Search

Objective: To evaluate the efficacy of psychosocial treatments for posttraumatic stress disorder (PTSD) among individuals with a comorbid severe mental illness (SMI; ie, schizophrenia, bipolar disorder, major depressive disorder). Data Sources: PubMed, PsycINFO, CINAHL, and Cochrane Library were searched from January 1998 to March 2020 using keywords related to PTSD, treatment, and severe mental illness. Study Selection: All clinical trials for PTSD psychotherapy among individuals with SMI were included. From 38 potentially eligible studies, a total of 14 clinical trials across 684 individuals with comorbid SMI and PTSD were identified and included in the analysis. Data Extraction: Data on demographic, SMI diagnosis, symptom severity, sample attrition, and treatment protocol received were extracted. Effect size calculations and subsequent meta-analyses were conducted using the Meta-Analysis Package for R (metafor) version 2.1-0 in R (3.6.0). Results: PTSD treatments had a large effect on PTSD outcomes among individuals with SMI, with patients experiencing a standard deviation reduction in PTSD symptomatology pre- to post-treatment (g = -1.009, P

The COVID-19 pandemic has caused many Veterans Healthcare Administration providers working with veterans diagnosed with posttraumatic stress disorder to question the feasibility and appropriateness of continuing to provide trauma-focused treatment during this crisis. The Veterans Healthcare Administration is in a unique position to continue to provide trauma-informed care because of its capacity to offer telemental health services. Data from a Veterans Affairs medical center's posttraumatic stress disorder clinical team suggest that not only are veterans interested in continuing with treatment but also that the treatments can be modified to accommodate the current climate. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

Background Posttraumatic stress disorder (PTSD) rarely remits over time, and if left untreated, leads to significant distress, functional impairment, and increased health care costs. Fortunately, effective evidence-based treatments (EBTs) for PTSD, such as Prolonged Exposure (PE), exist. Despite their availability and efficacy, a significant number of individuals with PTSD do not initiate treatment when offered or dropout prematurely. One proposed theory suggests that the emotional-numbing symptoms of PTSD (e.g., blunted affect, apathy) can serve as a barrier to engaging in, and successfully completing, treatment; and the broad human-animal interaction (HAI) literature available suggests that HAI can potentially reduce emotional numbing related to PTSD. Accordingly, this manuscript describes an ongoing, federally funded, randomized controlled trial testing the efficacy of RESCUE, an HAI intervention, as a viable adjunctive treatment component for PE. Methods/design The study will include 70 veterans with PTSD treated at a Southeastern Veterans Affairs Medical Center (VAMC). All participants in the trial receive up to 12 sessions of PE. Participants are randomly assigned 1:1 to (1) volunteer at a local animal shelter or (2) volunteer at a community agency of their choice as part of their in-vivo exposure exercises for PE. Outcomes will be examined via standard clinical interviews, self-report questionnaires, and thematic interviews. Discussion It is hypothesized that participants in the HAI condition will report greater decreases in emotional-numbing symptoms and increased treatment compliance and completion rates relative to those in the community volunteer condition. If successful, RESCUE, could be easily incorporated into standard PE and broadly disseminated. Trial registration ClinicalTrials.gov. ID: NCT03504722. Retrospectively registered on 2 May 2017.

Objectives Exposure-based psychotherapies for posttraumatic stress disorder (PTSD) are effective for many, but not all patients. It is important to determine for whom these treatments work and to examine predictors of success. Method An 8-week modified prolonged exposure (PE) treatment, including components of behavioral activation and reducing the number of imaginal exposure sessions, was administered to a sample of 231 Veterans (mean age = 45.7 years, standard deviation = 14.89). Growth mixture modeling was used to model PTSD symptom trajectories across the 8-week intervention and a postintervention appointment. Further, baseline demographics, social support, clinician-rated PTSD symptoms, anxiety, and depression were examined as predictors of trajectories. Results Three classes emerged, labeled responders (n = 35), nonresponders (n = 190), and immediate responders (n = 6). The only significant baseline difference between responders and nonresponders was higher anxiety symptoms in the nonresponders. At follow-up time points, there were higher levels of clinician-rated PTSD, anxiety, and depression symptoms and lower social support in the nonresponders compared to the responders. Conclusion Findings suggest that modifying standard PE treatments by reducing imaginal exposure sessions while adding behavioral activation may not be advisable for most Veterans with PTSD.

