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Cognitive Therapy and Research

, Volume 42, Issue 6, pp 735–746 | Cite as

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

  • Christy Capone
  • Candice Presseau
  • Elizabeth Saunders
  • Erica Eaton
  • Jessica Hamblen
  • Mark McGovern
Original Article

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.

Keywords

Posttraumatic stress disorder Substance use Veterans Cognitive behavioral therapy Treatment outcomes 

Notes

Funding

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

Compliance with Ethical Standards

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.

References

  1. 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.CrossRefPubMedGoogle Scholar
  2. 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.CrossRefPubMedGoogle Scholar
  3. 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.CrossRefPubMedGoogle Scholar
  4. 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.CrossRefGoogle Scholar
  5. 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.CrossRefGoogle Scholar
  6. 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.CrossRefGoogle Scholar
  7. 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.CrossRefPubMedGoogle Scholar
  8. 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.CrossRefPubMedGoogle Scholar
  9. 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.CrossRefGoogle Scholar
  10. 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.CrossRefGoogle Scholar
  11. 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
  12. Fitzmaurice, G. M., Laird, N. M., & Ware, J. H. (2011). Applied longitudinal analysis. Trenton, NJ: Wiley.Google Scholar
  13. Foa, E. B., Hembree, E. A., & Rothbaum, B. O. (2007). Prolonged exposure therapy for PTSD. New York: Oxford University Press.Google Scholar
  14. 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.CrossRefGoogle Scholar
  15. 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.CrossRefPubMedGoogle Scholar
  16. 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.CrossRefGoogle Scholar
  17. 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.CrossRefPubMedGoogle Scholar
  18. IBM Corporation. (2013). SPSS Statistics for Windows, Version 22.0. Armonk, NY: IBM Corpotation.Google Scholar
  19. 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.CrossRefPubMedGoogle Scholar
  20. 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.CrossRefPubMedGoogle Scholar
  21. 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.CrossRefPubMedPubMedCentralGoogle Scholar
  22. 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.CrossRefPubMedPubMedCentralGoogle Scholar
  23. 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
  24. 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.CrossRefGoogle Scholar
  25. 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.CrossRefPubMedGoogle Scholar
  26. 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.PubMedGoogle Scholar
  27. 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.CrossRefPubMedPubMedCentralGoogle Scholar
  28. 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.CrossRefPubMedGoogle Scholar
  29. 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.CrossRefPubMedGoogle Scholar
  30. 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.CrossRefPubMedGoogle Scholar
  31. 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.CrossRefPubMedGoogle Scholar
  32. 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.CrossRefPubMedGoogle Scholar
  33. 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.CrossRefGoogle Scholar
  34. 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.CrossRefGoogle Scholar
  35. 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.CrossRefPubMedGoogle Scholar
  36. 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.CrossRefPubMedGoogle Scholar
  37. 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.CrossRefPubMedGoogle Scholar
  38. 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.CrossRefPubMedGoogle Scholar
  39. 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.CrossRefGoogle Scholar
  40. 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
  41. 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.CrossRefPubMedGoogle Scholar
  42. Schafer, J. L., & Graham, J. W. (2002). Missing data: Our view of the state of the art. Psychological Methods, 7(2), 147–177.CrossRefGoogle Scholar
  43. 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.CrossRefPubMedGoogle Scholar
  44. 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.CrossRefPubMedGoogle Scholar
  45. 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.CrossRefGoogle Scholar
  46. 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.CrossRefPubMedGoogle Scholar
  47. 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.CrossRefPubMedPubMedCentralGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC, part of Springer Nature 2018

Authors and Affiliations

  1. 1.Providence VA Medical CenterProvidenceUSA
  2. 2.Department of Psychiatry and Human BehaviorBrown UniversityProvidenceUSA
  3. 3.Massachusetts Veterans Epidemiology Research and Information Center (MAVERIC), VA Boston Healthcare SystemBostonUSA
  4. 4.The Dartmouth Institute (TDI) for Health Policy and Clinical PracticeLebanonUSA
  5. 5.National Center for PTSDWhite River JunctionUSA
  6. 6.Stanford University School of MedicinePalo AltoUSA

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