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Buckheit KA, Barden E, Shaw R, Possemato K, Mastroleo NR, Rauch SAM. Primary Care Treatment Integrating Motivation and Exposure for PTSD Symptoms and Hazardous Alcohol Use: A Case Series. COGNITIVE AND BEHAVIORAL PRACTICE 2023; 30:551-563. [PMID: 37745164 PMCID: PMC10513004 DOI: 10.1016/j.cbpra.2022.02.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Symptoms of posttraumatic stress disorder (PTSD) and hazardous alcohol use are highly comorbid. Research on integrated interventions to address PTSD symptoms and hazardous alcohol use concurrently has demonstrated efficacy, yet integrated treatments are underutilized. Both patient (e.g., stigma, scheduling/logistics) and clinician (e.g., concern about symptom exacerbation and/or treatment dropout) barriers may impede utilization of integrated interventions among those with comorbid PTSD symptoms and hazardous alcohol use. Primary care behavioral health models (PCBH), in which embedded behavioral health providers deliver treatment to individuals with mild or moderate behavioral health symptoms in primary care, may help address treatment barriers by offering accessible behavioral health interventions in a destigmatizing setting. This paper presents two case examples from a randomized controlled trial testing the efficacy of an integrated intervention for PTSD symptoms and hazardous alcohol use developed for and delivered in primary care. Outcome data and session-by-session content for two participants are included, along with discussion of barriers encountered during the course of treatment. Clinician-suggested strategies for navigating barriers to facilitate utilization of integrated interventions for PTSD symptoms and hazardous alcohol use are also discussed.
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Affiliation(s)
| | - Eileen Barden
- VA Center for Integrated Healthcare, Syracuse VA Medical Center and Binghamton University
| | - Rachael Shaw
- VA Center for Integrated Healthcare, Western NY VA Healthcare Systems and University at Buffalo (SUNY)
| | - Kyle Possemato
- VA Center for Integrated Healthcare, Syracuse VA Medical Center
| | | | - Sheila A M Rauch
- Mental Health Service Line, Atlanta VA Healthcare System and Emory University School of Medicine
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Barkell GA, Parekh SV, Paniccia JE, Martin AJ, Reissner KJ, Knapp DJ, Robinson SL, Thiele TE, Lysle DT. Chronic ethanol consumption exacerbates future stress-enhanced fear learning, an effect mediated by dorsal hippocampal astrocytes. Alcohol Clin Exp Res 2022; 46:2177-2190. [PMID: 36349797 PMCID: PMC10187052 DOI: 10.1111/acer.14963] [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: 06/23/2022] [Revised: 09/23/2022] [Accepted: 10/21/2022] [Indexed: 11/11/2022]
Abstract
BACKGROUND Alcohol use disorder (AUD) and post-traumatic stress disorder (PTSD) are highly comorbid, yet there is a lack of preclinical research investigating how prior ethanol (EtOH) dependence influences the development of a PTSD-like phenotype. Furthermore, the neuroimmune system has been implicated in the development of both AUD and PTSD, but the extent of glial involvement in this context remains unclear. A rodent model was developed to address this gap in the literature. METHODS We used a 15-day exposure to the 5% w/v EtOH low-fat Lieber-DeCarli liquid diet in combination with the stress-enhanced fear learning (SEFL) paradigm to investigate the effects of chronic EtOH consumption on the development of a PTSD-like phenotype. Next, we used a reverse transcription quantitative real-time polymerase chain reaction to quantify mRNA expression of glial cell markers GFAP (astrocytes) and CD68 (microglia) following severe footshock stress in EtOH-withdrawn rats. Finally, we tested the functional contribution of dorsal hippocampal (DH) astrocytes in the development of SEFL in EtOH-dependent rats using astrocyte-specific Gi designer receptors exclusively activated by designer drugs (Gi -DREADD). RESULTS Results demonstrate that chronic EtOH consumption and withdrawal exacerbate future SEFL. Additionally, we found significantly increased GFAP mRNA expression in the dorsal and ventral hippocampus and amygdalar complex following the severe stressor in EtOH-withdrawn animals. Finally, the stimulation of the astroglial Gi -DREADD during EtOH withdrawal prevented the EtOH-induced enhancement of SEFL. CONCLUSIONS Collectively, results indicate that prior EtOH dependence and withdrawal combined with a severe stressor potentiate future enhanced fear learning. Furthermore, DH astrocytes significantly contribute to this change in behavior. Overall, these studies provide insight into the comorbidity of AUD and PTSD and the potential neurobiological mechanisms behind increased susceptibility to a PTSD-like phenotype in individuals with AUD.
