Skip to main content

Advertisement

SpringerLink
Log in

Is Integrated CBT Effective in Reducing PTSD Symptoms and Substance Use in Iraq and Afghanistan Veterans? Results from a Randomized Clinical Trial

  • Original Article
  • Published:
Cognitive Therapy and Research Aims and scope Submit manuscript

Abstract

This study is the first to examine integrated cognitive behavioral therapy (ICBT) in a sample of military veterans with co-occurring posttraumatic stress disorder (PTSD) and substance use disorders (SUD). Generalized linear mixed models were used to examine primary outcomes from a small, randomized clinical trial comparing ICBT plus treatment as usual (TAU) to TAU only in a sample (N = 44) of U.S. veterans who served in Iraq and/or Afghanistan. A significant reduction in PTSD and SUD symptoms over time was detected in both conditions. One significant time-by-condition interaction effect for re-experiencing symptoms was observed, with ICBT showing greater reductions from baseline to post-treatment. Overall, the efficacy of ICBT in this veteran sample was not as robust as outcomes with non-veteran patients. Challenges to engagement and retention in treatment and further intervention adaptations for veterans are discussed.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1
Fig. 2
Fig. 3

Similar content being viewed by others

References

  • Barrera, T. L., Mott, J. M., Hofstein, R. F., & Teng, E. J. (2013). A meta-analytic review of exposure in group cognitive behavioral therapy for posttraumatic stress disorder. Clinical Psychology Review, 33(1), 24–32. https://doi.org/10.1016/j.cpr.2012.09.005.

    Article  CAS  PubMed  Google Scholar 

  • Blake, D. D., Weathers, F. W., Nagy, L. M., Kaloupek, D. G., Gusman, F. D., Charney, D. S., & Keane, T. M. (1995). The development of a Clinician-Administered PTSD Scale. Journal of Traumatic Stress, 8(1), 75–90. https://doi.org/10.1002/jts.2490080106.

    Article  CAS  PubMed  Google Scholar 

  • Boden, M. T., Kimerling, R., Jacobs-Lentz, J., Bowman, D., Weaver, C., Carney, D., … Trafton, J. A. (2012). Seeking safety treatment for male veterans with a substance use disorder and post-traumatic stress disorder symptomatology. Addiction, 107(3), 578–586. https://doi.org/10.1111/j.1360-0443.2011.03658.x.

    Article  PubMed  Google Scholar 

  • Brady, K. T., Back, S. E., & Coffey, S. F. (2004). Substance abuse and posttraumatic stress disorder. Current Directions in Psychological Science, 13(5), 206–209. https://doi.org/10.1111/j.0963-7214.2004.00309.x.

    Article  Google Scholar 

  • Brady, K. T., Dansky, B. S., Back, S. E., Foa, E. B., & Carroll, K. M. (2001). Exposure therapy in the treatment of PTSD among cocaine-dependent individuals: Preliminary findings. Journal of Substance Abuse Treatment, 21(1), 47–54.

    Article  CAS  Google Scholar 

  • Breslau, N., Davis, G. C., Peterson, E. L., & Schultz, L. (1997). Psychiatric sequelae of posttraumatic stress disorder in women. Archives of General Psychiatry, 54(1), 81–87.

    Article  CAS  Google Scholar 

  • Calabrese, J. R., Prescott, M., Tamburrino, M., Liberzon, I., Slembarski, R., Goldmann, E.,.. . Galea, S. (2011). PTSD comorbidity and suicidal ideation associated with PTSD within the Ohio Army National Guard. Journal of Clinical Psychiatry, 72(8), 1072–1078. https://doi.org/10.4088/JCP.11m06956.

    Article  PubMed  Google Scholar 

  • Capone, C., Eaton, E., McGrath, A. C., & McGovern, M. P. (2014). Integrated Cognitive Behavioral Therapy (ICBT) for PTSD and substance use in Iraq and Afganistan Veterans: A feasibility study. Journal of Traumatic Stress Disorders and Treatment. https://doi.org/10.4172/2324-8947.1000134.

