A Randomized Controlled Trial for Veterans with PTSD and Substance Use Disorder: Creating Change versus Seeking Safety

Systemic biases promoting the under-inclusion of marginalized groups in randomized controlled trials for co-occurring alcohol use and posttraumatic stress disorder: an intersectional analysis

Co-occurring posttraumatic stress disorder and alcohol use disorder is a major public health concern affecting millions of people. Although this disorder affects people from all groups, research shows that, when compared to White people, people of color systematically suffer worse chronicity and burden of disorder. Additionally, research shows that people of color endure a variety of barriers to accessing treatment and often require specialized or culturally appropriate care. Consequently, the array of treatments available must have been determined to be effective for people of color when they access treatment, and people of color must be well represented in research to ensure effective treatment. Therefore, randomized controlled trials testing treatments for this disorder must include racially diverse samples and ensure treatments are effective for all groups. Further, if they lack diversity, it is necessary to explore whether and how the process of conducting randomized controlled trials is biased toward the constrained inclusion of people of color. This study used a Matrix of Domination framework as an intersectional method to investigate this question. It assessed the inclusion of people by race and sex in randomized controlled trials for co-occurring posttraumatic stress disorder and alcohol use disorder. We found that people of color and White women are significantly underincluded in randomized controlled trials and that these studies are hegemonically, disciplinarily, and structurally biased in ways that facilitate the overrepresentation of White men and the underrepresentation of marginalized groups.

Validation of the Italian version of the Neuroception of Psychological Safety Scale (NPSS)

Research on the neuroscience of fear in both humans and non-humans has suggested that a lack of acquisition of safety cues might be a biological hallmark of posttraumatic stress disorder (PTSD). Danger perception, and in particular, feeling as one's own life is in danger, is thought to represent a major predictor of PTSD. Persistent danger perception is concurrently associated with a persistence of lack of safety. However, despite several research efforts, no validated psychometric tools exist regarding psychological safety as a unique core construct in the domain of a soothing-contentment system. By including social, compassionate, and bodily components, the Neuroception of Psychological Safety Scale (NPSS), neurophysiologically rooted in the polyvagal theory, aims to specifically assess psychological safety. Originally developed in English, we employed a rather large non clinical sample to validate our Italian translation of the NPSS (n = 338) and the scale was found to retain a three-factor structure. In light of its positive moderate correlations with the Unconditional Self-Kindness Scale (ρ = 0.376) and the Self-Compassion Scale-Short-Form (ρ = 0.481), good convergent validity and robust psychometric properties were shown by the NPSS. The Subjective Traumatic Outlook Questionnaire (ρ = -0.283) and the three subscales of the Body Perception Questionnaire-22-Body Awareness (ρ = -0.103), Supradiaphragmatic Reactivity (ρ = -0.234), and Body Awareness/Subdiaphragmatic Reactivity (ρ = -0.146)-were found to have weak negative correlations with the NPSS, which further demonstrated its good discriminant validity. Eventually, the NPSS was found to show good test-retest reliability (intraclass correlation coefficient = 0.922; three-week time interval), and its usage is fostered in clinical and research contexts where the evaluation of psychological safety is of relevance.

Chatbot-assisted therapy for patients with methamphetamine use disorder: a preliminary randomized controlled trial

Background

Methamphetamine (MA) use disorder is associated with a large public health burden. Despite the therapeutic effects of psychosocial interventions based on current evidence, finding an approach to retain patients in treatment remains a real-world challenge. The rapid development of mobile health (mHealth) systems suggests the potential to provide real-time personalized care at any time and from any location, minimize barriers to treatment, maximize use, and promote the dissemination of accessible therapeutic tools in at-risk populations. Our study aimed to investigate the feasibility and effectiveness of chatbots for the treatment of MA use disorder.

Method

The inclusion criteria were (a) a diagnosis of MA use disorder as defined by the DSM-5, (b) age between 18 and 65 years, (c) no acute exacerbation of severe mental illness during the initial assessment, such as schizophrenia or bipolar I disorder, (d) willingness to participate in standard outpatient treatment for ≥ 6 months, and (e) an Android phone. Participants were randomly allocated to either a chatbot-assisted therapy via smartphone (CAT) group or a control group following simple randomization procedures (computerized random numbers) without blinding. All participants were followed up for 6 months. Treatment retention and monthly urine test results were analyzed as outcome measures. Participants' satisfaction with CAT was also assessed.