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Affiliation(s)
- Gillian A Barkell
- Department of Psychology and Neuroscience, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Shveta V Parekh
- Department of Psychology and Neuroscience, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Jacqueline E Paniccia
- Department of Psychology and Neuroscience, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Alia J Martin
- Department of Psychology and Neuroscience, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Kathryn J Reissner
- Department of Psychology and Neuroscience, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Darin J Knapp
- Department of Psychology and Neuroscience, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Stacey L Robinson
- Department of Psychology and Neuroscience, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Todd E Thiele
- Department of Psychology and Neuroscience, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Donald T Lysle
- Department of Psychology and Neuroscience, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
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Abstract
Over 30% of veterans treated for psychiatric disorders in the Veterans Health Administration (VHA) are diagnosed with Post-Traumatic Stress Disorder (PTSD), with most receiving treatment for war-zone stress they experienced decades previously. We examined psychiatric multimorbidity among these patients and consider its implications for treatment and research. Using national VHA data from Fiscal Year 2012 on all veterans diagnosed with PTSD, we compared those with PTSD only to those with one, two, and three or more concurrent (non-substance use) psychiatric disorders. Comparisons of these four groups on sociodemographic characteristics, medical and substance use co-morbidities, health service use, and psychotropic prescription fills were conducted using bi-variate and ordinal logistic regression methods. Of 638,451 veterans diagnosed with PTSD in FY2012, only 29.8% had PTSD alone; 36.7% had one concurrent psychiatric diagnosis, 21.3% had two, and 12.2% had three or more. Anxiety disorder and major depressive disorder were the most common concurrent diagnoses. Veterans with higher levels of multimorbidity were younger, had greater likelihood of recent homelessness, substance use disorder, and diverse medical diagnoses, along with increased mental health and medical service use and greater psychotropic medication use. Psychiatric multimorbidity is highly prevalent among VHA patients diagnosed with PTSD, and may represent an underappreciated and poorly understood clinical complication that poses unique challenges to effective treatment. Clinical attention and both epidemiological and interventional research on multimorbidity in PTSD patients are needed in order to better understand and treat this common but understudied phenomenon.
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Does trauma-focused exposure therapy exacerbate symptoms among patients with comorbid PTSD and substance use disorders? Behav Cogn Psychother 2019; 48:38-53. [PMID: 31010449 DOI: 10.1017/s1352465819000304] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
BACKGROUND Although exposure-based therapy is a well-established, effective treatment for post-traumatic stress disorder (PTSD), some practitioners report reluctance to implement it due to concerns that it may exacerbate symptoms of PTSD and commonly comorbid disorders, such as substance use disorders (SUD). AIM This study compared the exacerbation of psychological symptoms among participants with comorbid PTSD and SUD who received either SUD treatment alone or SUD treatment integrated with exposure therapy for PTSD. METHOD Participants (N = 71) were treatment-seeking, military Veterans with comorbid PTSD and SUD who were randomized to 12 individual sessions of either (1) an integrated, exposure-based treatment (Concurrent Treatment of PTSD and Substance Use Disorders using Prolonged Exposure; COPE); or (2) a non-exposure-based, SUD-only treatment (Relapse Prevention; RP). We examined between-group differences in the frequency of statistically reliable exacerbations of PTSD, SUD and depression symptoms experienced during treatment. RESULTS At each of the 12 sessions, symptom exacerbation was minimal and generally equally likely in either treatment group. However, an analysis of treatment completers suggests that RP participants experienced slightly more exacerbations of PTSD symptoms during the course of treatment. CONCLUSIONS This study is the first to investigate symptom exacerbation throughout trauma-focused exposure therapy for individuals with comorbid PTSD and SUD. Results add to a growing literature which suggests that trauma-focused, exposure-based therapy does not increase the risk of symptom exacerbation relative to non-exposure-based therapy.
