1
|
Hammock JA, López-Castro T, Fox AD. Prior incarceration, restrictive housing, and posttraumatic stress disorder symptoms in a community sample of persons who use drugs. HEALTH & JUSTICE 2024; 12:20. [PMID: 38668954 PMCID: PMC11046833 DOI: 10.1186/s40352-024-00276-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 08/21/2023] [Accepted: 04/22/2024] [Indexed: 04/29/2024]
Abstract
BACKGROUND Criminalization of drugs in the United States (US) has extensive consequences for people who use drugs (PWUD). Incarceration and substance use overlap with 65% of the US prison population meeting substance use disorder (SUD) criteria. Exposure to the criminal-legal system negatively impacts the health of PWUD. PTSD is commonly comorbid with SUDs, and exposure to restrictive housing (RH) during incarceration may worsen mental health. Because PWUD are disproportionately incarcerated, experiences occurring during incarceration, such as RH, may contribute to the development or exacerbation of PTSD and SUDs. This study of PWUD investigated prior criminal-legal system exposure and its association with PTSD symptoms in community-dwelling PWUD. METHODS This cross-sectional study recruited PWUD from syringe service programs (SSP). Inclusion criteria were: age 18+, current or past opioid use disorder, and SSP enrollment. Data collected included: sociodemographics; incarceration, substance use, SUD treatment history, and PTSD assessments (Life Events Checklist for DSM-5 and the PTSD Checklist for DSM-5). Bivariate testing and multivariate logistic regression analyses, with probable PTSD as the dependent variable and a three-level variable for criminal legal history as the independent variable, were conducted to determine whether incarceration and RH were associated with probable PTSD. RESULTS Of 139 participants, 78% had an incarceration history with 57% of these having a history of RH. 57% of participants screened positive for probable PTSD, and physical assault was the most common traumatic exposure. Any history of incarceration was not associated with probable PTSD diagnosis; however, in multivariate testing, adjusting for age, sex, and substance use, a history of RH (adjusted odds ratio [aOR]: 3.76, 95% CI 1.27-11.11) was significantly associated with probable PTSD. CONCLUSIONS RH and PTSD were both exceptionally common in a sample of SSP participants. RH can be detrimental to physical and mental health. Clinicians and policy makers may not consider incarceration as a traumatic experience for PWUD; however, our data suggest that among highly marginalized PWUD, prior exposure to incarceration and RH may add an additional burden to their daily struggles, namely PTSD.
Collapse
Affiliation(s)
- James A Hammock
- Albert Einstein College of Medicine, 1300 Morris Park Ave, Bronx, NY, 10461, USA
| | - Teresa López-Castro
- The City College of New York, City University of New York, 160 Convent Ave, New York, NY, 10031, USA
| | - Aaron D Fox
- Albert Einstein College of Medicine, 1300 Morris Park Ave, Bronx, NY, 10461, USA.
- Montefiore Medical Center, 111 E 210th St, Bronx, NY, 10467, USA.
| |
Collapse
|
2
|
Hill ML, Kline AC, Saraiya TC, Gette J, Ruglass LM, Norman SB, Back SE, Saavedra LM, Hien DA, Morgan-López AA. Cannabis use and trauma-focused treatment for co-occurring posttraumatic stress disorder and substance use disorders: A meta-analysis of individual patient data. J Anxiety Disord 2024; 102:102827. [PMID: 38266511 PMCID: PMC11138203 DOI: 10.1016/j.janxdis.2024.102827] [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: 09/01/2023] [Revised: 12/22/2023] [Accepted: 01/05/2024] [Indexed: 01/26/2024]
Abstract
High rates of cannabis use among people with posttraumatic stress disorder (PTSD) have raised questions about the efficacy of evidence-based PTSD treatments for individuals reporting cannabis use, particularly those with co-occurring alcohol or other substance use disorders (SUDs). Using a subset of four randomized clinical trials (RCTs) included in Project Harmony, an individual patient meta-analysis of 36 RCTs (total N = 4046) of treatments for co-occurring PTSD+SUD, we examined differences in trauma-focused (TF) and non-trauma-focused (non-TF) treatment outcomes for individuals who did and did not endorse baseline cannabis use (N = 410; 70% male; 33.2% endorsed cannabis use). Propensity score-weighted mixed effects modeling evaluated main and interactive effects of treatment assignment (TF versus non-TF) and baseline cannabis use (yes/no) on attendance rates and within-treatment changes in PTSD, alcohol, and non-cannabis drug use severity. Results revealed significant improvements across outcomes among participants in all conditions, with larger PTSD symptom reductions but lower attendance among individuals receiving TF versus non-TF treatment in both cannabis groups. Participants achieved similar reductions in alcohol and drug use across all conditions. TF outperformed non-TF treatments regardless of recent cannabis use, underscoring the importance of reducing barriers to accessing TF treatments for individuals reporting cannabis use.