    Article  PubMed  Google Scholar 

  • Cook, J. M., Kane, D. W. R., Ruzek, V., J. I., & Woody, G. (2006). Dissemination and feasibility of a cognitive-behavioral treatment for substance use disorders and posttraumatic stress disorder in the Veterans Administration. Journal of Psychoactive Drugs, 38(1), 89–92.

    Article  Google Scholar 

  • Cook, J. M., Schnurr, P. P., & Foa, E. B. (2004). Bridging the gap between posttraumatic stress disorder research and clinical practice: The example of exposure therapy. Psychotherapy: Theory, Research, Practice, Training, 41, 374–387.

    Article  Google Scholar 

  • First, M. B., Spitzer, R. L., Gibbon, M., & Williams, J. B. W. (2002). Structured clinical interview for DSM-IV-TR Axis I disorders, research version, patient edition (SCID-I/P). New York: Biometrics Research, New York State Psychiatric Institute.

    Google Scholar 

  • Fitzmaurice, G. M., Laird, N. M., & Ware, J. H. (2011). Applied longitudinal analysis. Trenton, NJ: Wiley.

    Google Scholar 

  • Foa, E. B., Hembree, E. A., & Rothbaum, B. O. (2007). Prolonged exposure therapy for PTSD. New York: Oxford University Press.

    Google Scholar 

  • Foa, E. B., Yusko, D. A., McLean, C. P., Suvak, M. K., Bux, D. A. Jr., Oslin, D., … Volpicelli, J. (2013). Concurrent naltrexone and prolonged exposure therapy for patients with comorbid alcohol dependence and PTSD: A randomized clinical trial. JAMA, 10(5), 488–495. https://doi.org/10.1001/jama.2013.8268.

    Article  CAS  Google Scholar 

  • Haller, M., Myers, U. S., McKnight, A., Angkaw, A. C., & Norman, S. B. (2016). Predicting engagement in psychotherapy, pharmacotherapy, or both psychotherapy and pharmacotherapy among returning veterans seeking PTSD treatment. Psychological Services, 13(4), 341–348. https://doi.org/10.1037/ser0000093.

    Article  PubMed  Google Scholar 

  • Hien, D. A., Wells, E. A., Jiang, H., Suarez-Morales, L., Campbell, A. N., Cohen, L. R., … Nunes, E. V. (2009). Multisite randomized trial of behavioral interventions for women with co-occurring PTSD and substance use disorders. Journal of Consulting and Clinical Psychology, 77(4), 607–619.

    Article  Google Scholar 

  • Hoge, C. W., Grossman, S. H., Auchterlonie, J. L., Riviere, L. A., Milliken, C. S., & Wilk, J. E. (2014). PTSD treatment for soldiers after combat deployment: Low utilization of mental health care and reasons for dropout. Psychiatric Services. https://doi.org/10.1176/appi.ps.201300307.

    Article  PubMed  Google Scholar 

  • IBM Corporation. (2013). SPSS Statistics for Windows, Version 22.0. Armonk, NY: IBM Corpotation.

    Google Scholar 

  • Jacobsen, L. K., Southwick, S. M., & Kosten, T. R. (2001). Substance use disorders in patients with posttraumatic stress disorder: A review of the literature. The American Journal of Psychiatry, 158(8), 1184–1190. https://doi.org/10.1176/appi.ajp.158.8.1184.

    Article  CAS  PubMed  Google Scholar 

  • Kehle-Forbes, S. M., Meis, L. A., Spoont, M. R., & Polusny, M. A. (2016). Treatment initiation and dropout from prolonged exposure and cognitive processing therapy in a VA outpatient clinic. Psychological Trauma, 8(1), 107–114. https://doi.org/10.1037/tra0000065.

