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Latest Research on Treating PTSD and Addiction

Researchers at the Dartmouth Psychiatric Research Center highlight findings on the efforts to integrate treatment of co-occurring PTSD and substance use disorders.

Among people seeking treatment for substance use disorders, it's estimated that nearly one in three are suffering symptoms of PTSD. Rates of alcohol and substance use disorders among those diagnosed with PTSD are also strikingly high. While historically the practice may have been to treat the addiction first, there has long been an awareness of the degree to which each disorder impedes treatment.

In a recent special issue of the Journal of Dual Diagnosis (vol. 7, issue 4), guest editors Mark McGovern and Tracy Stecker review the research on interventions for co-occurring substance use disorders and PTSD. Research twenty years ago pointed to the need to integrate the treatment of PTSD and addiction, and McGovern and Stecker note the growing number of studies in the past decade on integrated- treatment interventions. (Read the editorial.)

The identification and implementation of effective treatment for co-occurring disorders is a particular research focus of the Dartmouth Psychiatric Research Center. In this column, we'll highlight a few of the journal issue's articles that provide both new findings on interventions as well as analysis of existing studies.

Despite research support for exposure therapy in the treatment of PTSD, until recently few addiction-treatment settings have employed it. Researchers Therese Killeen, Sudie Black, and Kathleen Brady discuss the development and implementation of one such intervention in their article, "The Use of Exposure-Based Treatment among Individuals with PTSD and Co-occurring Substance Use Disorders: Clinical Considerations." The program Concurrent Treatment of PTSD and Substance Use Disorders with Prolonged Exposure (known as COPE) employs imaginal and in vivo exposure along with relapse-prevention therapy and psychoeducation on PTSD symptoms. According to Killeen and co-authors, recent studies, including one randomized controlled trial, indicate that participants in COPE experienced improved PTSD and substance use outcomes. Attrition rates in programs remained high, although the authors note they are similar to rates of attrition in substance use programs for this population.

An integrated-treatment program employing cognitive-behavioral therapy, rather than exposure therapy, similarly shows promise in treating co-occurring PTSD and addiction. In a randomized controlled trial, Integrated Cognitive-Behavioral Therapy was found to be more effective than individual addiction treatment in reducing symptoms of PTSD, particularly in cases of severe PTSD. While both approaches resulted in a reduction of substance use, integrated CBT had more of a marked impact on PTSD diagnosis and re-experiencing symptom severity. Community counselors were found to be able to implement both interventions with fidelity. The randomized controlled study drew on fifty-three participants from seven community addiction treatment programs. A large, randomized control trial of integrated CBT is underway.

Researchers Mark McGovern and co-authors review the findings in their article, "A Randomized Controlled Trial Comparing Integrated Cognitive Behavioral Therapy versus Individual Addiction Counseling for Co-occurring Substance Use and Posttraumatic Stress Disorders." A non-exposure-based treatment, Integrated CBT combines patient education, anxiety reduction techniques, and coping skill development. (The Integrated CBT program is published through Hazelden as Cognitive Behaviorial Therapy for PTSD.)

Seeking Safety is among the first manualized programs to treat co-occurring trauma or PTSD and substance abuse together. Gregory J. McHugo and Roger D. Fallot analyze the methods and findings of the NIDA Clinical Trials Network study on Seeking Safety, as reported by Hien et al. in 2009. In the trial, client outcomes from participants in Seeking Safety, a structured cognitive-behavioral treatment, were compared to outcomes for those participating in another psychoeducation curriculum that did not address trauma or PTSD or substance abuse directly. The results indicate that the severity of PTSD symptoms improved significantly for both groups, while no significant changes in substance use from baseline to one-year follow-up were apparent. The results echo a 2004 study by Hein, Cohen, Miele, Litt, and Capstick. McHugo and Fallot outline various possible explanations for the results, including the possibility that a range of interventions may help symptoms of PTSD or that frequent PTSD symptom assessments might function as a version of exposure therapy. The authors map out suggested avenues for future research. (Read more in their article "Multisite Randomized Trial of Behavioral
Interventions for Women with Co-occurring PTSD and Substance Use Disorders

In an article on the recently revised Veterans Administration and Department of Defense clinical practice guidelines, Nancy Bernardy and co-authors note that the release of the guidelines along with the arrival of new mental health staff to treat veterans of the Iraq and Afghanistan wars have made the integrated treatment of PTSD and substance use disorders more feasible. The authors review the recommendations, the research supporting them, and new VA programs addressing the disorders, noting areas of success as well as continuing obstacles.

To read the full article, see "Co-occurring Posttraumatic Stress Disorder and Substance Use Disorder: Recommendations for Management and Implementation in the Department of Veterans Affairs" by Nancy C. Bernardy, Jessica L. Hamblen, Matthew J. Friedman, and Daniel R. Kivlahan.


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