Collapse
Affiliation(s)
- Melanie L Hill
- Department of Psychiatry, University of California San Diego, San Diego, CA, USA.
| | | | - Tanya C Saraiya
- Center of Alcohol & Substance Use Studies, Rutgers University, Piscataway, NJ, USA; Department of Psychiatry & Behavioral Sciences, Medical University of South Carolina, Charleston, SC, USA
| | - Jordan Gette
- Center of Alcohol & Substance Use Studies, Rutgers University, Piscataway, NJ, USA
| | - Lesia M Ruglass
- Center of Alcohol & Substance Use Studies, Rutgers University, Piscataway, NJ, USA; Department of Psychology, The City College of New York, New York, NY, USA
| | - Sonya B Norman
- Department of Psychiatry, University of California San Diego, San Diego, CA, USA; Veterans Affairs San Diego Healthcare System, San Diego, CA, USA; National Center for PTSD, Executive Division, White River Junction, VT, USA
| | - Sudie E Back
- Department of Psychiatry & Behavioral Sciences, Medical University of South Carolina, Charleston, SC, USA; Ralph H. Johnson Veterans Affairs Healthcare System, Charleston, SC, USA
| | | | - Denise A Hien
- Center of Alcohol & Substance Use Studies, Rutgers University, Piscataway, NJ, USA
| | | |
Collapse
|
3
|
Ney LJ, Akosile W, Davey C, Pitcher L, Felmingham KL, Mayo LM, Hill MN, Strodl E. Challenges and considerations for treating PTSD with medicinal cannabis: the Australian clinician's perspective. Expert Rev Clin Pharmacol 2023; 16:1093-1108. [PMID: 37885234 DOI: 10.1080/17512433.2023.2276309] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2023] [Accepted: 10/24/2023] [Indexed: 10/28/2023]
Abstract
INTRODUCTION Preclinical and experimental research have provided promising evidence that medicinal cannabis may be efficacious in the treatment of posttraumatic stress disorder (PTSD). However, implementation of medicinal cannabis into routine clinical therapies may not be straightforward. AREAS COVERED In this review, we describe some of the clinical, practical, and safety challenges that must be addressed for cannabis-based treatment of PTSD to be feasible in a real-world setting. These issues are especially prevalent if medicinal cannabis is to be combined with trauma-focused psychotherapy. EXPERT OPINION Future consideration of the clinical and practical considerations of cannabis use in PTSD therapy will be essential to both the efficacy and safety of the treatment protocols that are being developed. These issues include dose timing and titration, potential for addiction, product formulation, windows of intervention, and route of administration. In particular, exposure therapy for PTSD involves recall of intense emotions, and the interaction between cannabis use and reliving of trauma memories must be explored in terms of patient safety and impact on therapeutic outcomes.
Collapse
Affiliation(s)
- Luke J Ney
- School of Psychology and Counselling, Faculty of Health, Queensland University of Technology, Brisbane, Australia
| | - Wole Akosile
- Greater Brisbane Clinical School, Faculty of Medicine, University of Queensland, Brisbane, Australia
| | - Chris Davey
- Department of Psychiatry, Medicine, Dentistry and Health Sciences, University of Melbourne, Parkville, Australia
| | | | - Kim L Felmingham
- School of Psychological Sciences, Medicine, Dentistry and Health Sciences, University of Melbourne, Parkville, Australia
| | - Leah M Mayo
- Department of Psychiatry, Mathison Centre for Mental Health Research, and Hotchkiss Brain Institute, University of Calgary, Calgary, Canada
| | - Matthew N Hill
- Department of Psychiatry, Mathison Centre for Mental Health Research, and Hotchkiss Brain Institute, University of Calgary, Calgary, Canada
| | - Esben Strodl
- School of Psychology and Counselling, Faculty of Health, Queensland University of Technology, Brisbane, Australia
| |
Collapse
|
4
|
Hahn CK, Kilimnik CD, Brady KT, Marx BP, Rothbaum BO, Saladin ME, Gilmore AK, Metts CL, Back SE. Early intervention using written exposure therapy for PTSD and AUD symptoms following sexual assault: Description of design and methodology. Contemp Clin Trials 2023; 125:107002. [PMID: 36436732 PMCID: PMC9989773 DOI: 10.1016/j.cct.2022.107002] [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] [Received: 06/28/2022] [Revised: 10/31/2022] [Accepted: 11/09/2022] [Indexed: 11/25/2022]
Abstract
The co-occurrence of posttraumatic stress disorder (PTSD) and alcohol use disorder (AUD) is common following sexual assault and associated with more severe symptomology and increased likelihood of sexual revictimization. Integrated interventions aimed at reducing PTSD and AUD symptoms following recent sexual assault are needed and should address barriers to care and early treatment termination. The proposed study will test a novel, brief (5 to 7 sessions) intervention that integrates Written Exposure Therapy for PTSD and Cognitive Behavioral Therapy for AUD, and is initiated within the first six weeks post-assault. In Phase 1, qualitative analysis of content gathered during focus groups with treatment providers will be conducted to inform intervention development. In Phase 2, a proof-of-concept pilot study (n = 10) of the intervention, Substance Use Skills Training and Exposure Post-Sexual Assault (STEPS), will be conducted. In Phase 3, a pilot randomized controlled trial (RCT) among 54 recent sexual assault survivors will be implemented using the updated manualized STEPS intervention to evaluate feasibility and preliminary efficacy in reducing PTSD and AUD symptoms. Ecological momentary assessments will be used to assess daily alcohol use, craving, affect, intrusions and avoidance. The effects of STEPS on commonly associated symptoms (e.g., depression, substance use) will be examined. The proposed study has the potential to make a significant public health impact by advancing knowledge on the link between sexual assault and co-occurring PTSD and AUD and informing early intervention efforts for this high-risk population.