    Article  PubMed  Google Scholar 

  • McGovern, M. P., Lambert-Harris, C., Alterman, A. I., Xie, H., & Meier, A. (2011). A randomized controlled trial comparing integrated cognitive behavioral therapy versus individual addiction counseling for co-occurring substance use and posttraumatic stress disorders. Journal of Dual Diagnosis, 7(4), 207–227. https://doi.org/10.1080/15504263.2011.620425.

    Article  PubMed  PubMed Central  Google Scholar 

  • McGovern, M. P., Lambert-Harris, C., Xie, H., Meier, A., McLeman, B., & Saunders, E. C. (2015). A randomized controlled trial of treatments for co-occurring substance use disorders and PTSD. Addiction, 110(7), 1194–1204. https://doi.org/10.1111/add.12943.

    Article  PubMed  PubMed Central  Google Scholar 

  • McGovern, M. P., Mueser, K. T., Hamblen, J. L., & Jankowski, M. K. (2010). Cognitive-behavioral therapy for PTSD: A program for addiction professionals. Center City, MN: Hazelden.

    Google Scholar 

  • McLellan, A. T., Alterman, A. I., Woody, G. E., & Metzger, D. (1992). A quantitative measure of substance use treatments: The Treatment Services Review. Journal of Nervous and Mental Disease, 180, 101–110.

    Article  CAS  Google Scholar 

  • McLellan, A. T., Luborsky, L., Cacciola, J., Griffith, J., Evans, F., Barr, H. L., & O’Brien, C. P. (1985). New data from the Addiction Severity Index: Reliability and validity in three centers. Journal of Nervous and Mental Disease, 173(7), 412–423. https://doi.org/10.1097/00005053-198507000-00005.

    Article  CAS  PubMed  Google Scholar 

  • Meier, A., McGovern, M. P., Lambert-Harris, C., McLeman, B., Franklin, A., Saunders, E. C., & Xie, H. (2015). Adherence and competence in two manual-guided therapies for co-occurring substance use and posttraumatic stress disorders: Clinician factors and patient outcomes. American Journal of Drug and Alcohol Abuse, 41(6), 527–534.

    PubMed  Google Scholar 

  • Mills, K. L., Barrett, E. L., Merz, S., Rosenfeld, J., Ewer, P. L., Sannibale, C., … Teesson, M. (2016). Integrated exposure-based therapy for co-occurring post traumatic stress disorder (PTSD) and substance dependence: Predictors of change in PTSD symptom severity. Journal of Clinical Medicine. https://doi.org/10.3390/jcm5110101.

    Article  PubMed  PubMed Central  Google Scholar 

  • Mills, K. L., Teesson, M., Back, S. E., Brady, K. T., Baker, A. L., Hopwood, S., … Ewer, P. L. (2012). Integrated exposure-based therapy for co-occurring posttraumatic stress disorder and substance dependence: A randomized controlled trial. The Journal of the American Medical Association, 308(7), 690–699. https://doi.org/10.1001/jama.2012.9071;10.1001/jama.2012.9071.

    Article  CAS  PubMed  Google Scholar 

  • Najavits, L. M., Krinsley, K., Waring, M. E., Gallagher, M. W., & Skidmore, C. (2018). A randomized controlled trial for veterans with PTSD and substance use disorder: Creating change versus seeking safety. Substance Use and Misuse. https://doi.org/10.1080/10826084.2018.1432653.

    Article  PubMed  Google Scholar 

  • Najavits, L. M., Lande, R. G., Gragnani, C., Isenstein, D., & Schmitz, M. (2016). Seeking safety pilot outcome study at Walter Reed National Military Medical Center. Military Medicine, 181(8), 740–746. https://doi.org/10.7205/milmed-d-15-00270.

