Medicine, Department of Psychiatry, San Diego, CA, USA; Veterans Affairs Center of Excellence for Stress and Mental Health, San Diego, CA, USA; National Center for PTSD, White River Junction, VT, USA
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28
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Szafranski DD, Snead A, Allan NP, Gros DF, Killeen T, Flanagan J, Pericot-Valverde I, Back SE. Integrated, exposure-based treatment for PTSD and comorbid substance use disorders: Predictors of treatment dropout. Addict Behav 2017; 73:30-35. [PMID: 28460246 DOI: 10.1016/j.addbeh.2017.04.005] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2016] [Revised: 03/23/2017] [Accepted: 04/03/2017] [Indexed: 01/09/2023]
Abstract
High rates of comorbid posttraumatic stress disorder (PTSD) and substance use disorders (SUD) have been noted in veteran populations. Fortunately, there are a number of evidence-based psychotherapies designed to address comorbid PTSD and SUD. However, treatments targeting PTSD and SUD simultaneously often report high dropout rates. To date, only one study has examined predictors of dropout from PTSD/SUD treatment. To address this gap in the literature, this study aimed to 1) examine when in the course of treatment dropout occurred, and 2) identify predictors of dropout from a concurrent treatment for PTSD and SUD. Participants were 51 male and female veterans diagnosed with current PTSD and SUD. All participants completed at least one session of a cognitive-behavioral treatment (COPE) designed to simultaneously address PTSD and SUD symptoms. Of the 51 participants, 22 (43.1%) dropped out of treatment prior to completing the full 12 session COPE protocol. Results indicated that the majority of dropout (55%) occurred after session 6, with the largest amount of dropout occurring between sessions 9 and 10. Results also indicated a marginally significant relationship between greater baseline PTSD symptom severity and premature dropout. These findings highlight inconsistencies related to timing and predictors of dropout, as well as the dearth of information noted about treatment dropout within PTSD and SUD literature. Suggestions for procedural changes, such as implementing continual symptom assessments during treatment and increasing dialog between provider and patient about dropout were made with the hopes of increasing consistency of findings and eventually reducing treatment dropout.
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Identifying attendance patterns in a smoking cessation treatment and their relationships with quit success. Drug Alcohol Depend 2017; 174:65-69. [PMID: 28315809 PMCID: PMC5423398 DOI: 10.1016/j.drugalcdep.2017.01.007] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2016] [Revised: 01/19/2017] [Accepted: 01/23/2017] [Indexed: 11/22/2022]
Abstract
BACKGROUND While important for substance use outcomes, knowledge about treatment attendance patterns, and their relation with clinical outcomes is limited. We examined the association between attendance patterns and smoking outcomes in a randomized, controlled smoking cessation intervention trial. METHODS In addition to standard smoking cessation treatment, participants were randomized to 15 weeks of an exercise intervention (n=72) or an education control condition (n=64). Latent class growth analysis (LCGA) tested whether intervention attendance would be better modeled as qualitatively distinct attendance patterns rather than as a single mean pattern. Multivariate generalized linear mixed modeling (GLMM) was used to evaluate associations between the attendance patterns and abstinence at the end of treatment and at 6-month follow-up. RESULTS The LCGA solution with three patterns characterized by high probability of attendance throughout (Completers, 46.3%), gradual decreasing probability of attendance (Titrators, 23.5%), and high probability of dropout within the first few weeks (Droppers, 30.1%) provided the best fit. The GLMM analysis indicated an interaction of attendance pattern by treatment condition, such that titration was associated with lower probability of quit success for those in the control condition. Probability of quit success was not significantly different between Titrators and Completers in the exercise condition. CONCLUSIONS These findings underscore the importance of examining how treatment efficacy may vary as a function of attendance patterns. Importantly, treatment discontinuation is not necessarily indicative of poorer abstinence outcome.
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Belleau EL, Chin EG, Wanklyn SG, Zambrano-Vazquez L, Schumacher JA, Coffey SF. Pre-treatment predictors of dropout from prolonged exposure therapy in patients with chronic posttraumatic stress disorder and comorbid substance use disorders. Behav Res Ther 2017; 91:43-50. [PMID: 28147254 PMCID: PMC5328858 DOI: 10.1016/j.brat.2017.01.011] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2016] [Revised: 01/17/2017] [Accepted: 01/23/2017] [Indexed: 11/16/2022]
Abstract
Posttraumatic stress disorder (PTSD) and substance use disorders (SUDs) are commonly co-occurring disorders associated with more adverse consequences than PTSD alone. Prolonged exposure therapy (PE) is one of the most efficacious treatments for PTSD. However, among individuals with PTSD-SUD, 35-62% of individuals drop out of trauma-focused exposure treatments. Thus, it is important to identify predictors of PTSD treatment dropout among substance abusers with PTSD in order to gain information about adapting treatment strategies to enhance retention and outcomes. The current study explored pre-treatment predictors of early termination from PE treatment in a sample of 85 individuals receiving concurrent treatment for PTSD and a SUD in a residential treatment facility as part of a randomized controlled trial. The results indicated that less education and more anxiety sensitivity uniquely predicted PE treatment dropout. Demographic variables, PTSD severity, SUD severity, mental health comorbidities, and emotion regulation difficulties did not predict treatment dropout. These results suggest that adding pre-treatment interventions that address anxiety sensitivity, and promote social adjustment and cognitive flexibility, could possibly improve PE retention rates in clients with high anxiety or low education.
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Affiliation(s)
- Emily L Belleau
- Department of Psychiatry and Human Behavior, The University of Mississippi Medical Center, United States
| | - Eu Gene Chin
- Department of Psychiatry and Human Behavior, The University of Mississippi Medical Center, United States
| | - Sonya G Wanklyn
- Department of Psychiatry and Human Behavior, The University of Mississippi Medical Center, United States
| | - Laura Zambrano-Vazquez
- Department of Psychiatry and Human Behavior, The University of Mississippi Medical Center, United States
| | - Julie A Schumacher
- Department of Psychiatry and Human Behavior, The University of Mississippi Medical Center, United States
| | - Scott F Coffey
- Department of Psychiatry and Human Behavior, The University of Mississippi Medical Center, United States.
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