Collapse
Affiliation(s)
- Christine K Hahn
- Department of Psychiatry & Behavioral Sciences, Medical University of South Carolina, 67 President St., 2nd Fl. S., MSC 861, Charleston, SC, USA.
| | - Chelsea D Kilimnik
- Department of Psychiatry & Behavioral Sciences, Medical University of South Carolina, 67 President St., 2nd Fl. S., MSC 861, Charleston, SC, USA.
| | - Kathleen T Brady
- Department of Psychiatry & Behavioral Sciences, Medical University of South Carolina, 67 President St., 2nd Fl. S., MSC 861, Charleston, SC, USA.
| | - Brian P Marx
- Department of Psychiatry, Boston University School of Medicine, 720 Harrison Avenue, Boston, MA 02118, USA.
| | - Barbara O Rothbaum
- Emory School of Medicine, Emory University, 01 Dowman Dr., Atlanta, GA 30322, USA.
| | - Michael E Saladin
- Department of Psychiatry & Behavioral Sciences, Medical University of South Carolina, 67 President St., 2nd Fl. S., MSC 861, Charleston, SC, USA
| | - Amanda K Gilmore
- Department of Health Policy and Behavioral Sciences, Mark Chaffin Center for Healthy Development, School of Public Health, Georgia State University, Atlanta, GA 30303, USA.
| | - Christopher L Metts
- Department of Psychiatry & Behavioral Sciences, Medical University of South Carolina, 67 President St., 2nd Fl. S., MSC 861, Charleston, SC, USA.
| | - Sudie E Back
- Department of Psychiatry & Behavioral Sciences, Medical University of South Carolina, 67 President St., 2nd Fl. S., MSC 861, Charleston, SC, USA; Ralph H. Johnson Veterans Affairs Medical Center, 109 Bee St. Charleston, SC 29401, USA.
| |
Collapse
|
5
|
Brewerton TD. Mechanisms by which adverse childhood experiences, other traumas and PTSD influence the health and well-being of individuals with eating disorders throughout the life span. J Eat Disord 2022; 10:162. [PMID: 36372878 PMCID: PMC9661783 DOI: 10.1186/s40337-022-00696-6] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2022] [Accepted: 11/09/2022] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND Multiple published sources from around the world have confirmed an association between an array of adverse childhood experiences (ACEs) and other traumatic events with eating disorders (EDs) and related adverse outcomes, including higher morbidity and mortality. METHODS In keeping with this Special Issue's goals, this narrative review focuses on the ACEs pyramid and its purported mechanisms through which child maltreatment and other forms of violence toward human beings influence the health and well-being of individuals who develop EDs throughout the life span. Relevant literature on posttraumatic stress disorder (PTSD) is highlighted when applicable. RESULTS At every level of the pyramid, it is shown that EDs interact with each of these proclaimed escalating mechanisms in a bidirectional manner that contributes to the predisposition, precipitation and perpetuation of EDs and related medical and psychiatric comorbidities, which then predispose to early death. The levels and their interactions that are discussed include the contribution of generational embodiment (genetics) and historical trauma (epigenetics), social conditions and local context, the ACEs and other traumas themselves, the resultant disrupted neurodevelopment, subsequent social, emotional and cognitive impairment, the adoption of health risk behaviors, and the development of disease, disability and social problems, all resulting in premature mortality by means of fatal complications and/or suicide. CONCLUSIONS The implications of these cascading, evolving, and intertwined perspectives have important implications for the assessment and treatment of EDs using trauma-informed care and trauma-focused integrated treatment approaches. This overview offers multiple opportunities at every level for the palliation and prevention of EDs and other associated trauma-related conditions, including PTSD.
Collapse
Affiliation(s)
- Timothy D Brewerton
- Department of Psychiatry and Behavioral Sciences, Medical University of South Carolina, Charleston, SC, USA.
| |
Collapse
|
6
|
Examining the associations between PTSD symptom clusters and alcohol-related problems in a sample of low-SES treatment-seeking Black/African American adults. J Psychiatr Res 2022; 154:261-267. [PMID: 35963024 PMCID: PMC9481727 DOI: 10.1016/j.jpsychires.2022.07.060] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2022] [Revised: 06/22/2022] [Accepted: 07/26/2022] [Indexed: 11/20/2022]
Abstract
Posttraumatic stress disorder (PTSD) and alcohol use disorder (AUD) often co-occur. This comorbidity negatively influences treatment outcomes, functioning, and quality of life. To better understand the relation between PTSD and AUD, research has begun to examine the influence of PTSD symptom clusters on alcohol-related problems. The current study is the first to analyze the associations between PTSD symptom clusters and alcohol consumption and AUD symptom severity in a treatment-seeking sample of Black/African American (AA) adults with co-occurring AUD and PTSD symptoms. Examination of these associations may help to facilitate greater recovery in this underserved population by identifying more precise targets for treatment. PTSD symptom clusters were identified from both the current 4-factor model identified in the DSM-5 and from a recently proposed 7-factor model. Participants were Black/AA adults (50.6% male) who endorsed trauma exposure and were seeking treatment for alcohol misuse. The majority (66%) were unemployed and almost half (45%) reported an income at or lower than $20,000. In the 4-factor model, results showed Cluster D symptoms of PTSD (i.e., negative alterations in cognitions and mood) were independently associated with alcohol consequences. Use of the 7-factor model, which divides Cluster D into symptoms of negative affect and anhedonia, further demonstrated that only anhedonic symptoms were independently associated with alcohol consequences. No symptom clusters were uniquely associated with alcohol consumption. Results suggest the absence of positive emotions, rather than the presence of negative emotions, are primarily associated with alcohol-related problems in a sample of trauma-exposed, Black/AA adults seeking treatment for alcohol misuse.
