Integrated Exposure-Based Therapy for Co-occurring Posttraumatic Stress Disorder and Substance Dependence

Abstract

Context There is concern that exposure therapy, an evidence-based cognitivebehavioral treatment for posttraumatic stress disorder (PTSD), may be inappropriate because of risk of relapse for patients with co-occurring substance dependence.Objective To determine whether an integrated treatment for PTSD and substance dependence, Concurrent Treatment of PTSD and Substance Use Disorders Using Prolonged Exposure (COPE), can achieve greater reductions in PTSD and substance dependence symptom severity compared with usual treatment for substance dependence.Design, Setting, and Participants Randomized controlled trial enrolling 103 participants who met DSM-IV-TR criteria for both PTSD and substance dependence. Participants were recruited from 2007-2009 in Sydney, Australia; outcomes were assessed at 9 months postbaseline, with interim measures collected at 6 weeks and 3 months postbaseline.Interventions Participants were randomized to receive COPE plus usual treatment (n=55) or usual treatment alone (control) (n=48). COPE consists of 13 individual 90minute sessions (ie, 19.5 hours) with a clinical psychologist. Main Outcome MeasuresChange in PTSD symptom severity as measured by the Clinician-Administered PTSD Scale (CAPS; scale range, 0-240) and change in severity of substance dependence as measured by the number of dependence criteria met according to the Composite International Diagnostic Interview version 3.0 (CIDI; range, 0-7), from baseline to 9-month follow-up. A change of 15 points on the CAPS scale and 1 dependence criterion on the CIDI were considered clinically significant. ResultsFrom baseline to 9-month follow-up, significant reductions in PTSD symptom severity were found for both the treatment group (mean difference, −38.24 [95% CI, −47.93 to −28.54]) and the control group (mean difference, −22.14 [95% CI, −30.33 to −13.95]); however,thetreatmentgroupdemonstratedasignificantlygreaterreductioninPTSDsymptom severity (mean difference, −16.09 [95% CI, −29.00 to −3.19]). No significant between-group difference was found in relation to improvement in severity of substance dependence (0.43 vs 0.52; incidence rate ratio, 0.85 [95% CI, 0.60 to 1.21), nor were there any significant between-group differences in relation to changes in substance use, depression, or anxiety. ConclusionAmong patients with PTSD and substance dependence, the combined use of COPE plus usual treatment, compared with usual treatment alone, resulted in improvement in PTSD symptom severity without an increase in severity of substance dependence.

Clinical Factor 2012

“…Mills et al [12] in Sydney, Australia, attempted to determine whether an integrated treatment for PTSD and substance dependence, concurrent treatment of PTSD and substance use disorders using prolonged exposure (COPE), can achieve greater reduction in PTSD and substance dependence symptom severity than the usual treatment for substance dependence. Participants were randomly assigned to COPE (n = 55; 13 individual 90-min sessions) plus usual treatment, or usual treatment alone (n = 48; any type of substance abuse treatment, including outpatient counseling, inpatient or outpatient detoxification, residential rehabilitation, and pharmacotherapies such as methadone, buprenorphine, naltrexone etc.).…”

Expanding the Boundaries of PTSD Treatment

“…There were no data on how concurrent psychotherapies may have affected outcomes or whether the couples were compensated financially for their participation in the trial, and neither the patients assigned to the wait-list condition nor patients who dropped out of treatment were included in the follow-up assessment. From a clinical perspective, the study sample also appeared generally "easier to treat" than is typical in community settings (including the study by Mills et al 3 ), as indicated by baseline measurements of relationship satisfaction, a general lack of severe comorbidities, and the support of an intimate partner who was willing to participate in treatment. In the report by Monson et al, 4 the sample was predominantly white and employed, with virtually no substance use disorder at baseline.…”

“…2 In this issue of JAMA, the findings of 2 randomized controlled trials of interventions for PTSD expand the boundaries of treatment to relatively underserved populations: the trial by Mills et al 3 assesses interventions in persons with PTSD and substance dependence, and the trial by Monson et al 4 assesses interventions in couples in which 1 partner has PTSD. 4 The trial by Mills et al 3 evaluated Concurrent Treatment of PTSD and Substance Use Disorders Using Prolonged Exposure (COPE) plus usual treatment for substance dependence (n = 55) vs usual treatment for substance dependence alone (n=48). COPE involved an individual modality treatment totaling 19.5 hours, whereas usual treatment was any type of substance use treatment available in the patient's community, including counseling, detoxification, residential rehabilitation, and pharmacotherapy.…”

Evolving Research on the Treatment of Health Effects of Violence and Human Rights Abuses

“…[6][7][8][9][10][11] This issue of JAMA includes reports of 3 new randomized trials of interventions: a trial of screening for intimate partner violence 12 and 2 trials of interventions for posttraumatic stress disorder for survivors of violence. 13,14 The implications of these trial reports for clinical practice and public health are discussed in accompanying Editorials, 15,16 as are the methodologic strengths and limitations of these studies. In this context, it is worth reflecting on what researchers, public health and international aid workers, and clinicians have been able to accomplish in the past several years of intensive work in the fields of violence and human rights.…”