Both pharmacotherapy and psychotherapy are effective treatments for posttraumatic stress disorder (PTSD). Better understanding factors that are associated with engaging in these different treatment options may improve treatment utilization and outcomes. This issue is especially important among veterans returning from Iraq and Afghanistan, given high rates of those seeking PTSD treatment. This study examined potential predictors of the type of treatment (psychotherapy, pharmacotherapy, or both) 232 returning veterans (92% male, mean age = 33.38) engaged in within 1 year of seeking treatment at a VA PTSD clinic. Results indicated that 32.3% of returning veterans engaged in pharmacotherapy only, 23.7% engaged in psychotherapy only, and 44.0% engaged in both. Veterans who engaged in pharmacotherapy only or in both pharmacotherapy and psychotherapy had higher pretreatment PTSD and depression symptoms than did those who engaged in psychotherapy only. History of pharmacotherapy treatment was associated with engagement in pharmacotherapy only or both pharmacotherapy and psychotherapy, as compared with psychotherapy only. Treatment engagement type was not significantly associated with differences in age, gender, race/ethnicity, service branch, alcohol use/misuse, history of psychotherapy, distance from the VA, or PTSD service connection. Implications for enhancing PTSD treatment engagement are discussed. (PsycINFO Database Record

Prolonged exposure therapy (PE) is effective in reducing posttraumatic stress disorder (PTSD) symptoms among individuals with comorbid substance use disorder (SUD) and PTSD. However, concerns that PE will lead to negative outcomes such as dropout and relapse remain a barrier to high-risk individuals, such as those warranting residential SUD care, receiving PE. The goal of this study was to gather information on feasibility, acceptability, and efficacy of offering PE in residential SUD treatment. Study therapists conducted PE (3 times/week, up to 15 sessions) with 9 patients admitted to a residential SUD treatment program at a Veterans Affairs (VA) hospital. Participants completed the PTSD Symptom Checklist (PCL-S) and Patient Health Questionnaire (PHQ-9) at admission, at discharge from the 4- to 6-week program, and 3-months postdischarge follow-up. Patients who were offered PE tolerated and engaged in PE as indicated by completion of the protocol, high satisfaction scores, and clinically significant decreases in PTSD and depression symptom severity. Symptom reduction at follow-up was significantly greater among patients who received PE than those who did not ( n = 21). This preliminary data provides initial support for further investigation of the efficacy of PE in residential SUD care.

This study examined: (a) the relationship between self-reported posttraumatic stress disorder (PTSD) symptoms and risk of obstructive sleep apnea (OSA) in a younger, Iraq and Afghanistan (OEF/OIF/OND) veteran sample seeking treatment for PTSD; and (b) the relationships between PTSD symptom scores and each risk factor of OSA (snoring, fatigue, high blood pressure/BMI).Participants were 195 Iraq and Afghanistan veterans presenting to a VA outpatient PTSD clinic for evaluation. Veterans were 21 to 59 years old (mean 33.40, SD 8.35) and 93.3% male (n = 182). Logistic regressions were run to examine whether veterans with greater PTSD symptom severity had an increased probability of screening as high risk for OSA, even after controlling for known risk factors (older age, positive smoking status, and use of CNS depressants).Of 159 veterans screened, 69.2% were assessed as being at high risk for OSA. PTSD symptom severity increased the risk of screening positive for OSA. PTSD symptom severity increased risk of screening positive for snoring and fatigue, but not high blood pressure/BMI.OEF/OIF/OND veterans with PTSD screen as high risk for OSA at much higher rates than those seen in community studies and may not show all classic predictors of OSA (i.e., older and higher BMI). This study is the first to suggest that the Berlin may be a useful screener for OSA in a younger OEF/OIF/OND veteran population with PTSD. Screening of younger veterans with PTSD for OSA should be standard care, and polysomnography and OSA interventions should be readily available to younger veterans.

