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Amstadter AB, Lönn S, Sundquist J, Sundquist K, Kendler KS. Post-traumatic stress disorder and drug use disorder: examination of aetiological models in a Swedish population-based cohort. Eur J Psychotraumatol 2023; 14:2258312. [PMID: 37800551 PMCID: PMC10561571 DOI: 10.1080/20008066.2023.2258312] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2022] [Accepted: 07/24/2023] [Indexed: 10/07/2023] Open
Abstract
Background: There are two primary phenotypic models of comorbidity between post-traumatic stress disorder (PTSD) and drug use disorder (DUD), i.e. self-medication (PTSD precedes and causes DUD) and susceptibility (DUD precedes and causes PTSD). We sought to clarify the longitudinal relationship between PTSD and DUD, while examining sex differences.Method: We used approximately 23 years of longitudinal data from Swedish population registries to conduct two complementary statistical models: Cox proportional hazard models (N ≈ 1.5 million) and a cross-lagged panel model (N ≈ 3.8 million).Results: Cox proportional hazards models, adjusting for cohort and socioeconomic status, found strong evidence for the self-medication hypothesis, as PTSD predicted increased risk for DUD among both women [hazard ratio (HR) = 5.34, 95% confidence interval (CI) 5.18, 5.51] and men (HR = 3.65, 95% CI 3.54, 3.77), and moreover, that the PTSD to DUD association was significantly higher among women (interaction term 0.68, 95% CI 0.65, 0.71). The results of the susceptibility model were significant, but not as strong as the self-medication model. DUD predicted risk for PTSD among both women (HR = 2.43, 95% CI 2.38, 2.50) and men (HR = 2.55, 95% CI 2.50, 2.60), and HR was significantly higher in men (interaction term 1.05, 95% CI 1.02, 1.08). Investigating the pathways simultaneously in the cross-lagged model yielded support for both pathways of risk. The cross-paths instantiating the susceptibility model (0.10-0.22 in females, 0.12-0.19 in males) were mostly larger than those capturing the self-medication model (0.01-0.16 in females, 0.04-0.22 in males).Conclusions: We demonstrate that the relationship between PTSD and DUD is bidirectional, with evidence that future research should prioritize examining specific pathways of risk that may differ between men and women.
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Affiliation(s)
- Ananda B. Amstadter
- Virginia Institute for Psychiatric and Behavioral Genetics, Virginia Commonwealth University, Richmond, VA, USA
- Department of Psychiatry, Virginia Commonwealth University, Richmond, VA, USA
| | - Sara Lönn
- Center for Primary Health Care Research, Lund University, Malmö, Sweden
| | - Jan Sundquist
- Center for Primary Health Care Research, Lund University, Malmö, Sweden
- Department of Family Medicine and Community Health, Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, USA
| | - Kristina Sundquist
- Center for Primary Health Care Research, Lund University, Malmö, Sweden
- Department of Family Medicine and Community Health, Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, USA
| | - Kenneth S. Kendler
- Virginia Institute for Psychiatric and Behavioral Genetics, Virginia Commonwealth University, Richmond, VA, USA
- Department of Psychiatry, Virginia Commonwealth University, Richmond, VA, USA
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Grekin R, Bohnert KM, Grau PP, Ganoczy D, Sripada RK. Rates and predictors of psychotherapy receipt among U.S. veterans with comorbid posttraumatic stress disorder and substance use disorders. DRUG AND ALCOHOL DEPENDENCE REPORTS 2021; 1:100010. [PMID: 36843911 PMCID: PMC9948867 DOI: 10.1016/j.dadr.2021.100010] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 09/06/2021] [Revised: 11/22/2021] [Accepted: 11/22/2021] [Indexed: 11/17/2022]
Abstract
Introduction Veterans with comorbid posttraumatic stress disorder (PTSD) and substance use disorder (SUD) have complex needs and often do not receive adequate mental health treatment. The purpose of this study was to examine rates and predictors of PTSD-only, SUD-only, or PTSD and SUD psychotherapy receipt among newly diagnosed Veterans with PTSD and SUD. Design and setting An administrative dataset including Veterans Health Administration (VHA) users. Participants The sample comprised 32,779 United States Veterans with a new PTSD and a new SUD diagnosis in fiscal year 2015. Measurement Multinomial logistic regression was used to identify predictors of receipt of any and adequate psychotherapy for PTSD, SUD, or PTSD and SUD across settings. Binomial logistic regression was used to identify predictors of PTSD psychotherapy among those who received any psychotherapy. Findings A total of 13,824 (42.17%) Veterans in this sample received any PTSD- or SUD-related therapy in the year following diagnosis. Low rates of veterans received an adequate dose of PTSD-related psychotherapy (6.58%), SUD-related psychotherapy (7.72%), or both PTSD and SUD-related psychotherapy (<1%) In adjusted models, older age, service-connected disability, and psychiatric comorbidities were associated with decreased odds of treatment. Specific types of SUDs, including alcohol, cocaine, and opioid use disorders, along with receipt of diagnosis in a PTSD or SUD clinic, were associated with increased odds of treatment. Conclusions Low rates of PTSD and SUD related psychotherapy highlight a need to better engage and retain Veterans with these disorders in care. Predictors of decreased treatment utilization, such as older age, service connection, and bipolar and major depressive disorders, may inform efforts by the VHA to further target and engage Veterans with indicated treatments.