Results

In total, 50 and 49 participants were allocated to the CAT and control groups, respectively. There were no significant differences in retention time between the two treatment groups (df = 1, p = 0.099). The CAT group had fewer MA-positive urine samples than the control group (19.5% vs. 29.6%, F = 9.116, p = 0.003). The proportion of MA-positive urine samples was positively correlated with the frequency of MA use (r = 0.323, p = 0.001), severity of MA use disorder (r = 0.364, p < 0.001), and polysubstance use (r = 0.212, p = 0.035), and negatively correlated with readiness to change (r = -0.330, p = 0.001). Totally 55 participants completed the study at the 6-month follow-up and 60% reported relative satisfaction.

Conclusion

Participants in this study had favorable acceptance and generally positive outcomes, which indicates that chatbot is feasible for treating people who use MA.

Motives for substance use and 6-month substance use outcomes among detoxification patients with a history of physical or sexual abuse or posttraumatic stress disorder

Trauma-exposed individuals with a history of physical or sexual abuse or documented posttraumatic stress disorder (PTSD) diagnosis may use substances to address trauma-related symptoms. However, the motives for using substances among adults with a trauma history or PTSD are unclear despite their informative role in treatment planning. Additionally, trauma is associated with poorer substance use outcomes, although this has not been examined among detoxification patients. The current study examined motives for substance use at baseline and substance use outcomes during 6 months postbaseline among 298 veteran detoxification patients (i.e., alcohol, opioids, or both) with and without (a) a history of physical or sexual abuse and (b) a PTSD diagnosis. At baseline, participants with a physical or sexual abuse history were more likely to report the use of substances to temporarily lower stress, forget problems, and avoid uncomfortable feelings than those without this history, ds = 0.25-0.40. Compared with participants without a PTSD diagnosis, participants with diagnosed PTSD were more likely to report using substances to temporarily lower stress, d = 0.25. Longitudinal analyses demonstrated that the baseline characteristics of physical abuse history, sexual abuse history, and diagnosed PTSD were all associated with higher scores on a measure of risk factors for relapse (e.g., cravings, family/social problems) as assessed during the postdetoxification period, φ = .13, .10, and .09, respectively. Detoxification patients with physical and/or sexual abuse histories or PTSD diagnoses may need treatments that better address trauma symptoms to help them sustain abstinence.

Functional outcomes from psychotherapy for people with posttraumatic stress disorder: A meta-analysis

People with posttraumatic stress disorder (PTSD) experience a wide array of symptoms, often accompanied by significant functional and quality of life impairments. Evidence-based psychotherapies are effective for alleviating symptoms in this group, but functional outcomes following psychotherapy are understudied. This study aimed to synthesize existing work on functional outcomes of psychotherapy to conduct a meta-analytic investigation examining whether people with PTSD experience significant improvements in functioning and quality of life following a course of psychotherapy. A literature search was conducted for studies reporting results of randomized clinical trials of psychotherapies for people diagnosed with PTSD that included a functional or quality of life outcome measured at pre- and post-intervention. Both between-groups and within-groups analyses were conducted using a random effects model. Fifty-six independent samples were included. Results suggest that, on average, people with PTSD experience significant, moderate improvement in functional outcomes after a course of psychotherapy. Taken together, this meta-analysis represents a substantial advance in our understanding of functional outcomes of psychotherapy for people with PTSD. Findings suggest that psychotherapy is one vehicle through which functional outcomes may be improved for this group, though notably to a lesser degree than symptom improvement.

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.

Efficacy and acceptability of interventions for co-occurring PTSD and SUD: A meta-analysis

Over the past 20 years, numerous treatments addressing comorbid Posttraumatic Stress Disorder (PTSD) and Substance Use Disorder (SUD) have been developed and tested. The current meta-analysis examined the efficacy and acceptability of the two central treatment types- trauma-focused and non-trauma-focused - compared with all comparators and with cognitive-behavioral manualized SUD treatments immediately post-treatment and at longest follow-up. Twenty-eight randomized clinical trials (N = 3247) were included. There were small to large within-group effects for all forms of active treatment (gs = 0.30-1.11). Trauma-focused but not non-trauma-focused treatments outperformed all comparators on PTSD outcomes at post-treatment. Neither trauma-focused nor non-trauma-focused treatment outperformed all comparators on SUD outcomes at post-treatment. Neither trauma- nor non-trauma-focused treatment outperformed manualized SUD treatments on PTSD outcomes at either time point. Manualized SUD treatments outperformed trauma-focused treatments on SUD outcomes at post-treatment and non-trauma-focused treatments on PTSD outcomes at follow-up. Regarding treatment retention, neither trauma-focused nor non-trauma-focused treatments significantly differed from all comparators or from manualized SUD treatments. Between-group results were largely unchanged in trim-and-fill analyses, but were not robust to fail-safe N. Few moderators were detected. Taken together, results suggest that trauma-focused, non-trauma-focused, and manualized SUD interventions are sound options for individuals with comorbid PTSD/SUD.

