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Hien DA, Papini S, Saavedra LM, Bauer AG, Ruglass LM, Ebrahimi CT, Fitzpatrick S, López-Castro T, Norman SB, Killeen TK, Back SE, Morgan-López AA. Project harmony: A systematic review and network meta-analysis of psychotherapy and pharmacologic trials for comorbid posttraumatic stress, alcohol, and other drug use disorders. Psychol Bull 2024; 150:319-353. [PMID: 37971855 PMCID: PMC10939977 DOI: 10.1037/bul0000409] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2023]
Abstract
We conducted a systematic review and network meta-analyses (NMA) of psychotherapy and pharmacologic treatments for individuals with co-occurring posttraumatic stress disorder (PTSD) and alcohol or other drug use disorder (AOD). A comprehensive search spanning 1995-2019 yielded a pool of 39 studies for systematic review, including 24 randomized controlled trials for the NMA. Study interventions were grouped by target of treatment (PTSD + AOD, PTSD-only, and AOD-only) and approach (psychotherapy or medication). Standardized mean differences (SMD) from the NMA yielded evidence that at the end of treatment, integrated, trauma-focused therapy for PTSD + AOD was more effective at reducing PTSD symptoms than integrated, non-trauma-focused therapy (SMD = -0.30), AOD-focused psychotherapy (SMD = -0.29), and other control psychotherapies (SMD = -0.43). End-of-treatment alcohol use severity was less for AOD medication compared to placebo medication (SMD = -0.36) and trauma-focused therapy for PTSD + placebo medication (SMD = -0.67), and less for trauma-focused psychotherapy + AOD medication compared to PTSD medication (SMD = -0.53), placebo medication (SMD = -0.50), and trauma-focused psychotherapy + placebo medication (SMD = -0.81). Key limitations include the small number of studies in the NMA for pharmacologic treatments and the lack of demographic diversity apparent in the existing literature. Findings suggest room for new studies that can address limitations in study sample composition, sample sizes, retention, and apply new techniques for conducting comparative effectiveness in PTSD + AOD treatment. (PsycInfo Database Record (c) 2024 APA, all rights reserved).
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Affiliation(s)
- Denise A Hien
- Department of Clinical Psychology, Center of Alcohol and Substance Use Studies, Graduate School of Applied and Professional Psychology, Rutgers University-New Brunswick
| | | | | | - Alexandria G Bauer
- Department of Clinical Psychology, Center of Alcohol and Substance Use Studies, Graduate School of Applied and Professional Psychology, Rutgers University-New Brunswick
| | | | - Chantel T Ebrahimi
- Department of Clinical Psychology, Center of Alcohol and Substance Use Studies, Graduate School of Applied and Professional Psychology, Rutgers University-New Brunswick
| | | | | | - Sonya B Norman
- Department of Psychiatry, University of California, San Diego
| | - Therese K Killeen
- Department of Psychiatry and Behavioral Sciences, Medical University of South Carolina
| | - Sudie E Back
- Department of Psychiatry and Behavioral Sciences, Medical University of South Carolina
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Vujanovic AA, Back SE, Leonard SJ, Zoller L, Kaysen DL, Norman SB, Flanagan JC, Schmitz JM, Resick P. Mental Health Clinician Practices and Perspectives on Treating Adults with Co-Occurring Posttraumatic Stress and Substance Use Disorders. J Dual Diagn 2023; 19:189-198. [PMID: 37796916 DOI: 10.1080/15504263.2023.2260338] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/07/2023]
Abstract
OBJECTIVE Posttraumatic stress disorder (PTSD) and substance use disorders (SUD) commonly co-occur and represent a complex, challenging clinical comorbidity. Meta-analytic studies and systematic reviews suggest that trauma-focused treatments are more efficacious than non-trauma focused interventions for co-occurring PTSD/SUD. However, relatively little is known about mental health clinicians' practices or preferences for treating co-occurring PTSD/SUD. The present study aimed to describe the current clinical practices of mental health clinicians who treat PTSD and/or SUD-related conditions and to assess interest in novel integrative treatments for PTSD/SUD. METHODS Licensed mental health clinicians (N = 76; Mage = 39.59, SD = 8.14) who