Predictors of attendance in outpatient group treatment for women with posttraumatic stress disorder and substance use disorder

Determinants of preference for telehealth versus in-person treatment for substance use disorders: A discrete choice experiment

INTRODUCTION

Access to substance use disorder (SUD) treatment remains a significant issue in the United States. Telehealth has potential for increasing access to services; however, it is underutilized in SUD treatment compared to mental health treatment. This study uses a discrete choice experiment (DCE) to examine stated preferences for telehealth (videoconferencing, text-based + video, text only) versus in-person SUD treatment (community-based, in-home) and the attributes (location, cost, therapist choice, wait time, evidence-based practices) most important when choosing between modalities. Subgroup analyses are reported about preference differences based on type of substance and substance use severity.

METHODS

Four hundred participants completed a survey containing a DCE with eighteen choice sets, the alcohol use disorders inventory test, drug abuse screening test, and a brief demographic questionnaire. The study collected data between April 15, 2020, and April 22, 2020. Conditional logit regression provided a measure of strength for participant preferences for technology-assisted treatment compared to in-person care. The study provides willingness to pay estimates as a real-world measure for the importance of each attribute in participants' decision-making.

RESULTS

Telehealth options that include a video conference option were equally preferrable to in-person care modalities. Text-only treatment was significantly less preferable to all other modalities of care. The ability to choose one's own therapist was a significant driver of treatment preference beyond modality, while wait time did not appear significant in making decisions. Participants with the most severe substance use differed in that they were open to text-based care without video conferencing, did not express a preference for evidence-based care, and valued therapist choice significantly more than those with only moderate substance use.

CONCLUSIONS

Telehealth for SUD treatment is equally preferable to in-person care offered in the community or at home, signifying preference is not a barrier for utilization. Text-only modalities may be enhanced by offering videoconference options for most individuals. Individuals with the most severe substance use issues may be willing to engage in text-based support without synchronous meetings with a provider. This approach may offer a less intensive method to engage individuals in treatment who may not otherwise access services.

Predictors of Treatment Completion among Women Receiving Integrated Treatment for Comorbid Posttraumatic Stress and Substance Use Disorders

Background: Retention in treatment for individuals with comorbid posttraumatic stress disorder (PTSD) and substance use disorders (SUD) is an area of concern in treatment outcome studies. The current study explores key variables related to retention in a group of women with comorbid PTSD and SUD enrolled in community SUD treatment randomized to eight weekly sessions of a trauma adapted mindfulness-based relapse prevention (TA-MBRP) or an integrated coping skills (ICS) group intervention. Methods: Two unadjusted and adjusted logistic discrete failure time (DFT) models were fit to examine associations between participants and the time (in weeks) to treatment completion status. Key covariates of interest, including time-varying PTSD Symptom Scale-Self Report (PSS) total score, time-varying Five Factors Mindfulness Questionnaire (FFMQ) total score, group assignment, baseline endorsements of substance use and demographics such as age, race and employment status were fit into the model. Results: In the adjusted PSS model, increased levels of PTSD symptom severity (PSS) scores at week 5 and 7 (PSS OR: 1:06: OR 1.13, respectively) were associated with higher odds of non-completion. In the FFMQ model, increased levels of FFMQ scores at week 6 (OR: 0:92) were associated with lower odds of non-completion. In both models, assignment to the ICS control group and unemployment were associated with lower odds of completion and baseline use of cocaine and sedatives were associated with higher odds of completion. Conclusion: Monitoring PTSD symptom severity and measures of mindfulness can inform providers on strategies to enhance retention early in treatment for individuals with comorbid PTSD/SUD.ClinicalTrials.gov # NCT02755103.

A systematic review and meta-analysis of psychological interventions for comorbid post-traumatic stress disorder and substance use disorder

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.

Clinical symptoms and personality traits predict subpopulations of treatment-seeking substance users

BACKGROUND

The heterogeneity of treatment-seeking substance users represents a challenge, as most studies include participants having problems with specific substances or merge polysubstance users into the same category without considering differences between profiles. Considering the inconsistent literature on predictors of treatment outcomes, this study aimed to identify subpopulations of individuals with substance use disorders (SUDs) and analyze the association among class membership, previous relapses, and treatment retention.

METHODS

The study recruited a total of 159 participants (mean age = 40.60, SD = 8.70; 85.5% males) from two treatment facilities (outpatient daycare and inpatient residential centers). The baseline assessment gathered lifetime and current substance use, and personality and psychopathology measures. The study performed a latent class analysis to identify subpopulations of substance users and explored predictors of class membership using a multinomial regression analysis.

RESULTS

The study found six different classes of substance users based on their diagnosis and pattern of substance use: class 1 (6.92% of participants): individuals with cannabis as primary substance, alcohol/cocaine as secondary substance and additional use of stimulants or other drugs; class 2 (30.82%): cocaine as primary substance, alcohol as secondary and additional cannabis use; class 3 (20.13%): alcohol as primary substance, cocaine as secondary and additional cannabis use; class 4 (17.61%): cocaine as primary substance, cannabis as secondary and additional alcohol/other drugs use; class 5 (16.35%): alcohol as primary and cannabis as secondary substance; class 6 (8.18%): heroin as primary substance, cocaine as secondary and additional alcohol use. Several traits and clinical symptoms predicted distinct class memberships. Participants pertaining to class 6 presented the highest number of relapses (M = 2.54, SD = 1.56).

CONCLUSIONS

These results have several clinical implications. Belonging to class 6 was associated with a greater number of previous relapses. Also, specific psychopathological symptoms and personality traits may impact SUD treatment response, which may help clinicians to guide initial assessment and treatment allocation.