Collapse
|
7
|
McCormick R, Rosenblad SR, Newmeyer M. Untapped Therapeutic Potential: Using Sandtray in Substance Abuse Treatment Groups. JOURNAL OF CREATIVITY IN MENTAL HEALTH 2020. [DOI: 10.1080/15401383.2020.1789016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Affiliation(s)
- Rachael McCormick
- Serenity House Substance Abuse Treatment Facility, Abilene, Texas, USA
| | | | | |
Collapse
|
8
|
Myers B, Carney T, Johnson K, Browne FA, Wechsberg WM. Service providers' perceptions of barriers to the implementation of trauma-focused substance use services for women in Cape Town, South Africa. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2020; 75:102628. [PMID: 31830616 PMCID: PMC7021212 DOI: 10.1016/j.drugpo.2019.102628] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2019] [Revised: 11/14/2019] [Accepted: 12/02/2019] [Indexed: 12/17/2022]
Abstract
BACKGROUND A substantial number of South African women with substance use disorders also report psychological trauma related to experiences of physical and sexual abuse. Trauma-focused substance use programmes may support recovery from co-occurring substance use disorders and psychological trauma, yet integrated programmes are not widely available in South Africa. As part of the process of developing a trauma-focused substance use programme for South African women, we explored service providers' views of the feasibility of implementing trauma-focused substance use interventions within usual care settings in Cape Town, including potential barriers that need to be considered when planning for implementation. METHODS We conducted 16 in-depth interviews with key informants responsible for planning or delivering substance use, psychological trauma or gender-based violence services to women in Cape Town. Guided by Extended Normalisation Process Theory, interviews explored participants' perceptions of the potential value of trauma-focused substance use programmes, the feasibility of their implementation, and factors that may facilitate or hinder the implementation of trauma-focused substance use programmes. Qualitative data were analysed using the framework approach. RESULTS Three themes emerged: (1) Potential for the implementation of trauma-focused substance use programmes, describing participants' views of the acceptability of these programmes; (2) Capacity for intersectoral collaboration, which participants considered necessary for limiting barriers to implementation; and (3) Co-operation with community structures to enhance capability for implementation. CONCLUSION Findings show potential for implementing trauma-focused substance use interventions in South Africa, however context-specific capacity and capability barriers need to be considered and addressed for implementation to be successful.
Collapse
Affiliation(s)
- Bronwyn Myers
- Alcohol, Tobacco and Other Drug Research Unit, South African Medical Research Council, PO Box 19070, Francie van Zyl Drive, Tygerberg 7505, South Africa; Division of Addiction Psychiatry, Psychiatry and Mental Health, University of Cape Town, South Africa.
| | - Tara Carney
- Alcohol, Tobacco and Other Drug Research Unit, South African Medical Research Council, PO Box 19070, Francie van Zyl Drive, Tygerberg 7505, South Africa; Division of Addiction Psychiatry, Psychiatry and Mental Health, University of Cape Town, South Africa.
| | - Kim Johnson
- Alcohol, Tobacco and Other Drug Research Unit, South African Medical Research Council, PO Box 19070, Francie van Zyl Drive, Tygerberg 7505, South Africa.
| | - Felicia A Browne
- Substance Use, Gender and Applied Research, RTI International, 3040 East Cornwallis Road, Research Triangle Park, NC, United States.
| | - Wendee M Wechsberg
- Substance Use, Gender and Applied Research, RTI International, 3040 East Cornwallis Road, Research Triangle Park, NC, United States; Health Policy and Administration, Gillings School of Global Public Health, The University of North Carolina, Chapel Hill, NC, United States; Department of Psychology, North Carolina State University, United States; Psychiatry and Behavioral Sciences, Duke University School of Medicine, Durham, United States.