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Affiliation(s)
- Rebecca Grekin
- VA Serious Mental Illness Treatment Resource and Evaluation Center (SMITREC), 2800 Plymouth Road, Bldg 16, Ann Arbor, MI 48109, United States
- Great Lakes Perinatal Wellness, Ann Arbor, MI 48105, United States
- Department of Psychological and Brain Sciences, University of Iowa, United States
| | - Kipling M. Bohnert
- Department of Epidemiology and Biostatistics, Michigan State University, United States
| | - Peter P. Grau
- VA Serious Mental Illness Treatment Resource and Evaluation Center (SMITREC), 2800 Plymouth Road, Bldg 16, Ann Arbor, MI 48109, United States
- VA Ann Arbor Healthcare System, 2215 Fuller Road, Ann Arbor, MI 48105, United States
- Department of Psychiatry, University of Michigan Medical School, United States
| | - Dara Ganoczy
- Veterans Affairs Center for Clinical Management Research, Health Services Research and Development, Ann Arbor Michigan, United States
| | - Rebecca K. Sripada
- VA Ann Arbor Healthcare System, 2215 Fuller Road, Ann Arbor, MI 48105, United States
- Department of Psychiatry, University of Michigan Medical School, United States
- Veterans Affairs Center for Clinical Management Research, Health Services Research and Development, Ann Arbor Michigan, United States
- Corresponding author at: Serious Mental Illness Treatment Resource and Evaluation Center, 2800 Plymouth Road, 016, Ann Arbor, MI 48109, United States.
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Stefanovics EA, Rosenheck RA. Gender Difference in Substance Use and Psychiatric Outcomes Among Dually Diagnosed Veterans Treated in Specialized Intensive PTSD Programs. J Dual Diagn 2020; 16:382-391. [PMID: 33002376 DOI: 10.1080/15504263.2020.1822569] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
OBJECTIVES Posttraumatic stress disorder (PTSD) is a problem of growing importance among female veterans, which is especially challenging when accompanied by comorbid substance use disorder (SUD). Since women are still a small minority of Veterans Health Administration (VHA) patients, there is concern that outcomes among dually diagnosed women may be worse than among men. METHOD National program evaluation data were collected at admission and 4 months after discharge from 7,074 dually diagnosed veterans including 203 women (2.9%) treated at 57 specialized intensive VHA PTSD treatment programs between 1993 and 2011. Multiple regression was used to compare clinical change in women and men adjusting for baseline differences. RESULTS Women showed no significant differences from men in measures of substance use or total PTSD symptoms at admission although they were more likely to have experienced sexual trauma and less likely to report combat exposure. With adjustment for these differences, there were no significant gender differences in length of stay, satisfaction with treatment, or measures of change in substance use or total PTSD symptoms 4 months after discharge. Reductions in an index of days of substance use was associated with reduction in total PTSD symptoms among both women (R = 0.33; p = .01) and men (R = 0.44, p < .0001) with no significant gender difference. CONCLUSION No significant gender differences were observed in substance use or PTSD outcomes, despite the extreme minority status of women in VHA programs. Highly vulnerable women can benefit as much as men, even when treatment is not formally tailored to address gender-specific needs.