treat PTSD and/or SUD completed an anonymous online survey from April 2021 to July 2021. RESULTS The majority (61.8%) of clinicians reported using integrative treatments for PTSD/SUD. The most commonly used trauma-focused treatments were 1) Cognitive Processing Therapy (CPT: 71.1%) and 2) Prolonged Exposure Therapy (PE: 68.4%) for PTSD. Approximately half (51.3%) of clinicians endorsed using Relapse Prevention (RP) for SUD. The vast majority (97.4%) of clinicians were somewhat or very interested in a new integrative CPT-RP intervention, and 94.7% of clinicians believed patients would be interested in a CPT-RP intervention. In the absence of an available evidence-based integrative treatment using CPT, 84.0% of clinicians reported modifying extant treatment protocols on their own to address PTSD and SUD concurrently. CONCLUSIONS The findings demonstrate mental health clinician support of integrative treatments for PTSD/SUD. The most commonly used trauma-focused intervention was CPT and clinicians expressed strong interest in an integrative intervention that combines CPT and RP. Implications for future treatment development are discussed.
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Affiliation(s)
- Anka A Vujanovic
- Texas A&M University, College Station, TX, USA
- University of Houston, Houston, TX, USA
| | - Sudie E Back
- Medical University of South Carolina, Charleston, SC, USA
- Ralph H. Johnson VA Medical Center, Charleston, SC, USA
| | | | | | - Debra L Kaysen
- Stanford University School of Medicine, Palo Alto, CA, USA
- National Center for PTSD, Executive Division, White River Junction, VT, USA
| | - Sonya B Norman
- National Center for PTSD, Executive Division, White River Junction, VT, USA
- San Diego School of Medicine, San Diego, CA, USA
- VA Center of Excellence for Stress and Mental Health, San Diego, CA, USA
| | - Julianne C Flanagan
- Medical University of South Carolina, Charleston, SC, USA
- Ralph H. Johnson VA Medical Center, Charleston, SC, USA
| | - Joy M Schmitz
- University of Texas Health Science Center at Houston, Houston, TX, USA
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Simpson TL, Kaysen DL, Fleming CB, Rhew IC, Jaffe AE, Desai S, Hien DA, Berliner L, Donovan D, Resick PA. Cognitive Processing Therapy or Relapse Prevention for comorbid Posttraumatic Stress Disorder and Alcohol Use Disorder: A randomized clinical trial. PLoS One 2022; 17:e0276111. [PMID: 36445895 PMCID: PMC9707793 DOI: 10.1371/journal.pone.0276111] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2022] [Accepted: 08/12/2022] [Indexed: 12/03/2022] Open
Abstract
OBJECTIVE To compare a Posttraumatic Stress Disorder (PTSD) treatment (Cognitive Processing Therapy; CPT), an Alcohol Use Disorder (AUD) treatment (Relapse Prevention; RP), and assessment-only (AO) for those meeting diagnostic criteria for both PTSD and AUD. METHOD Participants with current PTSD/AUD (N = 101; mean age = 42.10; 56% female) were initially randomized to CPT, RP, or AO and assessed post-treatment or 6-weeks post-randomization (AO). AO participants were then re-randomized to CPT or RP. Follow-ups were at immediate post-treatment, 3-, and 12-months. Mixed effects intent-to-treat models compared conditions on changes in PTSD symptom severity, drinking days, and heavy drinking days. RESULTS At post-treatment, participants assigned to CPT showed significantly greater improvement than those in AO on PTSD symptom severity (b = -9.72, 95% CI [-16.20, -3.23], d = 1.22); the RP and AO groups did not differ significantly on PTSD. Both active treatment conditions significantly decreased heavy drinking days relative to AO (CPT vs. AO: Count Ratio [CR] = 0.51, 95% CI [0.30, 0.88]; RP vs. AO: CR = 0.34, 95% CI [0.19, 0.59]). After re-randomization both treatment conditions showed substantial improvements in PTSD symptoms and drinking between pre-treatment and post-treatment over the 12-month follow-up period, with RP showing an advantage on heavy drinking days. CONCLUSION Treatments targeting one or the other aspects of the PTSD/AUD comorbidity may have salutary effects on both PTSD and drinking outcomes. These preliminary results suggest that people with this comorbidity may have viable treatment options whether they present for mental health or addiction care. TRIAL REGISTRATION The trial is registered at clinicaltrials.gov (NCT01663337).