IMPORTANCE: Co-occurrence of posttraumatic stress disorder (PTSD) and alcohol use disorder (AUD) is common and associated with psychiatric and functional problems. Understanding whether exposure therapy is tolerable and efficacious for treating PTSD and AUD is critical to ensure that best practice treatments are available. OBJECTIVE: To compare the efficacy of integrated (ie, targeting both PTSD and alcohol use) prolonged exposure (I-PE) therapy with present-centered integrated coping skills (I-CS) therapy, a more commonly available treatment, in reducing PTSD symptoms and alcohol use. DESIGN, SETTING, AND PARTICIPANTS: This prospective randomized clinical trial with masked assessments considered 186 veterans seeking Veterans Affairs mental health services. A total of 119 veterans with PTSD and AUD were randomized. Data were collected from February 1, 2013, to May 31, 2017, before treatment, after treatment, and at 3- and 6-month follow-ups. Intention-to-treat analyses were performed. INTERVENTIONS: Veterans underwent I-PE (Concurrent Treatment of PTSD and Substance Use Disorder Using Prolonged Exposure) or I-CS (Seeking Safety) therapy. MAIN OUTCOMES AND MEASURES: A priori planned outcomes were PTSD symptoms (Clinician Administered PTSD Scale for DSM-5) and percentage of heavy drinking days (Timeline Follow-Back) before treatment, after treatment, and at 3- and 6-month follow-ups. RESULTS: A total of 119 veterans (mean [SD] age, 41.6 [12.6] years; 107 [89.9%] male) were randomized. Linear mixture models found that PTSD symptoms decreased in both conditions, with a significantly greater decrease for I-PE treatment compared with I-CS treatment (treatment × time interaction, −2.83; F(3,233.1) = 4.92; Cohen d = 0.41; P = .002). The percentage of heavy drinking days improved in both conditions but was not statistically different between I-PE and I-CS treatment (treatment × time interaction, 1.8%; F(3,209.9) = 0.18; Cohen d = 0.04; P = .91). CONCLUSIONS AND RELEVANCE: The I-PE arm had a greater reduction in PTSD symptoms than the I-CS arm and comparable drinking decreases. The study provides evidence that exposure therapy is more efficacious in treating PTSD than a more commonly available integrated treatment without exposure for comorbid PTSD and AUD. TRIAL REGISTRATION: ClinicalTrials.gov identifier: NCT01601067

As previous work has highlighted the significance of the cannabinoid receptor 1 (CNR1) and fatty acid amide hydrolase (FAAH) genes with respect to cannabis dependence (CD), this study sought to characterize the neural mechanisms that underlie these genetic effects. To this end, we collected DNA samples and fMRI data using a cue-elicited craving paradigm in thirty-seven 3-day-abstinent regular marijuana users. The participants were grouped according to their genotype on two single-nucleotide polymorphisms (SNPs) earlier associated with CD phenotypes: rs2023239 in CNR1 and rs324420 in FAAH. Between-group comparisons showed that carriers of the CNR1 rs2023239 G allele had significantly greater activity in reward-related areas of the brain, such as the orbitofrontal cortex (OFC), inferior frontal gyrus (IFG), and anterior cingulate gyrus (ACG), during exposure to marijuana cues, as compared with those with the A/A genotype for this SNP. The FAAH group contrasts showed that FAAH rs324420 C homozygotes also had greater activation in widespread areas within the reward circuit, specifically in the OFC, ACG, and nucleus accumbens (NAc), as compared with the FAAH A-allele carriers. Moreover, there was a positive correlation between neural response in OFC and NAc and the total number of risk alleles (cluster-corrected p

Treatment engagement rates are low for individuals with comorbid posttraumatic stress disorder (PTSD) and alcohol use disorders across available interventions and treatment modalities. A better understanding of who does and does not engage in treatment can help improve retention, completion, and subsequent treatment outcomes.Forty female survivors of intimate partner violence with PTSD and alcohol use disorder participated in a randomized controlled trial comparing twenty-five 90-minute sessions of either modified Seeking Safety or Facilitated Twelve-Step in a community-based outpatient clinic. This study examined differences in demographics and pre-treatment PTSD symptoms and alcohol use between participants who engaged in treatment (attended ≥ 6 sessions, n = 18) and those who dropped out (n = 22).There were no significant differences in PTSD or alcohol use disorder symptoms between treatment conditions. Women who engaged in therapy versus those who did not were significantly older (M = 46.2, SD = 9.14 vs. M = 38.95, SD = 10.49, respectively; p =.027), and had fewer dependents (M =.17, SD =.38, range = 0-1 vs. M =.95, SD = 1.66, range = 1-7, respectively; p =.046). Greater avoidance/numbing PTSD symptoms (OR = 1.13, p =.028, 95% CI [1.02-1.25]) and more years of heavy drinking (OR = 1.04, p =.03, 95% CI [1.00-1.07]) were also significantly associated with treatment engagement.This study replicates previous findings suggesting a need for additional retention strategies for younger women with dependents in comorbid PTSD and alcohol use disorder treatment. This is an analysis of data collected as part of a clinical trial registered as NCT00607412, at www.clinicaltrials.gov.