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Affiliation(s)
- Elina A Stefanovics
- Department of Psychiatry, School of Medicine, Yale University, New Haven, Connecticut, USA.,Department of Veterans Affairs Connecticut Healthcare System, New England Mental Illness, Research, Education, and Clinical Center (MIRECC), West Haven, Connecticut, USA
| | - Robert A Rosenheck
- Department of Psychiatry, School of Medicine, Yale University, New Haven, Connecticut, USA.,Department of Veterans Affairs Connecticut Healthcare System, New England Mental Illness, Research, Education, and Clinical Center (MIRECC), West Haven, Connecticut, USA
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4
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Exclusion of participants based on substance use status: Findings from randomized controlled trials of treatments for PTSD. Behav Res Ther 2017; 89:33-40. [DOI: 10.1016/j.brat.2016.10.006] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2016] [Revised: 10/26/2016] [Accepted: 10/26/2016] [Indexed: 01/19/2023]
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Haller M, Colvonen PJ, Davis BC, Trim RS, Bogner R, Sevcik J, Norman SB. Examining Pretreatment Differences Between Veterans in Residential Versus Outpatient Treatment for Alcohol Use Disorder and Comorbid Combat-Related PTSD. J Dual Diagn 2016; 12:282-289. [PMID: 27808661 DOI: 10.1080/15504263.2016.1256516] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
OBJECTIVE Veterans with alcohol use disorder (AUD) and co-occurring posttraumatic stress disorder (PTSD) have access to various residential and outpatient treatment programs through the VA Healthcare System. There is a need to better understand the characteristics and needs of veterans who engage in residential versus outpatient treatment in order to help inform veteran care and decisions about treatment services. METHODS The present study examined whether veterans with both AUD and combat-related PTSD who were enrolled in residential (n = 103) or outpatient treatment programs (n = 76) differed on pretreatment psychiatric symptoms, substance use and associated problems/behaviors, or demographics. Veterans completed self-report measures (which referenced symptoms in the past 30 days or 2 weeks) within the first week of PTSD/AUD treatment. RESULTS Veterans in residential treatment had slightly worse PTSD symptoms compared to outpatient veterans; the groups reported similar levels of depression symptoms. Residential veterans had higher frequency of drug use, were more confident in their ability to be abstinent, attended more self-help meetings, spent more time around risky people or places, were more satisfied with their progress toward recovery goals, were more bothered by arguments with family/friends, and spent fewer days at work or school compared to outpatient veterans; the groups did not differ on drinking (frequency of use, binge drinking) or cravings. With respect to demographics, residential veterans were more likely to be married and non-Hispanic Caucasian (rather than minority races/ethnicities) compared to outpatient veterans. CONCLUSIONS The finding that PTSD symptoms were more severe among veterans in residential substance use treatment highlights the importance of taking advantage of this crucial opportunity to engage veterans in evidence-based PTSD treatment. Consistent with other research, findings also indicated that individuals entering residential care have a higher level of impairment than those beginning outpatient care.