| |
Collapse
|
9
|
Bedard-Gilligan M, Garcia N, Zoellner LA, Feeny NC. Alcohol, cannabis, and other drug use: Engagement and outcome in PTSD treatment. PSYCHOLOGY OF ADDICTIVE BEHAVIORS 2018; 32:277-288. [PMID: 29595297 PMCID: PMC9377391 DOI: 10.1037/adb0000355] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/24/2023]
Abstract
The co-occurrence of posttraumatic stress disorder (PTSD) and substance use is related to poorer outcome and increased dropout from trauma-focused treatment. Investigating PTSD and substance use can inform the intervention approaches. Exploring cannabis use in particular is especially important because rates of cannabis use have been increasing with recent legalization trends. A better understanding of how substance use is associated with treatment processes and outcome for individuals with PTSD is needed to enhance care. In this study, both lifetime diagnoses of alcohol and drug use disorders and current alcohol and drug use severity were examined in 200 men and women with chronic PTSD who received either prolonged exposure (PE) or sertraline. No lifetime or current alcohol use variables predicted dropout, adherence, or poorer outcome. However, lifetime diagnosis of both an alcohol and drug disorder (OR = 3.42) and recent cannabis use (OR = 3.38) strongly predicted higher dropout. Recent cannabis use and drug use severity predicted poorer adherence to PE (β = -.22 to -.29) but not to sertraline. Drug use severity (β = -.22) also predicted worse treatment outcome, as did lifetime diagnosis of an alcohol and drug disorder (β = -.48). Overall, patients with drug use improved with treatment but had less treatment retention, adherence, and symptom reduction. Strategies to increase engagement and retention may be indicated for these patients. Individuals who are using cannabis or other drugs may be at higher risk for not completing PTSD treatment, potentially prolonging the cycle of PTSD and substance use. (PsycINFO Database Record
Collapse
Affiliation(s)
| | | | | | - Norah C Feeny
- Department of Psychology, Case Western Reserve University
| |
Collapse
|
10
|
Concurrent Treatment of PTSD and Substance Use Disorders Using Prolonged Exposure (COPE): A Pilot Study in Alcohol-dependent Women. J Addict Med 2017; 11:119-125. [PMID: 28079572 DOI: 10.1097/adm.0000000000000286] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
OBJECTIVES Posttraumatic stress disorder (PTSD) and substance use disorders are highly comorbid. Effective treatments are largely lacking. This pilot study evaluated the safety and feasibility of a novel intervention, Concurrent Treatment of PTSD and Substance Use Disorders Using Prolonged Exposure (COPE), in preparation for a randomized controlled trial. METHODS Twenty-two treatment-seeking women with current DSM-IV-TR PTSD and alcohol dependence (AD) were recruited. Participants received COPE. Safety and feasibility were evaluated, as were efficacy-related outcomes: PTSD and depression symptom severity, alcohol use, craving, and dependence severity. RESULTS No adverse events occurred. COPE was implemented in routine clinical practice. Among the assessed women, 95.8% were eligible to participate. Treatment attendance and completion were higher than in previous studies. Post treatment, all efficacy-related outcomes, including PTSD and depression symptom severity, alcohol use, craving, and dependence severity, were significantly reduced. CONCLUSIONS COPE was safe and feasible to use. Concerns that trauma-focused, exposure-based therapy might promote relapse in this population appear unwarranted. Our findings provide initial evidence suggestive of COPE efficacy for comorbid PTSD and AD in women. These results provide a strong rationale for investigating the efficacy of COPE for comorbid PTSD and AD in women in a randomized controlled trial.
Collapse
|
11
|
Korte KJ, Bountress KE, Tomko RL, Killeen T, Moran-Santa Maria M, Back SE. Integrated Treatment of PTSD and Substance Use Disorders: The Mediating Role of PTSD Improvement in the Reduction of Depression. J Clin Med 2017; 6:E9. [PMID: 28098747 PMCID: PMC5294962 DOI: 10.3390/jcm6010009] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2016] [Revised: 12/15/2016] [Accepted: 12/30/2016] [Indexed: 01/05/2023] Open
Abstract
Posttraumatic stress disorder (PTSD) represents one of the most common mental health disorders, particularly among veterans, and is associated with significant distress and impairment. This highly debilitating disorder is further complicated by common comorbid psychiatric disorders, such as substance use disorders (SUD). Individuals with PTSD and co-occurring SUD also commonly present with secondary symptoms, such as elevated depression. Little is known, however, about how these secondary symptoms are related to treatment outcome. The aim of the present study, therefore, was to examine (1) the effects of treatment of comorbid PTSD/SUD on depressive symptoms; and (2) whether this effect was mediated by changes in PTSD severity or changes in SUD severity. Participants were 81 U.S. military veterans (90.1% male) with PTSD and SUD enrolled in a randomized controlled trial examining the efficacy of an integrated, exposure-based treatment (Concurrent Treatment of PTSD and Substance Use Disorders Using Prolonged Exposure; n = 54) versus relapse prevention (n = 27). Results revealed significantly lower depressive symptoms at post-treatment in the COPE group, as compared to the relapse prevention group. Examination of the mechanisms associated with change in depression revealed that reduction in PTSD severity, but not substance use severity, mediated the association between the treatment group and post-treatment depression. The findings underscore the importance of treating PTSD symptoms in order to help reduce co-occurring symptoms of depression in individuals with PTSD/SUD. Clinical implications and avenues for future research are discussed.
Collapse
Affiliation(s)
- Kristina J Korte
- Psychiatry Department, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114, USA.
| | - Kaitlin E Bountress
- Department of Psychiatry & Behavioral Sciences, Medical University of South Carolina, Charleston, SC 29401, USA.
| | - Rachel L Tomko
- Department of Psychiatry & Behavioral Sciences, Medical University of South Carolina, Charleston, SC 29401, USA.
| | - Therese Killeen
- Department of Psychiatry & Behavioral Sciences, Medical University of South Carolina, Charleston, SC 29401, USA.
| | - Megan Moran-Santa Maria
- Department of Psychiatry & Behavioral Sciences, Medical University of South Carolina, Charleston, SC 29401, USA.
| | - Sudie E Back
- Department of Psychiatry & Behavioral Sciences, Medical University of South Carolina, Charleston, SC 29401, USA.