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Jarnecke AM, Allan NP, Badour CL, Flanagan JC, Killeen TK, Back SE. Substance use disorders and PTSD: Examining substance use, PTSD symptoms, and dropout following imaginal exposure. Addict Behav 2019; 90:35-39. [PMID: 30355535 DOI: 10.1016/j.addbeh.2018.10.020] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2018] [Revised: 10/12/2018] [Accepted: 10/15/2018] [Indexed: 12/26/2022]
Abstract
Integrated exposure-based interventions to treat substance use disorders (SUD) and posttraumatic stress disorder (PTSD) may not be widely utilized, in part, because of clinician concerns that such interventions will worsen symptomatology and lead to treatment dropout. In order to address this question, the current pilot study examined whether participants' ratings of craving and distress following imaginal exposure predicted increased substance use, PTSD severity, and treatment dropout. Participants (N = 46) were U.S. military Veterans who met criteria for current SUD and PTSD. Subjective ratings of craving and distress, and past-week substance use and PTSD symptom severity were assessed at each treatment session. Multilevel modeling tested whether lagged ratings of craving and distress predicted the following week's frequency of substance use and PTSD severity. Discrete time survival analysis, using proportional odds Cox ratio, examined whether craving and distress ratings predicted treatment dropout. The findings revealed that neither craving nor distress following imaginal exposure were associated with the following week's substance use or PTSD severity. However, participants with higher craving and distress were more likely to drop out before completing treatment. Future research is needed to develop strategies to increase treatment retention for individuals at-risk for treatment dropout and identify mechanisms that account for the association between in-session ratings of craving and distress and dropout.
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Affiliation(s)
- Amber M Jarnecke
- Medical University of South Carolina, Charleston, SC, United States.
| | | | | | | | | | - Sudie E Back
- Medical University of South Carolina, Charleston, SC, United States; Ralph H. Johnson VAMC, Charleston, SC, United States
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Back SE, Killeen T, Badour CL, Flanagan JC, Allan NP, Ana ES, Lozano B, Korte KJ, Foa EB, Brady KT. Concurrent treatment of substance use disorders and PTSD using prolonged exposure: A randomized clinical trial in military veterans. Addict Behav 2019; 90:369-377. [PMID: 30529244 DOI: 10.1016/j.addbeh.2018.11.032] [Citation(s) in RCA: 104] [Impact Index Per Article: 20.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2018] [Revised: 11/17/2018] [Accepted: 11/22/2018] [Indexed: 12/25/2022]
Abstract
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.
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Affiliation(s)
- Sudie E Back
- Department of Psychiatry & Behavioral Sciences, Medical University of South Carolina, Charleston, SC, USA; Ralph H. Johnson Veterans Affairs Medical Center, Charleston, SC, USA.
| | - Therese Killeen
- Department of Psychiatry & Behavioral Sciences, Medical University of South Carolina, Charleston, SC, USA
| | - Christal L Badour
- Department of Psychology, University of Kentucky, Lexington, KY, USA
| | - Julianne C Flanagan
- Department of Psychiatry & Behavioral Sciences, Medical University of South Carolina, Charleston, SC, USA
| | | | - Elizabeth Santa Ana
- Department of Psychiatry & Behavioral Sciences, Medical University of South Carolina, Charleston, SC, USA; Ralph H. Johnson Veterans Affairs Medical Center, Charleston, SC, USA
| | - Brian Lozano
- Department of Psychiatry & Behavioral Sciences, Medical University of South Carolina, Charleston, SC, USA; Ralph H. Johnson Veterans Affairs Medical Center, Charleston, SC, USA
| | - Kristina J Korte
- Psychiatry Department, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Edna B Foa
- Department of Psychiatry, University of Pennsylvania, Philadelphia, PA, USA
| | - Kathleen T Brady
- Department of Psychiatry & Behavioral Sciences, Medical University of South Carolina, Charleston, SC, USA; Ralph H. Johnson Veterans Affairs Medical Center, Charleston, SC, USA