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Affiliation(s)
- Moira Haller
- a VA San Diego Healthcare System , San Diego , California , USA.,b University of California , San Diego, San Diego , California , USA
| | - Peter J Colvonen
- a VA San Diego Healthcare System , San Diego , California , USA.,c VA Center of Excellence for Stress and Mental Health , San Diego , California , USA
| | - Brittany C Davis
- a VA San Diego Healthcare System , San Diego , California , USA.,b University of California , San Diego, San Diego , California , USA
| | - Ryan S Trim
- a VA San Diego Healthcare System , San Diego , California , USA.,b University of California , San Diego, San Diego , California , USA
| | - Rebecca Bogner
- a VA San Diego Healthcare System , San Diego , California , USA
| | - John Sevcik
- a VA San Diego Healthcare System , San Diego , California , USA
| | - Sonya B Norman
- a VA San Diego Healthcare System , San Diego , California , USA.,b University of California , San Diego, San Diego , California , USA.,c VA Center of Excellence for Stress and Mental Health , San Diego , California , USA.,d National Center for PTSD, White River Junction , Vermont , USA
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6
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Saunders EC, McLeman BM, McGovern MP, Xie H, Lambert-Harris C, Meier A. The influence of family and social problems on treatment outcomes of persons with co-occurring substance use disorders and PTSD. JOURNAL OF SUBSTANCE USE 2016; 21:237-243. [PMID: 27182200 DOI: 10.3109/14659891.2015.1005184] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
OBJECTIVE Family and social problems may contribute to negative recovery outcomes in patients with co-occurring substance use and psychiatric disorders, yet few studies have empirically examined this relationship. This study investigates the impact of family and social problems on treatment outcomes among patients with co-occurring substance use and posttraumatic stress disorder (PTSD). METHOD A secondary analysis was conducted using data collected from a randomized controlled trial of an integrated therapy for patients with co-occurring substance use and PTSD. Substance use, psychiatric symptoms, and social problems were assessed. Longitudinal outcomes were analyzed using generalized estimating equations (GEE) and multiple linear regression. RESULTS At baseline, increased family and social problems were associated with more severe substance use and psychiatric symptoms. Over time, all participants had comparable decreases in substance use and psychiatric problem severity. However, changes in family and social problem severity were predictive of PTSD symptom severity, alcohol use, and psychiatric severity at follow-up. CONCLUSIONS For patients with co-occurring substance use and PTSD, family and social problem severity is associated with substance use and psychiatric problem severity at baseline and over time. Targeted treatment for social and family problems may be optimal.
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Affiliation(s)
- Elizabeth C Saunders
- Dartmouth Psychiatric Research Center, Geisel School of Medicine at Dartmouth, 85 Mechanic Street, Suite B4-1, Lebanon, NH, USA
| | - Bethany M McLeman
- Dartmouth Psychiatric Research Center, Geisel School of Medicine at Dartmouth, 85 Mechanic Street, Suite B4-1, Lebanon, NH, USA
| | - Mark P McGovern
- Department of Psychiatry and of Community and Family Medicine, Geisel School of Medicine at Dartmouth, Lebanon, NH, USA
| | - Haiyi Xie
- Department of Community & Family Medicine, Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire, USA
| | - Chantal Lambert-Harris
- Department of Psychiatry, Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire, USA
| | - Andrea Meier
- Department of Psychiatry, Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire, USA
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7
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Prolonged Exposure With Veterans in a Residential Substance Use Treatment Program. COGNITIVE AND BEHAVIORAL PRACTICE 2016. [DOI: 10.1016/j.cbpra.2015.08.002] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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8
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Manhapra A, Stefanovics E, Rosenheck R. Treatment outcomes for veterans with PTSD and substance use: Impact of specific substances and achievement of abstinence. Drug Alcohol Depend 2015; 156:70-77. [PMID: 26429726 PMCID: PMC4633308 DOI: 10.1016/j.drugalcdep.2015.08.036] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2015] [Revised: 08/22/2015] [Accepted: 08/24/2015] [Indexed: 10/23/2022]
Abstract
BACKGROUND Scant longitudinal data exists about the interplay between specific substances of abuse, the achievement of abstinence, and clinical outcomes in the treatment of dually diagnosed Veterans with post-traumatic stress disorder (PTSD). METHODS As part of a national program evaluation, Veterans admitted from the community to specialized intensive PTSD programs were assessed at intake and 4 months after discharge. Seven mutually exclusive groups were identified from admission self-report data (N=22,948): no substance use, exclusive use of alcohol, opiates, sedatives, cocaine, marijuana, and use of three or more substances. Analysis of covariance, adjusting for potentially confounding baseline variables was used to compare change among these seven groups in non-substance use outcomes (PTSD symptoms, violent behavior, suicidality, medical problems, and employment). The effect of abstinence on specific groups was evaluated as the interaction of group membership by abstinence. RESULTS All outcome measures except for employment showed significant improvement, with few differences between the groups. Although rate of abstinence differed markedly between the groups, abstinence achievement was associated with greater improvement on all the outcomes except employment in every group. No significant differences in the effect of abstinence across the substance abuse groups were observed. CONCLUSION The specific type of substance used prior to entry into treatment among dually diagnosed PTSD patients seems to have limited effect on treatment outcomes. However, attainment of abstinence at 4 months after treatment, irrespective of the substances abused, was strongly associated with improvement in PTSD symptoms, violence, suicidality and medical problems.