    Article  PubMed  Google Scholar 

  • Najavits, L. M., Weiss, R. D., Shaw, S. R., & Muenz, L. R. (1998). Seeking safety: Outcome of a new cognitive-behavioral psychotherapy for women with posttraumatic stress disorder and substance dependence. Journal of Traumatic Stress, 11(3), 437–456. https://doi.org/10.1023/a:1024496427434.

    Article  CAS  PubMed  Google Scholar 

  • Norman, S. B., Tate, S. R., Anderson, K. G., & Brown, S. A. (2007). Do trauma history and PTSD symptoms influence addiction relapse context? Drug and Alcohol Dependence, 90(1), 89–96. https://doi.org/10.1016/j.drugalcdep.2007.03.002.

    Article  PubMed  Google Scholar 

  • Norman, S. B., Wilkins, K. C., Tapert, S. F., Lang, A. J., & Najavits, L. M. (2010). A pilot study of seeking safety therapy with OEF/OIF veterans. Journal of Psychoactive Drugs, 42(1), 83–87.

    Article  Google Scholar 

  • Ouimette, P. C., Brown, P. J., & Najavits, L. M. (1998). Course and treatment of patients with both substance use and posttraumatic stress disorders. Addictive Behaviors, 23(6), 785–795.

    Article  CAS  Google Scholar 

  • Ouimette, P. C., Moos, R. H., & Finney, J. W. (2003). PTSD treatment and 5-year remission among patients with substance use and posttraumatic stress disorders. Journal of Consulting and Clinical Psychology, 71(2), 410–414. https://doi.org/10.1037/0022-006X.71.2.410.

    Article  PubMed  Google Scholar 

  • Resick, P. A., Wachen, J. S., Dondanville, K. A., Pruiksma, K. E., Yarvis, J. S., Peterson, A. L., … Young-McCaughan, S. (2017). Effect of group vs individual Cognitive Processing Therapy in active-duty military seeking treatment for posttraumatic stress disorder: A randomized clinical trial. JAMA Psychiatry, 74(1), 28–36. https://doi.org/10.1001/jamapsychiatry.2016.2729.

    Article  PubMed  Google Scholar 

  • Roberts, N. P., Roberts, P. A., Jones, N., & Bisson, J. I. (2015). Psychological interventions for post-traumatic stress disorder and comorbid substance use disorder: A systematic review and meta-analysis. Clinical Psychology Review, 38, 25–38. https://doi.org/10.1016/j.cpr.2015.02.007.

    Article  PubMed  Google Scholar 

  • Rosen, C. S., Chow, H. C., Finney, J. F., Greenbaum, M. A., Moos, R. H., Sheikh, J. I., & Yesavage, J. A. (2004). VA practice patterns and practice guidelines for treating posttraumatic stress disorder. Journal of Traumatic Stress, 17(3), 213–222. https://doi.org/10.1023/b:jots.0000029264.23878.53.

    Article  PubMed  Google Scholar 

  • Rosen, C. S., Henson, B. R., Finney, J. W., & Moos, R. H. (2000). Consistency of self-administered and interview-based Addiction Severity Index composite scores. Addiction, 95(3), 419–425.

    Article  CAS  Google Scholar 

  • Rounsaville, B. J., Carroll, K. M., & Onken, L. S. (2001). A stage model of behavioral therapies research: Getting started and moving on from Stage I. Clinical Psychology: Science and Practice, 8(2), 133–142.

    Google Scholar 

  • Ruzek, J. I., Eftekhari, A., Rosen, C. S., Crowley, J. J., Kuhn, E., Foa, E. B., … Karlin, B. E. (2014). Factors related to clinician attitudes toward prolonged exposure therapy for PTSD. Journal of Traumatic Stress, 27(4), 423–429. https://doi.org/10.1002/jts.21945.

    Article  PubMed  Google Scholar 

  • Schafer, J. L., & Graham, J. W. (2002). Missing data: Our view of the state of the art. Psychological Methods, 7(2), 147–177.