- Ralph H. Johnson Veterans Affairs Medical Center, Charleston, SC 29401, USA.
| |
Collapse
|
12
|
Mills KL, Barrett EL, Merz S, Rosenfeld J, Ewer PL, Sannibale C, Baker AL, Hopwood S, Back SE, Brady KT, Teesson M. Integrated Exposure-Based Therapy for Co-Occurring Post Traumatic Stress Disorder (PTSD) and Substance Dependence: Predictors of Change in PTSD Symptom Severity. J Clin Med 2016; 5:jcm5110101. [PMID: 27854264 PMCID: PMC5126798 DOI: 10.3390/jcm5110101] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2016] [Revised: 10/26/2016] [Accepted: 11/08/2016] [Indexed: 11/26/2022] Open
Abstract
This paper examines factors associated with change in PTSD symptom severity among individuals randomised to receive an integrated exposure-based psychotherapy for PTSD and substance dependence–Concurrent Treatment of PTSD and Substance Use Disorders Using Prolonged Exposure (COPE). Outcomes examined include change in PTSD symptom severity as measured by the Clinician Administered PTSD Scale (CAPS), and the reliability and clinical significance of change in PTSD symptom severity. Factors examined include patient baseline characteristics, treatment characteristics, and events over follow-up. The mean difference in CAPS score was 38.24 (SE 4.81). Approximately half (49.1%) demonstrated a reliable and clinically significant improvement in PTSD symptom severity. No one was classified as having demonstrated clinically significant worsening of symptoms. Three independent predictors of reductions in PTSD symptom severity were identified: baseline PTSD symptom severity (β 0.77, SE 0.23, p = 0.001), number of traumas experienced prior to baseline (β −0.30, SE 0.15, p = 0.049), and number of sessions attended (β 2.05, SE 0.87, p = 0.024). The present study provides further evidence regarding the safety of the COPE treatment and factors associated with improvement in PTSD symptom severity. The identification of only a small number of predictors of the outcome points to the broad applicability of the COPE treatment to PTSD and substance use disorder (SUD) patients.
Collapse
Affiliation(s)
- Katherine L Mills
- National Drug & Alcohol Research Centre, University of New South Wales, Sydney 2052, NSW, Australia.
- Centre of Research Excellence in Mental Health and Substance Use, University of New South Wales, Sydney 2052, NSW, Australia.
| | - Emma L Barrett
- National Drug & Alcohol Research Centre, University of New South Wales, Sydney 2052, NSW, Australia.
- Centre of Research Excellence in Mental Health and Substance Use, University of New South Wales, Sydney 2052, NSW, Australia.
- Department of Psychiatry and Behavioral Sciences, Medical University of South Carolina, Charleston, SC 29425, USA.
| | - Sabine Merz
- National Drug & Alcohol Research Centre, University of New South Wales, Sydney 2052, NSW, Australia.
| | - Julia Rosenfeld
- National Drug & Alcohol Research Centre, University of New South Wales, Sydney 2052, NSW, Australia.
| | - Philippa L Ewer
- National Drug & Alcohol Research Centre, University of New South Wales, Sydney 2052, NSW, Australia.
- Centre of Research Excellence in Mental Health and Substance Use, University of New South Wales, Sydney 2052, NSW, Australia.
| | - Claudia Sannibale
- National Drug & Alcohol Research Centre, University of New South Wales, Sydney 2052, NSW, Australia.
| | - Amanda L Baker
- School of Medicine and Public Health, University of Newcastle, Callaghan 2308, NSW, Australia.
| | - Sally Hopwood
- School of Psychology, University of New South Wales, Sydney 2052, NSW, Australia.
| | - Sudie E Back
- Department of Psychiatry and Behavioral Sciences, Medical University of South Carolina, Charleston, SC 29425, USA.
| | - Kathleen T Brady
- Department of Psychiatry and Behavioral Sciences, Medical University of South Carolina, Charleston, SC 29425, USA.
| | - Maree Teesson
- National Drug & Alcohol Research Centre, University of New South Wales, Sydney 2052, NSW, Australia.
- Centre of Research Excellence in Mental Health and Substance Use, University of New South Wales, Sydney 2052, NSW, Australia.
| |
Collapse
|
13
|
Kehle-Forbes SM, Drapkin ML, Foa EB, Koffel E, Lynch KG, Polusny MA, Van Horn DHA, Yusko DA, Charlesworth M, Blasco M, Oslin DW. Study design, interventions, and baseline characteristics for the Substance use and TRauma Intervention for VEterans (STRIVE) trial. Contemp Clin Trials 2016; 50:45-53. [PMID: 27444425 PMCID: PMC9873310 DOI: 10.1016/j.cct.2016.07.017] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2016] [Revised: 07/09/2016] [Accepted: 07/17/2016] [Indexed: 01/26/2023]
Abstract
While comorbidity between posttraumatic stress disorder (PTSD) and substance use disorders (SUD) is common among veterans, there is debate regarding how to best treat individuals suffering from both conditions. Despite data supporting the effectiveness of integrated treatments that simultaneously address both disorders, due to concerns that an early focus on trauma may increase dropout and reduce the likelihood of achieving SUD-related goals, providers continue to prefer a sequential approach, where the addiction is treated first and PTSD treatment is instituted following sustained abstinence or reduced use. This project is designed to directly examine these provider concerns by evaluating the benefits and harms of an integrated versus a sequential approach to treating comorbid PTSD and SUD. This paper reviews the study's methodology, treatment approaches, and baseline participant characteristics. In this randomized clinical trial, one hundred eighty-three veterans with co-occurring PTSD and SUD have been randomized to one of two psychotherapies that include the same treatment components for SUD and PTSD (Motivational Enhancement Therapy and Prolonged Exposure respectively), but differ by whether the components are delivered sequentially or are integrated such that PTSD and SUD symptoms are addressed concurrently. We hypothesize that veterans assigned to integrated treatment will show greater improvement in PTSD and SUD symptoms than veterans assigned to sequential treatment. If this hypothesis is supported, the findings have the potential to change clinicians' beliefs and challenge long-standing practice patterns that require participation in SUD treatment prior to initiating trauma-focused therapies for PTSD.