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Affiliation(s)
- Ajay Manhapra
- VA New England Mental Illness Research and Education Center, West Haven, CT, United States; Department of Psychiatry, Yale School of Medicine, New Haven, CT, United States; Department of Internal Medicine, Yale School of Medicine, New Haven, CT, United States.
| | - Elina Stefanovics
- VA New England Mental Illness Research and Education Center, West Haven, CT, Department of Psychiatry, Yale School of Medicine, New Haven, CT
| | - Robert Rosenheck
- VA New England Mental Illness Research and Education Center, West Haven, CT, Department of Psychiatry, Yale School of Medicine, New Haven, CT
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9
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Wilkinson ST, Stefanovics E, Rosenheck RA. Marijuana use is associated with worse outcomes in symptom severity and violent behavior in patients with posttraumatic stress disorder. J Clin Psychiatry 2015; 76:1174-80. [PMID: 26455669 PMCID: PMC6258013 DOI: 10.4088/jcp.14m09475] [Citation(s) in RCA: 83] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2014] [Accepted: 01/22/2015] [Indexed: 12/17/2022]
Abstract
OBJECTIVE An increasing number of states have approved posttraumatic stress disorder (PTSD) as a qualifying condition for medical marijuana, although little evidence exists evaluating the effect of marijuana use in PTSD. We examined the association between marijuana use and PTSD symptom severity in a longitudinal, observational study. METHOD From 1992 to 2011, veterans with DSM-III/-IV PTSD (N = 2,276) were admitted to specialized Veterans Affairs treatment programs, with assessments conducted at intake and 4 months after discharge. Subjects were classified into 4 groups according to marijuana use: those with no use at admission or after discharge ("never-users"), those who used at admission but not after discharge ("stoppers"), those who used at admission and after discharge ("continuing users"), and those using after discharge but not at admission ("starters"). Analyses of variance compared baseline characteristics and identified relevant covariates. Analyses of covariance then compared groups on follow-up measures of PTSD symptoms, drug and alcohol use, violent behavior, and employment. RESULTS After we adjusted for relevant baseline covariates, marijuana use was significantly associated with worse outcomes in PTSD symptom severity (P < .01), violent behavior (P < .01), and measures of alcohol and drug use (P < .01) when compared with stoppers and never-users. At follow-up, stoppers and never-users had the lowest levels of PTSD symptoms (P < .0001), and starters had the highest levels of violent behavior (P < .0001). After adjusting for covariates and using never-users as a reference, starting marijuana use had an effect size on PTSD symptoms of +0.34 (Cohen d = change/SD), and stopping marijuana use had an effect size of -0.18. CONCLUSIONS In this observational study, initiating marijuana use after treatment was associated with worse PTSD symptoms, more violent behavior, and alcohol use. Marijuana may actually worsen PTSD symptoms or nullify the benefits of specialized, intensive treatment. Cessation or prevention of use may be an important goal of treatment.