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Affiliation(s)
- Tracy L. Simpson
- Center of Excellence in Substance Addiction Treatment and Education, VA Puget Sound Health Care, Seattle, WA, United States of America
- Department of Psychiatry and Behavioral Sciences, School of Medicine, University of Washington, Seattle, WA, United States of America
- * E-mail:
| | - Debra L. Kaysen
- Department of Psychiatry and Behavioral Sciences, School of Medicine, University of Washington, Seattle, WA, United States of America
- Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford, CA, United States of America
| | - Charles B. Fleming
- Center for the Study of Health and Risk Behaviors, Department of Psychiatry and Behavioral Sciences, School of Medicine, University of Washington, Seattle, WA, United States of America
| | - Isaac C. Rhew
- Center for the Study of Health and Risk Behaviors, Department of Psychiatry and Behavioral Sciences, School of Medicine, University of Washington, Seattle, WA, United States of America
| | - Anna E. Jaffe
- Department of Psychology, University of Nebraska-Lincoln, Lincoln, NE, United States of America
| | - Sruti Desai
- Center for the Study of Health and Risk Behaviors, Department of Psychiatry and Behavioral Sciences, School of Medicine, University of Washington, Seattle, WA, United States of America
| | - Denise A. Hien
- Department of Clinical Psychology, Graduate School of Applied and Professional Psychology, Rutgers University, Center of Alcohol & Substance Use Studies, Piscataway, NJ, United States of America
| | - Lucy Berliner
- Harborview Center for Sexual Assault and Traumatic Stress, University of Washington, Seattle, WA, United States of America
| | - Dennis Donovan
- Alcohol and Drug Abuse Institute, Department of Psychiatry and Behavioral Sciences, School of Medicine, University of Washington, Seattle, WA, United States of America
| | - Patricia A. Resick
- Department of Psychiatry and Behavioral Sciences, Duke Health, Durham, NC, United States of America
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Holder N, Batten AJ, Shiner B, Li Y, Madden E, Neylan TC, Seal KH, Patterson OV, DuVall SL, Maguen S. Veterans receiving a second course of cognitive processing therapy or prolonged exposure therapy: is it better to switch or stay the same? Cogn Behav Ther 2022; 51:456-469. [PMID: 35475499 DOI: 10.1080/16506073.2022.2058996] [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: 11/03/2022]
Abstract
Cognitive processing therapy (CPT) and prolonged exposure therapy (PE) are effective psychotherapies for post-traumatic stress disorder (PTSD). However, these treatments also have high rates of dropout and non-response. Therefore, patients may need a second course of treatment. We compared outcomes for patients who switched between CPT/PE and those who repeated CPT/PE during a second course of treatment. We collected data from Iraq and Afghanistan war veterans (n = 2,958) who received a second course of CPT/PE in the Veterans Health Administration from 2001 to 2017 and had symptom outcomes (PTSD checklist; PCL). We measured the association between treatment sequence and change in PCL score over the second course of treatment using hierarchical Bayesian regression, adjusted for sociodemographic and clinical characteristics. All treatment sequences showed a significant reduction in PCL score over time (β = -4.80; HDI95: -5.74, -3.86). Veterans who switched from CPT to PE had modestly greater PCL reductions during the second course than those who repeated CPT. However, no significant difference in PCL change during the second course was observed between veterans who repeated PE and those who switched from PE to CPT. Veterans participating in a second course of CPT/PE can benefit, and switching treatment may be slightly more beneficial following CPT.