Collapse
Affiliation(s)
- Shannon M Kehle-Forbes
- National Center for PTSD Women's Health Sciences Division at VA Boston Healthcare System, Boston, MA 02130, United States; Minneapolis VA Healthcare System, Minneapolis, MN 55417, United States; Department of Medicine, University of Minnesota, Minneapolis, MN 55455, United States.
| | - Michelle L Drapkin
- Rutgers, The State University of New Jersey, New Brunswick, NJ 08901, United States; Mental Illness Research, Education, and Clinical Center, at the Corporal Michael J. Crescenz VA Medical Center, and Center of Excellence for Substance Abuse Treatment and Evaluation, Philadelphia, PA 19104, United States
| | - Edna B Foa
- Department of Psychiatry, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA 19104, United States
| | - Erin Koffel
- Minneapolis VA Healthcare System, Minneapolis, MN 55417, United States; Department of Psychiatry, University of Minnesota, Minneapolis, MN 55454, United States
| | - Kevin G Lynch
- Department of Psychiatry, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA 19104, United States
| | - Melissa A Polusny
- Minneapolis VA Healthcare System, Minneapolis, MN 55417, United States; Department of Psychiatry, University of Minnesota, Minneapolis, MN 55454, United States
| | - Deborah H A Van Horn
- Department of Psychiatry, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA 19104, United States
| | - David A Yusko
- Department of Psychiatry, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA 19104, United States
| | | | - Molly Blasco
- Mental Illness Research, Education, and Clinical Center, at the Corporal Michael J. Crescenz VA Medical Center, and Center of Excellence for Substance Abuse Treatment and Evaluation, Philadelphia, PA 19104, United States
| | - David W Oslin
- Mental Illness Research, Education, and Clinical Center, at the Corporal Michael J. Crescenz VA Medical Center, and Center of Excellence for Substance Abuse Treatment and Evaluation, Philadelphia, PA 19104, United States; Department of Psychiatry, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA 19104, United States
| |
Collapse
|
14
|
Back SE, Killeen TK, Teer AP, Hartwell EE, Federline A, Beylotte F, Cox E. Substance use disorders and PTSD: an exploratory study of treatment preferences among military veterans. Addict Behav 2014; 39:369-73. [PMID: 24199930 DOI: 10.1016/j.addbeh.2013.09.017] [Citation(s) in RCA: 53] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2012] [Revised: 09/15/2013] [Accepted: 09/19/2013] [Indexed: 11/19/2022]
Abstract
BACKGROUND Substance use disorders (SUDs) and Post Traumatic Stress Disorder (PTSD) frequently co-occur among Veterans and are associated with poor treatment outcomes. Historically, treatments for SUDs and PTSD have been delivered sequentially and independently. More recently, however, integrated treatments have shown promise. This study investigated Veterans' perceptions of the interrelationship between SUDs and PTSD, as well as treatment preferences. METHODS Participants were 35 Veterans of recent military conflicts in Iraq and Afghanistan, and prior operations, who completed the Treatment Preferences Questionnaire as well as an in-depth interview. RESULTS The majority (94.3%) perceived a relationship between their SUD and PTSD symptoms. Veterans reported that PTSD symptom exacerbation was typically (85.3%) associated with an increase in substance use, and PTSD symptom improvement was typically (61.8%) followed by a decrease in substance use (p<.01). Approximately 66% preferred an integrated treatment approach. CONCLUSIONS Although preliminary, the findings provide clinically-relevant information that can be used to enhance the development and provision of care for Veterans with SUDs and PTSD.
Collapse
Affiliation(s)
- Sudie E Back
- Medical University of South Carolina, 171 Ashley Avenue, Charleston, SC, United States; Ralph H. Johnson Veterans Affairs Medical Center, 109 Bee Street, Charleston, SC, United States.