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Affiliation(s)
| | - Elina Stefanovics
- Department of Psychiatry, Yale School of Medicine, New Haven, CT, USA,Mental Illness Research, Education and Clinical Centers, VA Connecticut Healthcare System, West Haven, CT, USA
| | - Robert A. Rosenheck
- Department of Psychiatry, Yale School of Medicine, New Haven, CT, USA,Mental Illness Research, Education and Clinical Centers, VA Connecticut Healthcare System, West Haven, CT, USA
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Coker KL, Stefanovics E, Rosenheck R. Correlates of improvement in substance abuse among dually diagnosed veterans with post-traumatic stress disorder in specialized intensive VA treatment. PSYCHOLOGICAL TRAUMA-THEORY RESEARCH PRACTICE AND POLICY 2015; 8:41-8. [PMID: 26121176 DOI: 10.1037/tra0000061] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Substantial rates of substance use comorbidity have been observed among veterans with Post-Traumatic Stress Disorder (PTSD), highlighting the need to identify patient and program characteristics associated with improved outcomes for substance abuse. Data were drawn from 12,270 dually diagnosed veterans who sought treatment from specialized intensive Veterans Health Administration PTSD programs between 1993 and 2011. The magnitude of the improvement in Addiction Severity Index (ASI) alcohol and drug use composite scores from baseline was moderate, with effect sizes (ES) of -.269 and -.287, respectively. Multivariate analyses revealed that treatment in longer-term programs, being prescribed psychiatric medication, and planned participation in reunions were all associated with slightly improved outcomes. Reductions in substance use measures were associated with robust improvements in PTSD symptoms and violent behavior. These findings suggest not only synergistic treatment effects linking improvement in PTSD symptoms with substance use disorders among dually diagnosed veterans with PTSD, but also to reductions in violent behavior. Furthermore, the findings indicate that proper discharge planning in addition to intensity and duration of treatment for dually diagnosed veterans with severe PTSD may result in better outcomes. Further dissemination of evidence-based substance abuse treatment may benefit this population.
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Affiliation(s)
- Kendell L Coker
- Yale University School of Medicine, Forensic Drug Diversion Program
| | - Elina Stefanovics
- A New England Mental Illness, Research, Education, and Clinical Center
| | - Robert Rosenheck
- VA New England Mental Illness, Research, Education, and Clinical Center (MIRECC), VA Connecticut Health Care Center
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11
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The efficacy of recommended treatments for veterans with PTSD: A metaregression analysis. Clin Psychol Rev 2015; 40:184-94. [PMID: 26164548 DOI: 10.1016/j.cpr.2015.06.008] [Citation(s) in RCA: 129] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2014] [Revised: 05/14/2015] [Accepted: 06/25/2015] [Indexed: 11/20/2022]
Abstract
Soldiers and veterans diagnosed with PTSD benefit less from psychotherapy than non-military populations. The current meta-analysis identified treatment predictors for traumatised soldiers and veterans, using data from studies examining guideline recommended interventions, namely: EMDR, exposure, cognitive, cognitive restructuring, cognitive processing, trauma-focused cognitive behavioural, and stress management therapies. A systematic search identified 57 eligible studies reporting on 69 treated samples. Exposure therapy and cognitive processing therapy were more effective than EMDR and stress management therapy. Group-only therapy formats performed worse compared with individual-only formats, or a combination of both formats. After controlling for study design variables, EMDR no longer negatively predicted treatment outcome. The number of trauma-focused sessions, unlike the total number of psychotherapy sessions, positively predicted treatment outcome. We found a relationship between PTSD pretreatment severity levels and treatment outcome, indicating lower treatment gains at low and high PTSD severity levels compared with moderate severity levels. Demographic variables did not influence treatment outcome. Consequently, soldiers and veterans are best served using exposure interventions to target PTSD. Our results did not support a group-only therapy format. Recommended interventions appear less effective at relatively low and high patient PTSD severity levels. Future high-quality studies are needed to determine the efficacy of EMDR.
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Crane CA, Schlauch RC, Easton CJ. Dual diagnosis among veterans in the United States. ADVANCES IN DUAL DIAGNOSIS 2015. [DOI: 10.1108/add-09-2014-0035] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Purpose
– Over the course of their service, veterans are exposed to elevated levels of chronic stress that contribute to a greater prevalence of mental illness than observed in the general population. When mental illness is present, comorbidity is normative. Convergent evidence suggests that co-occurring substance use and mental illness is among the most prevalent forms of comorbidity within veteran samples. The purpose of this paper is to explore issues associated with dual diagnoses among veterans in the USA.
Design/methodology/approach
– Research on dual diagnoses among veterans was reviewed and consolidated for presentation into three substantive content areas consisting of prevalence, associated conditions, and treatment of dual diagnoses.
Findings
– Dually diagnosed veterans represent a group at particularly high risk for myriad adverse biopsychosocial and treatment outcomes, including poor health, suicidality, violence or aggressive behavior, arrest, homelessness, and unemployment. A comprehensive strategy has been implemented within the Veterans Health Administration to address dual diagnosis and related problems. Additional research is required to more readily identify co-occurring substance use and mental illness and to refine integrated intervention approaches to minimize burden while improving treatment outcomes for veterans and their families.