    Article  Google Scholar 

  • Seal, K. H., Cohen, G., Waldrop, A. E., Cohen, B. E., Maguen, S., & Ren, L. (2011). Substance use disorders in Iraq and Afghanistan veterans in VA healthcare, 2001–2010: Implications for screening, diagnosis and treatment. Drug and Alcohol Dependence, 116(1–3), 93–101. https://doi.org/10.1016/j.drugalcdep.2010.11.027.

    Article  PubMed  Google Scholar 

  • Seal, K. H., Maguen, S., Cohen, B., Gima, K. S., Metzler, T. J., Ren, L., … Marmar, C. R. (2010). VA mental health services utilization in Iraq and Afghanistan veterans in the first year of receiving new mental health diagnoses. Journal of Traumatic Stress, 23(1), 5–16. https://doi.org/10.1002/jts.20493.

    Article  PubMed  Google Scholar 

  • Sobell, L. C., Maisto, S. A., Sobell, M. B., & Cooper, A. M. (1979). Reliability of alcohol abusers’ self-reports of drinking behavior. Behavioral Research and Therapy, 17(2), 157–160. https://doi.org/10.1016/0005-7967(79)90025-1.

    Article  CAS  Google Scholar 

  • Steenkamp, M. M., & Litz, B. T. (2013). Psychotherapy for military-related posttraumatic stress disorder: Review of the evidence. Clinical Psychology Review, 33(1), 45–53. https://doi.org/10.1016/j.cpr.2012.10.002.

    Article  PubMed  Google Scholar 

  • Szafranski, D. D., Snead, A., Allan, N. P., Gros, D. F., Killeen, T., Flanagan, J., … Back, S. E. (2017). Integrated, exposure-based treatment for PTSD and comorbid substance use disorders: Predictors of treatment dropout. Addictive Behaviors, 73, 30–35. https://doi.org/10.1016/j.addbeh.2017.04.005.

    Article  PubMed  PubMed Central  Google Scholar 

Download references

Funding

This study was funded by the National Institute on Drug Abuse (NIDA; Grant R01DA030102).

Author information

Authors and Affiliations

  1. Providence VA Medical Center, Providence, RI, USA

    Christy Capone, Candice Presseau & Erica Eaton

  2. Department of Psychiatry and Human Behavior, Brown University, Providence, RI, USA

    Christy Capone & Erica Eaton

  3. Massachusetts Veterans Epidemiology Research and Information Center (MAVERIC), VA Boston Healthcare System, Boston, MA, USA

    Candice Presseau

  4. The Dartmouth Institute (TDI) for Health Policy and Clinical Practice, Lebanon, NH, USA

    Elizabeth Saunders & Jessica Hamblen

  5. National Center for PTSD, White River Junction, VT, USA

    Jessica Hamblen

  6. Stanford University School of Medicine, Palo Alto, CA, USA

    Mark McGovern

Authors
  1. Christy Capone
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Candice Presseau
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Elizabeth Saunders
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Erica Eaton
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Jessica Hamblen
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. Mark McGovern
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Christy Capone.

Ethics declarations

Conflict of interest

Christy Capone, Candice Presseau, Elizabeth Saunders, Erica Eaton, Jessica Hamblen and Mark McGovern declare that they have no conflicts of interest.

Ethical Approval

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.

Informed Consent

Informed consent was obtained from all individual participants included in the study.

Animal Rights

This article does not contain any studies with animals performed by any of the authors.

Additional information

Disclaimer

The views expressed in this article are those of the authors and do not necessarily reflect the views of the Department of Veterans Affairs or the United States government.

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Capone, C., Presseau, C., Saunders, E. et al. Is Integrated CBT Effective in Reducing PTSD Symptoms and Substance Use in Iraq and Afghanistan Veterans? Results from a Randomized Clinical Trial. Cogn Ther Res 42, 735–746 (2018). https://doi.org/10.1007/s10608-018-9931-8

Download citation

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s10608-018-9931-8

Keywords

Search

Navigation