| | | | | | | | | | | | | |
Collapse
|
15
|
Cognitive processing therapy for veterans with comorbid PTSD and alcohol use disorders. Addict Behav 2014; 39:420-7. [PMID: 24035644 DOI: 10.1016/j.addbeh.2013.08.016] [Citation(s) in RCA: 67] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2013] [Revised: 07/25/2013] [Accepted: 08/14/2013] [Indexed: 11/21/2022]
Abstract
Posttraumatic stress disorder (PTSD) and alcohol-use disorders (AUD) frequently present comorbidity in veteran populations. Traditionally those with alcohol dependence have been excluded from PTSD treatment outcome studies, thus we do not know how those with alcohol dependence may tolerate or respond to PTSD-specific interventions; no studies to date have examined the extent to which cognitive PTSD interventions are tolerated or effective for those with comorbid PTSD/AUD. The present study examines the extent to which CPT is tolerated by and effective in treating PTSD symptoms for veterans with PTSD and AUD, as compared to veterans with PTSD only in an outpatient treatment setting. Data were obtained through chart review of 536 veterans diagnosed with PTSD who had received at least 1 session of CPT at a Midwestern US Veterans Affairs hospital. Nearly half (n=264, 49.3%) of the veterans in the study exhibited a current or past AUD diagnosis. Participants were grouped into the following diagnostic groups: current AUD (past 12 months), past AUD (prior to 12 months), and no AUD. Participants completed an average of 9 sessions of CPT with no significant difference between AUD diagnostic groups on the number of CPT sessions completed. Individuals with past AUD had higher initial symptoms of self-reported PTSD symptoms than those with no AUD. All groups reported significant reductions in PTSD symptoms and depression over time. Overall, the results suggest that CPT appears well tolerated among veterans with comorbid AUD and is associated with significant reductions in symptoms of PTSD and depression in an outpatient treatment setting.
Collapse
|
16
|
McCauley JL, Killeen T, Gros DF, Brady KT, Back SE. Posttraumatic Stress Disorder and Co-Occurring Substance Use Disorders: Advances in Assessment and Treatment. ACTA ACUST UNITED AC 2012; 19. [PMID: 24179316 DOI: 10.1111/cpsp.12006] [Citation(s) in RCA: 170] [Impact Index Per Article: 14.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Posttraumatic stress disorder (PTSD) and substance use disorders (SUDs) are prevalent and frequently co-occur. Comorbid PTSD/SUD is associated with a more complex and costly clinical course when compared with either disorder alone, including increased chronic physical health problems, poorer social functioning, higher rates of suicide attempts, more legal problems, increased risk of violence, worse treatment adherence, and less improvement during treatment. In response, psychosocial treatment options have increased substantially over the past decade and integrated approaches - treatments that address symptoms of both PTSD and SUD concurrently -are fast becoming the preferred model for treatment. This paper reviews the prevalence, etiology and assessment practices as well as advances in the behavioral and pharmacologic treatment of comorbid PTSD and SUDs.
Collapse
|
17
|
van Dam D, Vedel E, Ehring T, Emmelkamp PMG. Psychological treatments for concurrent posttraumatic stress disorder and substance use disorder: a systematic review. Clin Psychol Rev 2012; 32:202-14. [PMID: 22406920 DOI: 10.1016/j.cpr.2012.01.004] [Citation(s) in RCA: 110] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2011] [Revised: 12/21/2011] [Accepted: 01/30/2012] [Indexed: 11/16/2022]
Abstract
This article gives an overview of research into psychological treatments for concurrent posttraumatic stress disorder (PTSD) and substance used disorder (SUD), with a special focus on the effectiveness of treatments addressing both disorders compared to treatments addressing one of the disorders alone. In addition, a distinction is made between trauma-focused versus non-trauma-focused therapies for concurrent PTSD and SUD. The databases Embase, Psychinfo, Medline and Web of science were searched for relevant articles. In total, seventeen studies were identified evaluating ten treatments protocols (six trauma-focused and four non-trauma-focused treatment approaches). In general, the studies showed pre-post reductions for PTSD and/or SUD symptoms. Although most treatments for concurrent PTSD and SUD did not prove to be superior to regular SUD treatments, there are some promising preliminary results suggesting that some patients might benefit from trauma-focused interventions. However, the lack of methodologically sound treatment trials makes it difficult to draw firm conclusions. Methodological limitations are discussed, along with recommendations for future research.
Collapse
Affiliation(s)
- Debora van Dam
- Department of Clinical Psychology, University of Amsterdam, Amsterdam, The Netherlands.
| | | | | | | |
Collapse
|
18
|
van Minnen A, Harned MS, Zoellner L, Mills K. Examining potential contraindications for prolonged exposure therapy for PTSD. Eur J Psychotraumatol 2012; 3:EJPT-3-18805. [PMID: 22893847 PMCID: PMC3406222 DOI: 10.3402/ejpt.v3i0.18805] [Citation(s) in RCA: 121] [Impact Index Per Article: 10.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2012] [Revised: 06/28/2012] [Accepted: 07/04/2012] [Indexed: 11/14/2022] Open
Abstract
Although prolonged exposure (PE) has received the most empirical support of any treatment for post-traumatic stress disorder (PTSD), clinicians are often hesitant to use PE due to beliefs that it is contraindicated for many patients with PTSD. This is especially true for PTSD patients with comorbid problems. Because PTSD has high rates of comorbidity, it is important to consider whether PE is indeed contraindicated for patients with various comorbid problems. Therefore, in this study, we examine the evidence for or against the use of PE with patients with problems that often co-occur with PTSD, including dissociation, borderline personality disorder, psychosis, suicidal behavior and non-suicidal self-injury, substance use disorders, and major depression. It is concluded that PE can be safely and effectively used with patients with these comorbidities, and is often associated with a decrease in PTSD as well as the comorbid problem. In cases with severe comorbidity, however, it is recommended to treat PTSD with PE while providing integrated or concurrent treatment to monitor and address the comorbid problems.
Collapse
Affiliation(s)
- Agnes van Minnen
- Behavioural Science Institute, Radboud University Nijmegen, NijCare, the Netherlands
| | | | | | | |
Collapse
|