Therapeutic alliance in psychological therapy for posttraumatic stress disorder: A systematic review and meta-analysis

BACKGROUND

Therapeutic alliance is a key element of successful therapy. Despite being particularly relevant in people with posttraumatic stress disorder (PTSD), due to fear, mistrust and avoidance, there has not yet been a comprehensive systematic review of therapeutic alliance in this population. This review explored (a) variables which may predict alliance and (b) whether alliance predicts PTSD outcomes.

METHOD

Following the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines, the review identified 34 eligible studies. Studies were subjected to a quality assessment. Predictors of alliance were considered in a narrative synthesis. Twelve studies were entered into a meta-analysis of the association between therapeutic alliance and PTSD outcomes.

RESULTS

There was some evidence for individual variables including attachment, coping styles and psychophysiological variables predicting the alliance. Therapy variables did not predict alliance. The therapeutic alliance was found to significantly predict PTSD outcomes, with an aggregated effect size of r = -.34, across both in-person and remote therapies.

LIMITATIONS

Included studies were restricted to peer-reviewed, English language studies. Quality of included studies was mostly rated weak to moderate, primarily reflecting issues with selection bias in this area of research.

CONCLUSIONS

This is the first review to demonstrate that therapeutic alliance is a consistent predictor of PTSD outcomes, in both in-person and remote therapies, and the effect appears at least as strong as in other populations. This is of relevance to clinicians working with traumatized populations. The review identified a need for further research to determine variables predicting alliance in therapy for PTSD.

Management of Post-traumatic Stress Disorder in Veterans and Military Service Members: A Review of Pharmacologic and Psychotherapeutic Interventions Since 2016

PURPOSE OF REVIEW

It is vitally important that providers treating post-traumatic stress disorder continue to stay abreast of research advances in the treatment of this disorder. This article updates the reader about advances in research in PTSD treatment in the past four years as well as the evolving recommendations of clinical practice guidelines.

RECENT FINDINGS

One of the most important developments is that trauma-focused therapy (TFT) has emerged as the first-line treatment for PTSD with pharmacologic options often being noted as second-line or adjunctive. The quality and quantity of research into the treatment of PTSD continue to grow; however, the pace of research into treatment options lags behind our understanding of the development, course, and prognosis of the disorder. The development of new research-based evidence in the treatment of PTSD, both pharmacologic and psychotherapeutic, is needed and likely to necessitate frequent updates and re-evaluations of clinical practice guidelines.

PTSD / substance use disorder comorbidity: Treatment options and public health needs

Purpose of Review

Posttraumatic stress disorder (PTSD) commonly co-occurs with substance use disorder (SUD) and is challenging to treat. We review all behavioral therapy models with at least one randomized controlled trial in a current PTSD/SUD population. We identify factors in selecting a model for clinical use, emphasizing a public health framework that balances the need for evidence with the need for feasibility in frontline settings.

Recent Findings

Seven published models and 6 unpublished models are reviewed. Public health considerations for choosing a model include: whether it's been studied across a broad range of SUDs and in complex SUD patients; whether it can be conducted in group modality; its appeal to patients and providers; its cost; workforce requirements; and its ability to reduce substance use in addition to PTSD.

Summary

There are two broad types of models: those that originated in the PTSD field versus the SUD field. Overall, the latter are stronger on public health factors and more feasible in SUD settings. Published models in this category include Relapse Prevention, BRENDA, and Seeking Safety. PTSD/SUD research is at an early stage and there is a need for methodology that quantifies "level of burden" (patients' socioeconomic disadvantages) across trials.

The Role of Affect in Psychosocial Treatments for Substance Use Disorders

PURPOSE OF REVIEW

This paper provides a narrative review of studies published over the past five years that have examined the role of affect, including both affective symptoms and affective disorders, in psychosocial treatments for substance use disorder.

RECENT FINDINGS

A growing body of literature suggests that affective symptoms and affective disorders may moderate substance use disorder treatment efficacy, mediate the effects of treatment on substance use outcomes, and may be directly changed by substance use disorder treatment.

SUMMARY

Substance use disorders and affective disorders commonly co-occur, and both affect and affective disorders are associated with substance use disorder treatment outcomes. Future research should continue to examine affect as a moderator, mediator, and outcome of substance use disorder treatments. In particular, new studies that are designed to test precision medicine hypotheses would greatly expand our understanding of the role of affective symptoms and disorders in substance use disorder treatment.