Guilt related to combat trauma is highly prevalent among veterans returning from Iraq and Afghanistan. Trauma-related guilt has been associated with increased risk for posttraumatic psychopathology and poorer response to treatment. Trauma Informed Guilt Reduction (TrIGR) therapy is a 4-module cognitive-behavioral psychotherapy designed to reduce guilt related to combat trauma. The goals of this study were to describe the key elements of TrIGR and report results of a pilot study with 10 recently deployed combat veterans. Ten combat veterans referred from a VA Posttraumatic Stress Disorder (PTSD) or mental health clinic completed TrIGR over 4 to 7 sessions. Nine veterans completed the posttreatment assessment. This initial pilot suggests that TrIGR may help to reduce trauma-related guilt severity and associated distress. Changes in trauma-related guilt were highly correlated with reductions in PTSD and depression symptoms over the course of treatment, suggesting a possible mechanistic link with severity of posttraumatic psychopathology. TrIGR warrants further evaluation as an intervention for reducing guilt related to traumatic experiences in combat.

Understanding how alcohol expectancies relate to alcohol use among individuals with concurrent alcohol use disorder (AUD) and posttraumatic stress disorder (PTSD) is important to understanding and treating this comorbidity. This study examined the role of positive and negative alcohol expectancies and PTSD symptoms in drinking behavior in a comorbid female sample. Participants were women (n = 33; 56% Caucasian) seeking AUD and PTSD treatment in an outpatient community co-occurring disorders program. Hypotheses related to drinking days and alcohol problems outcomes were evaluated using negative binomial hierarchical regression. PTSD symptoms were associated with fewer reported days of alcohol-related problems. Negative expectancies related to negative changes in social behavior associated with drinking days and cognitive and motor impairment associated with problems. Both the general positive expectancies score and specific global positive change subscale were uniquely associated with drinking and alcohol-related problems days after controlling for PTSD symptom severity and negative expectancies scores. Results suggest that both negative and positive expectancies about alcohol's effects are important correlates of drinking behavior among women with AUD and PTSD, with positive expectancies playing a potentially more salient role on use and consequences than symptom severity and negative expectancies.

In spite of evidence suggesting two possible mechanisms related to drug-seeking behavior, namely reward-seeking and harm avoidance, much of the addiction literature has focused largely on positive incentivization mechanisms associated with addiction. In this study, we examined the contributing neural mechanisms of avoidance of an aversive state to drug-seeking behavior during marijuana withdrawal. To that end, marijuana users were scanned while performing the monetary incentive delay task in order to assess positive and negative incentive processes. The results showed a group x incentive interaction, such that marijuana users had greater response in areas that underlie reward processes during positive incentives while controls showed greater response in the same areas, but to negative incentives. Furthermore, a negative correlation between withdrawal symptoms and response in the amygdala during negative incentives was found in the marijuana users. These findings suggest that although marijuana users have greater reward sensitivity and less harm avoidance than controls, that attenuated amygdala response, an area that underlies fear and avoidance, was present in marijuana users with greater marijuana withdrawal symptoms. This is concordant with models of drug addiction that involve multiple sources of reinforcement in substance use disorders, and suggests the importance of strategies that focus on respective mechanisms.

Posttraumatic stress disorder (PTSD) and alcohol/substance use disorder (A/SUD) are frequently comorbid. Comorbidity is associated with poorer psychological, functional, and treatment outcomes than either disorder alone. This review outlines biological mechanisms that are potentially involved in the development and maintenance of comorbid PTSD and A/SUD including neurotransmitter and hypothalamic–pituitary–adrenal dysregulation, structural differences in the brain, and shared genetic risk factors. The literature regarding pharmacological treatments that have been investigated for comorbid PTSD and A/SUD is also reviewed. Empirical data for each proposed mechanism and pharmacological approach is reviewed with the goal of making recommendations for future research. This article is part of a Special Issue entitled ‘Post-Traumatic Stress Disorder’.