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Trauma-focused treatment for comorbid post-traumatic stress and substance use disorder

  • Review article
  • Published:

From Nature Reviews Psychology

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Abstract

Trauma-focused treatments — psychotherapies that focus on trauma as a central component of treatment and use cognitive, emotional or behavioural techniques to facilitate the processing of a traumatic experience — are first-line interventions for post-traumatic stress disorder (PTSD). Although trauma-focused interventions are effective in treating PTSD and comorbid substance use disorder (SUD), these treatments are underused. Further, this comorbidity remains difficult to treat, with smaller treatment effect sizes and higher dropout rates than for PTSD alone. In this narrative Review, we examine the literature from clinical trials of trauma-focused treatment for patients with PTSD + SUD that might elucidate the attenuated treatment response and high rates of dropout. We first provide an overview of effective treatment for PTSD + SUD with respect to PTSD and substance use outcomes. We then review predictors of attendance and outcome in clinical trials evaluating trauma-focused treatments for PTSD + SUD. Next, we discuss possible strategies to improve response and reduce dropout in treatment for PTSD + SUD. Altogether, this Review provides the basis for recommendations for future research designed to improve treatment attendance and response and to increase the availability and reach of trauma-focused treatments for this population.

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Fig. 1: Pathways for PTSD and SUD, and their co-occurrence.

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Acknowledgements

The authors thank A. Klein and P. Hitchcock for comments on earlier versions of this manuscript.

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Authors and Affiliations

  1. Mental Health Service, VA San Diego Healthcare System, San Diego, CA, USA

    Alexander C. Kline, Kaitlyn E. Panza, Robert Lyons & Sonya B. Norman

  2. Department of Psychiatry, University of California San Diego, San Diego, CA, USA

    Alexander C. Kline, Kaitlyn E. Panza & Sonya B. Norman

  3. San Diego Joint Doctoral Program in Clinical Psychology, San Diego State University and University of California, San Diego, CA, USA

    Robert Lyons

  4. Center for Care Delivery and Outcomes Research, Minneapolis VA Healthcare System, Minneapolis, MN, USA

    Shannon M. Kehle-Forbes

  5. Department of Medicine, University of Minnesota, Minneapolis, MN, USA

    Shannon M. Kehle-Forbes

  6. Women’s Health Sciences Division, National Center for PTSD, Boston, MA, USA

    Shannon M. Kehle-Forbes

  7. Center of Alcohol & Substance Use Studies, Rutgers University, New Brunswick, NJ, USA

    Denise A. Hien

  8. Executive Division, National Center for PTSD, White River Junction, VT, USA

    Sonya B. Norman

  9. Center of Excellence for Stress and Mental Health, VA San Diego, San Diego, CA, USA

    Sonya B. Norman

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A.C.K. and S.B.N. developed the idea and outline for the manuscript. K.E.P. and R.L. researched data for the manuscript. All authors contributed substantially to discussion of the content. All authors wrote the article. All authors reviewed and/or edited the manuscript before submission.

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Kline, A.C., Panza, K.E., Lyons, R. et al. Trauma-focused treatment for comorbid post-traumatic stress and substance use disorder. Nat Rev Psychol 2, 24–39 (2023). https://doi.org/10.1038/s44159-022-00129-w

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