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Meshberg-Cohen S, Black AC, DeViva JC, Petrakis IL, Rosen MI. Trauma treatment for veterans in buprenorphine maintenance treatment for opioid use disorder. Addict Behav 2019; 89:29-34. [PMID: 30243036 DOI: 10.1016/j.addbeh.2018.09.010] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2018] [Revised: 08/12/2018] [Accepted: 09/08/2018] [Indexed: 01/22/2023]
Abstract
INTRODUCTION Opioid use disorder (OUD) rates are high among veterans. PTSD is also prevalent among veterans; those with comorbidity have worse outcomes than those without comorbidity. This study assessed buprenorphine retention rates in veterans initiating OUD treatment, comparing veterans without PTSD to veterans with PTSD who were receiving versus not receiving concurrent trauma treatment. METHODS This retrospective chart review examined consecutive referrals to buprenorphine maintenance (N = 140). PTSD diagnosis was identified by chart review and retention was defined as continuous buprenorphine maintenance 6-months post-admission. Logistic regression analyses compared buprenorphine retention for veterans without PTSD and PTSD-diagnosed veterans who received concurrent trauma treatment to a reference group of PTSD-diagnosed veterans who did not receive trauma treatment. Models adjusted for opioid type, age, and service-connected status. RESULTS Sixty-seven (47.9%) buprenorphine-seeking veterans carried a PTSD diagnosis; only 31.3% (n = 21) received trauma treatment while in buprenorphine maintenance, with 11.9% (n = 8) receiving evidence-based psychotherapy for PTSD. Among PTSD-diagnosed veterans who received trauma treatment, 90.5% (n = 19/21) were in buprenorphine maintenance at 6-months, compared to 23.9% (n = 11/46) of PTSD-diagnosed veterans without trauma treatment, and 46.6% (n = 34/73) of veterans without PTSD. In the full model, veterans with trauma treatment had 43.36 times greater odds of remaining in buprenorphine treatment than the reference group. CONCLUSIONS Most PTSD-diagnosed veterans in buprenorphine treatment were not receiving trauma treatment. Those receiving concurrent trauma treatment had better retention, suggesting OUD and trauma can be simultaneously addressed. Future clinical trials should investigate trauma-focused treatment for veterans with comorbid PTSD who are seeking buprenorphine for OUD.
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Affiliation(s)
- Sarah Meshberg-Cohen
- VA Connecticut Healthcare System, 950 Campbell Avenue, Psychology Service/Department of Psychiatry, 116A, West Haven, CT 06516, United States; Yale University School of Medicine, Department of Psychiatry, United States.
| | - Anne C Black
- VA Connecticut Healthcare System, 950 Campbell Avenue, Psychology Service/Department of Psychiatry, 116A, West Haven, CT 06516, United States; Yale University School of Medicine, Department of Psychiatry, United States
| | - Jason C DeViva
- VA Connecticut Healthcare System, 950 Campbell Avenue, Psychology Service/Department of Psychiatry, 116A, West Haven, CT 06516, United States; Yale University School of Medicine, Department of Psychiatry, United States
| | - Ismene L Petrakis
- VA Connecticut Healthcare System, 950 Campbell Avenue, Psychology Service/Department of Psychiatry, 116A, West Haven, CT 06516, United States; Yale University School of Medicine, Department of Psychiatry, United States
| | - Marc I Rosen
- VA Connecticut Healthcare System, 950 Campbell Avenue, Psychology Service/Department of Psychiatry, 116A, West Haven, CT 06516, United States; Yale University School of Medicine, Department of Psychiatry, United States
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Back SE, Jones JL. Alcohol Use Disorder and Posttraumatic Stress Disorder: An Introduction. Alcohol Clin Exp Res 2018; 42:836-840. [PMID: 29489019 DOI: 10.1111/acer.13619] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2017] [Accepted: 02/22/2018] [Indexed: 11/28/2022]
Affiliation(s)
- Sudie E Back
- Department of Psychiatry & Behavioral Sciences , Medical University of South Carolina, Charleston, South Carolina.,Ralph H. Johnson Veterans Affairs Medical Center , Charleston, South Carolina
| | - Jennifer L Jones
- Department of Psychiatry & Behavioral Sciences , Medical University of South Carolina, Charleston, South Carolina
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