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Affiliation(s)
- Nicholas Holder
- Mental Health Service, San Francisco Veterans Affairs Health Care System, San Francisco, California, USA.,Sierra Pacific Mental Illness Research, Education, and Clinical Center, San Francisco, California, USA.,Department of Psychiatry and Behavioral Sciences, University of California San Francisco School of Medicine, San Francisco, California, USA
| | - Adam J Batten
- Mental Health Service, San Francisco Veterans Affairs Health Care System, San Francisco, California, USA.,Department of Psychiatry and Behavioral Sciences, University of California San Francisco School of Medicine, San Francisco, California, USA.,Applied Statistics Unit, AB Evergreen Analytics LLC, Seattle, WA, USA
| | - Brian Shiner
- Mental Health Service, White River Junction Veterans Affairs Medical Center, White River Junction, Vermont, USA.,Department of Psychiatry, Geisel School of Medicine at Dartmouth, Executive Division Hanover, New Hampshire, USA.,Executive Division, National Center for Posttraumatic Stress Disorder, White River Junction, Vermont, USA
| | - Yongmei Li
- Mental Health Service, San Francisco Veterans Affairs Health Care System, San Francisco, California, USA
| | - Erin Madden
- Mental Health Service, San Francisco Veterans Affairs Health Care System, San Francisco, California, USA
| | - Thomas C Neylan
- Mental Health Service, San Francisco Veterans Affairs Health Care System, San Francisco, California, USA.,Sierra Pacific Mental Illness Research, Education, and Clinical Center, San Francisco, California, USA.,Department of Psychiatry and Behavioral Sciences, University of California San Francisco School of Medicine, San Francisco, California, USA
| | - Karen H Seal
- Department of Psychiatry and Behavioral Sciences, University of California San Francisco School of Medicine, San Francisco, California, USA.,Integrative Health Service, San Francisco Veterans Affairs Health Care System, San Francisco, California, USA.,Departments of Medicine, University of California San Francisco School of Medicine, San Francisco, California, USA
| | - Olga V Patterson
- VA Informatics and Computing Infrastructure, Department of Veterans Affairs Salt Lake City Health Care System, Salt Lake City, Utah, USA.,Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Scott L DuVall
- VA Informatics and Computing Infrastructure, Department of Veterans Affairs Salt Lake City Health Care System, Salt Lake City, Utah, USA.,Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Shira Maguen
- Mental Health Service, San Francisco Veterans Affairs Health Care System, San Francisco, California, USA.,Sierra Pacific Mental Illness Research, Education, and Clinical Center, San Francisco, California, USA.,Department of Psychiatry and Behavioral Sciences, University of California San Francisco School of Medicine, San Francisco, California, USA
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Munro S, Wahl K, Soon JA, Guilbert E, Wilcox ES, Leduc-Robert G, Ansari N, Devane C, Norman WV. Pharmacist dispensing of the abortion pill in Canada: Diffusion of Innovation meets integrated knowledge translation. Implement Sci 2021; 16:76. [PMID: 34344393 PMCID: PMC8330203 DOI: 10.1186/s13012-021-01144-w] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2021] [Accepted: 07/17/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Since Canadian drug regulatory approval of mifepristone for medical abortion in 2015 and its market availability in January 2017, the role of pharmacists in abortion provision has changed rapidly. We sought to identify the factors that influenced the initiation and provision of medical abortion from the perspectives of Canadian pharmacists, bridging two frameworks - Diffusion of Innovation in Health Service Organizations and integrated knowledge translation. METHODS We conducted one-on-one semi-structured interviews with pharmacists residing in Canada who intended to stock and dispense mifepristone within the first year of availability. Our data collection, analysis, and interpretation were guided by reflexive thematic analysis and supported by an integrated knowledge translation partnership with pharmacy stakeholders. RESULTS We completed interviews with 24 participants from across Canada: 33% had stocked and 21% had dispensed mifepristone. We found that pharmacists were willing and able to integrate medical abortion care into their practice and that those who had initiated practice were satisfied with their dispensing experience. Our analysis indicated that several key Diffusion of Innovation constructs impacted the uptake of mifepristone, including: innovation (relative advantage, complexity and compatibility, technical support), system readiness (innovation-system fit, dedicated time, resources), diffusion and dissemination (expert opinion, boundary spanners, champions, social networks, peer opinions), implementation (external collaboration), and linkage. Participants' experiences suggest that integrated knowledge translation facilitated evidence-based changes to mifepristone dispensing restrictions, and communication of those changes to front line pharmacists. CONCLUSIONS We illustrate how Diffusion of Innovation and integrated knowledge translation may work together as complimentary frameworks for implementation science research. Unlike in the USA, UK, and other highly regulated settings globally, pharmacists in Canada are permitted to dispense mifepristone for medical abortion. We contribute to literature that shows that mifepristone dispensed outside of hospitals, clinics, and medical offices is safe and acceptable to both patients and prescribers. This finding is of particular importance to the current COVID-19 pandemic response and calls for continued and equitable access to abortion care in primary practice.