Originality/value
– The current review includes a wide range of research spanning more than two decades and describing dual diagnosis among combat veterans of all modern eras. Areas in need of further research (e.g. dual diagnosis among female veterans; early detection of psychopathology and fully integrated care among returning veterans) are identified and discussed.
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Capone C, Eaton E, McGrath AC, McGovern MP. Integrated Cognitive Behavioral Therapy (ICBT) For PTSD and Substance Use in Iraq and Afghanistan Veterans: A Feasibility Study. JOURNAL OF TRAUMATIC STRESS DISORDERS & TREATMENT 2015; 3. [PMID: 25580442 DOI: 10.4172/2324-8947.1000134] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Co-occurring posttraumatic stress disorder (PTSD) and substance use disorder (SUD) is prevalent in military Veterans and is associated with poorer outcomes than either disorder alone. The current pilot study examines the feasibility of delivering integrated cognitive behavioral therapy (ICBT) for co-occurring PTSD-SUD to Veterans who served in Iraq and Afghanistan. Our primary aims were testing the feasibility of engaging and retaining Veterans with a complex clinical presentation in a 12-week structured therapy. We focused on two feasibility outcomes: 1) acceptability; and 2) tolerability. We also examined clinically meaningful change in PTSD and depressive symptoms as a secondary aim. Over the course of the study, we recruited 12 eligible Veterans, 6 of whom completed ICBT. We encountered challenges related to engaging and retaining Veterans in treatment and discuss adaptations and refinements of ICBT or other integrated treatments for returning Veterans with co-occurring PTSD-SUD to increase feasibility with military Veterans.
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Affiliation(s)
- Christy Capone
- Mental Health and Behavioral Sciences Service, Department of Veterans Affairs Medical Center, 830 Chalkstone Avenue Providence, RI 02908, USA ; Brown University, Center for Alcohol and Addiction Studies, Box G-S121-5 Providence, RI 02903, USA
| | - Erica Eaton
- Brown University, Center for Alcohol and Addiction Studies, Box G-S121-5 Providence, RI 02903, USA
| | - Ashlee C McGrath
- Mental Health and Behavioral Sciences Service, Department of Veterans Affairs Medical Center, 830 Chalkstone Avenue Providence, RI 02908, USA ; Brown University, Center for Alcohol and Addiction Studies, Box G-S121-5 Providence, RI 02903, USA
| | - Mark P McGovern
- Department of Psychiatry, Geisel School of Medicine at Dartmouth, 85 Mechanic Street, Suite B4-1, Lebanon, New Hampshire 03766, USA
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14
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Residential treatment for combat-related posttraumatic stress disorder: identifying trajectories of change and predictors of treatment response. PLoS One 2014; 9:e101741. [PMID: 25058403 PMCID: PMC4109915 DOI: 10.1371/journal.pone.0101741] [Citation(s) in RCA: 46] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2014] [Accepted: 06/10/2014] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Combat-related posttraumatic stress disorder (PTSD) can be a difficult condition to treat and has been associated with serious medical and economic issues among U.S. military veterans. Distinguishing between treatment responders vs. non-responders in this population has become an important public health priority. This study was conducted to identify pre-treatment characteristics of U.S. veterans with combat-related PTSD that might contribute to favorable and unfavorable responses to high value treatments for this condition. METHOD This study focused on 805 patients who completed a VHA PTSD residential program between 2000 and 2007. These patients completed the PTSD Clinical Checklist at pre-treatment, post-treatment, and a four-month follow-up assessment. Latent growth curve analysis (LCGA) was incorporated to determine trajectories of changes in PTSD across these assessments and whether several key clinical concerns for this population were associated with their treatment responses. STUDY FINDINGS LCGA indicated three distinct trajectories in PTSD outcomes and identified several clinical factors that were prospectively linked with changes in veterans' posttraumatic symptomatology. When compared to a group with high PTSD symptom severity that decreased over the program but relapsed at follow-up (41%), the near half (48.8%) of the sample with an improving trajectory had less combat exposure and superior physical/mental health. However, when compared to a minority (10.2%) with relatively low symptomatology that also remained somewhat stable, patients in the improving group were younger and also reported greater combat exposure, poorer physical/mental health status, and more problems with substance abuse before the start of treatment. CONCLUSIONS Findings suggest that veterans are most likely to benefit from residential treatment in an intermediate range of symptoms and risk factors, including PTSD symptom severity, history of combat exposure, and comorbid issues with physical/mental health. Addressing these factors in an integrative manner could help to optimize the effectiveness of treatments of combat-related PTSD in many cases.
