A randomized clinical trial in Sweden found that integrated trauma-focused therapy significantly reduced PTSD symptom severity in women with comorbid alcohol use disorder, compared with standard relapse prevention therapy. 

Findings

PTSD Symptoms

In the integrated Concurrent Treatment of Post-Traumatic Stress Disorder (PTSD) and Substance Use Disorders Using Prolonged Exposure (COPE) treatment group, the mean Clinician-Administered PTSD Scale for DSM-5 (CAPS-5) score decreased from 37 at baseline to 13 at 9 months—a statistically significant difference. In the relapse prevention group, the mean score dropped from 39 to 24. Self-reported PTSD symptoms also declined in both groups, with a significantly greater decrease in the integrated treatment group. 

AUD

Alcohol use also declined over time in both groups. In the COPE treatment group, weekly alcohol consumption fell from 144 g to 93 g. In the relapse prevention group, it declined from 133 g to 78 g. The difference between groups was not statistically significant. No significant changes were observed in phosphatidylethanol (PEth) levels, but at 9 months, they were 0.69 μmol/L in the integrated group and 0.29 μmol/L in the relapse prevention group (from 0.68 μmol/L in the integrated group and 0.45 μmol/L in the relapse prevention group at baseline).

Methods

The primary outcomes were changes in PTSD symptom severity and weekly alcohol use over a 9-month period. PTSD severity was assessed using CAPS-5, while alcohol use was measured using self-reported Timeline Followback and the PEth biomarker. Participants were randomized to receive 12 weekly individual sessions of either COPE integrated therapy or relapse prevention therapy across 3 outpatient addiction services in Sweden. 

COPE therapy combines evidence-based interventions for PTSD and substance use disorder (SUD), including prolonged exposure (imaginal and in vivo), psychoeducation on both conditions and their interplay, and SUD coping skills. Sessions lasted between 60 and 90 minutes weekly. Staff completed a 3-day training before administering the the intervention, followed by supervision from trained psychologists every 2 weeks. 

The relapse prevention arm used the Project MATCH Cognitive-Behavioral Coping Skills Therapy Manual, which is designed to address substance use. Participants' weekly sessions of 45 to 60 minutes each focused on:

• Awareness and management of cravings

• Cognitive restructuring around substance use

• Refusal skills training

• Managing negative moods and depression

• Assertiveness

• Anger awareness and regulation

Unlike COPE, the relapse prevention arm did not include trauma-focused exposure therapy. Treatment providers for this arm—primarily registered nurses or social workers with prior experience in substance use therapy—received 1 day of refresher training before delivering relapse prevention.

Participant Demographics and History

The trial enrolled 90 women (mean age = 45 years) who met DSM-5 criteria for PTSD and moderate-to-severe alcohol use disorder (AUD). The median duration of PTSD symptoms was 8 years. Median duration for AUD symptoms was 6 years. 

Participants reported complex trauma histories. Most had experienced multiple types of trauma: 64% reported trauma during childhood, and the mean number of trauma types was 6.9. Lifetime sexual abuse was reported by 41% of participants. The most common index traumas were:

• Physical assault (31%)

• Sexual assault (30%)

• Assault with a weapon (9%)

• Sudden accidental death (8%)

• Other trauma types (19%)

"They also had multiple psychiatric comorbidities in addition to PTSD and AUD," wrote the authors, led by Anna Persson, MSc, of the Centre for Psychiatry Research at Karolinska Institutet in Stockholm. They noted that these comorbidities included dissociative symptoms.

Adherence and Dropout

For COPE treatment, 7.5% of sessions were monitored for fidelity by a prolonged exposure trainer. The mean rating of 3 indicated good treatment adherence.

For relapse prevention, 24% of sessions were fidelity-monitored by a licensed psychotherapist. Ratings averaged 3.6 out of 5, which indicated adequate to good adherence. A total of 62.2% of participants completed all 12 therapy sessions. Dropout rates did not differ significantly between groups.

"Trauma-focused treatments are effective for PTSD but are rarely offered to patients with comorbid SUD," the authors wrote. “This trial indicates that integrated treatment for comorbid PTSD and SUD significantly reduces PTSD symptom severity in women with PTSD and AUD and ongoing alcohol use, and is associated with similar reductions in alcohol use as relapse prevention."

Full disclosures can be found in the published study.

Source: JAMA Network Open