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Affiliation(s)
- Sarah Munro
- Centre for Health Evaluation and Outcome Sciences, Providence Health Care Research Institute, Vancouver, British Columbia, Canada. .,Department of Obstetrics & Gynaecology, Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada.
| | - Kate Wahl
- Department of Obstetrics & Gynaecology, Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Judith A Soon
- Faculty of Pharmaceutical Sciences, University of British Columbia, Vancouver, British Columbia, Canada
| | - Edith Guilbert
- Department of Obstetrics, Gynaecology and Reproduction, Laval University, Quebec City, Quebec, Canada
| | - Elizabeth S Wilcox
- School of Population and Public Health, University of British Columbia, Vancouver, British Columbia, Canada
| | - Genevieve Leduc-Robert
- Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Nadra Ansari
- Faculty of Health Sciences, Simon Fraser University, Burnaby, British Columbia, Canada
| | - Courtney Devane
- School of Nursing, University of British Columbia, Vancouver, British Columbia, Canada
| | - Wendy V Norman
- Department of Family Practice, University of British Columbia, Vancouver, British Columbia, Canada.,Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, UK
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Treating Post-traumatic Stress Disorder with a Prolonged Exposure Protocol Within Primary Care Behavioral Health: A Case Example. J Clin Psychol Med Settings 2020; 28:575-583. [PMID: 33090302 DOI: 10.1007/s10880-020-09747-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/12/2020] [Indexed: 10/23/2022]
Abstract
Posttraumatic stress disorder (PTSD) is a debilitating condition that impacts anywhere from 2 to 39% of primary care patients. Research suggests overall health, instances of hospitalizations, emergency room visits, and utilization of primary care services are impacted by a diagnosis of PTSD. Evidenced based treatments such as cognitive process therapy and prolonged exposure (PE) are available in specialty mental health but pose many barriers to treatment and implementation into primary care. This case study serves as the first known case example with an ethnic minority civilian, examining the treatment of PTSD within the Primary Care Behavioral Health Model using the brief (5 visits), PE protocol for primary care (PE-PC). PTSD was assessed using the PCL-5. Additional variables were assessed and tracked with the following tools: PHQ-9 (depressive symptoms), GAD-7 (anxiety symptoms), QLES-SF (quality of life), and the AAQ-2 (psychological flexibility) pre/post treatment, 6 months post-treatment and 9 months post-treatment. The patient reported clinically significant decreases in symptoms of PTSD, depression, and anxiety symptoms. Additionally, the patient's scores on quality of life and psychological flexibility improved. Brief, exposure-based treatment for PTSD can be delivered within the PCBH model. This treatment may result in improved quality of life and has the potential to reduce health care costs. This case encourages the treatment of PTSD within primary care, increasing access to care for patients. Future research is needed to further investigate this protocol in primary care with underserved, civilian populations and to explore patient attitudes toward brief treatment for PTSD in a primary care setting.
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