The Coping Self-Efficacy Scale: Psychometric properties in an outpatient sample of active duty military personnel

Active duty military service members endure a unique constellation of stressors while deployed or at home. Yet, assessment of protective factors against these stressors among active duty service members represents an under studied area. The present study advances the assessment of protective factors through the psychometric evaluation of the Coping Self-Efficacy Scale (CSES) in a clinical sample of military service members in mental health or substance abuse treatment (n = 200). Cross-sectional data were drawn from military medical records and a supplemental self-report questionnaire. Data extracted included demographic (e.g., sex, age), military characteristics (e.g., rank, years in service), physical health and mental health (e.g., anxiety, depression), and coping self-efficacy. Findings suggest a 3-factor (i.e., problem-focused coping, thought-stopping, and getting social support) CSES structure with acceptable internal consistency. Further, there were small-to-moderate associations with physical and mental health outcomes, providing evidence of construct validity. There were few significant associations with military-related characteristics. Finally, controlling for covariates, thought-stopping beliefs explained unique variance in suicide-related behaviors. Together, findings support the use of the CSES to measure coping-related beliefs in military service members. Recommendations are offered for future research and practice with active duty service members.

PTSD Susceptibility and Challenges: Pathophysiological Consequences of Behavioral Symptoms

Introduction

Posttraumatic stress disorder (PTSD) can develop during the aftermath of traumatic events. Although many are impacted by several stressors, nearly 3.6% suffer from PTSD in the United States with higher incidence reported in military service personnel. Any injury to the blood-brain barrier can ignite an array of biological signaling molecules in the immune-privileged brain parenchyma, which can disrupt the synaptic neural network, resulting in altered behavior.

Materials and Methods

In this preliminary study, we compared 20 PTSD veterans with age-matched healthy veterans to identify plasma levels of brain-specific protein markers using enzyme-linked immunosorbent assay/immunofluorometric sandwich assay for neurotrophic factors and neuropoietic cytokines, and catalytic activity of matrix metalloproteinase (MMP) by zymography.

Results

We observed an increased level of glial fibrillary acidic protein, tumor necrosis factor-alpha, interleukin 6, and MMP2 and MMP9 but decreased level of brain-derived neurotrophic factor, nerve growth factor-beta, and negligible difference in astroglial marker S100 calcium-binding protein B compared to controls.

Conclusion

Identification of neural biomarkers is essential to understand the subclinical symptoms for the diagnosis PTSD, which may not be visible by magnetic resonance imaging (MRI/fMRI) and may take years to clinically manifest.

Concurrent treatment of substance use disorders and PTSD using prolonged exposure: A randomized clinical trial in military veterans

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.

A multisite randomized controlled trial of Seeking Safety vs. Relapse Prevention Training for women with co-occurring posttraumatic stress disorder and substance use disorders

Background: Co-occurring posttraumatic stress disorder (PTSD) and substance use disorders (SUD) are associated with a more severe course and worse outcome than either disorder alone. In Europe, few treatments have been evaluated for PTSD and SUD. Seeking Safety, a manualized, integrated, cognitive-behavioural treatment, has been shown to be effective in studies in the USA. Objective: To test the efficacy of Seeking Safety plus treatment as usual (TAU) in female outpatients with PTSD and SUD compared to Relapse Prevention Training (RPT) plus TAU and TAU alone. Method: In five German study centres a total of N = 343 women were randomized into one of the three study conditions. PTSD severity (primary outcome), substance use, depression and emotion dysregulation (secondary outcomes) were assessed at baseline, post-treatment, as well as at three months and six months post-treatment. Results: Treatment participants attended M = 6.6 sessions (Seeking Safety) and M = 6.1 sessions (RPT). In an intent-to-treat analysis, Seeking Safety plus TAU, RPT plus TAU and TAU alone showed comparable decreases in PTSD severity over the course of the study. Seeking Safety plus TAU showed superior efficacy to TAU alone on depression and emotion regulation and RPT plus TAU was more effective than TAU alone on number of substance-free days and alcohol severity. Minimum-dose analyses suggest additional effects of both programmes among participants who attended at least eight group sessions. Conclusions: With respect to PTSD symptoms, a brief dose of Seeking Safety and RPT in addition to TAU was not superior to TAU alone in women with PTSD and SUD. However, Seeking Safety and RPT showed greater reductions than TAU alone in other domains of psychopathology and substance use outcomes respectively. Future studies should investigate further variables, such as what aspects of each treatment appeal to particular patients and how best to disseminate them.