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Kalapatapu RK, Delucchi KL, Lasher BA, Vinogradov S, Batki SL. Alcohol use biomarkers predicting cognitive performance: a secondary analysis in veterans with alcohol dependence and posttraumatic stress disorder. Mil Med 2014; 178:974-80. [PMID: 24005546 DOI: 10.7205/milmed-d-13-00097] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
Abstract
OBJECTIVE We conducted a secondary analysis of baseline data from a recently completed pharmacological pilot clinical trial among 30 veterans with alcohol dependence and posttraumatic stress disorder (PTSD). This trial included baseline measures of alcohol use biomarkers, both indirect (carbohydrate-deficient transferrin, GGT [γ-glutamyltransferase], mean corpuscular volume, AST [aspartate aminotransferase], alanine aminotransferase) and direct (ethyl glucuronide, ethyl sulfate), as well as neurocognitive measures (Trail Making Test parts A and B, Hopkins Verbal Learning Test-Revised, Balloon Analogue Risk Task, Delay Discounting Task). METHODS Two regression models were estimated and tested for each neurocognitive measure (dependent measure). The first model included the alcohol use biomarker alone as the predictor. The second model included the alcohol use biomarker along with the following 3 additional predictors: Beck Depression Inventory, Clinician-Administered PTSD Scale, and receiving medications. RESULTS In both models, the indirect biomarkers, such as GGT and AST, significantly predicted performance on the Hopkins Verbal Learning Test-Revised %Retention. GGT alone significantly predicted performance on the Trail Making Test part A. CONCLUSIONS Indirect alcohol use biomarkers may have a specific role in identifying those veterans with alcohol dependence and PTSD who have impaired cognitive performance. However, direct alcohol use biomarkers may not share such a role.
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Affiliation(s)
- Raj K Kalapatapu
- Department of Psychiatry, University of California, 401 Parnassus Avenue, San Francisco, CA 94143, USA
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Kalapatapu RK, Neylan TC, Regan MC, Cohen BE. Association of alcohol use biomarkers and cognitive performance in veterans with problematic alcohol use and posttraumatic stress disorder: data from the mind your heart study. J Addict Dis 2014; 33:67-76. [PMID: 24717141 PMCID: PMC4071132 DOI: 10.1080/10550887.2014.909701] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
The authors conducted a study of alcohol use biomarkers and cognitive performance among 85 veterans with problematic alcohol use and posttraumatic stress disorder (PTSD). All analyses were adjusted for demographics, depression, anxiety, and PTSD symptoms. Elevated levels of aspartate aminotransferase were associated with worse performance on the Trail Making Test Part A and Hopkins Verbal Learning Test. Two other biomarkers were not associated with any neurocognitive measures. Indirect alcohol use biomarkers (e.g., aspartate aminotransferase) may have a specific role in identifying veterans with problematic alcohol use and PTSD who show a change in psychomotor speed and immediate verbal memory performance.
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Affiliation(s)
- Raj K. Kalapatapu
- Department of Psychiatry, University of California, San Francisco, CA, USA
- San Francisco Veterans Affairs Medical Center, San Francisco, CA, USA
| | - Thomas C. Neylan
- Department of Psychiatry, University of California, San Francisco, CA, USA
- San Francisco Veterans Affairs Medical Center, San Francisco, CA, USA
- Northern California Institute for Research and Education, San Francisco, CA, USA
| | - Mathilda C. Regan
- San Francisco Veterans Affairs Medical Center, San Francisco, CA, USA
| | - Beth E. Cohen
- San Francisco Veterans Affairs Medical Center, San Francisco, CA, USA
- Northern California Institute for Research and Education, San Francisco, CA, USA
- Department of Medicine, University of California, San Francisco, CA, USA
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