Cognitive Behavior Therapy Helpful for PTSD and Alcohol Abuse

April 26, 2013


Last Updated: 2013-04-26 17:13:26 -0400 (Reuters Health)

NEW YORK (Reuters Health) - Cognitive behavior therapy (CBT) helps people who have severe and complex post-traumatic stress disorder (PTSD) coexisting with alcohol use disorders (AUD), new research suggests.

The therapeutic effects of CBT on PTSD, AUD and psychopathology can be significant and well-maintained, the authors said in their report.

"These findings suggest that CBT, widely used to treat alcohol-related problems, is associated with clinically significant improved functioning of people affected by these problems," said lead investigator Dr. Claudia Sannibale of the National Drug and Alcohol Research Centre of the University of New South Wales in Sydney, Australia, in an email to Reuters Health.

The authors tested whether combining existing therapies for AUD and PTSD would produce better outcomes than treating AUD only.

To compare the efficacy of integrated exposure-based CBT (IT) for PTSD and AUD vs CBT for AUD plus supportive counseling, they conducted a randomized clinical trial of adults in clinics in and around Sydney. They published their findings online April 4th in Addiction.

Over two years, they recruited participants who consumed alcohol at hazardous levels and met the PTSD criteria of the Diagnostic and Statistical Manual of Mental Disorder (4th ed; DSM-IV), as determined by the clinician-administered PTSD scale (CAPS).

A hazardous drinking level was defined in men as at least 29 10-g ethanol drinks per week, and in women as 15 or more per week.

AUD was diagnosed according to the Structured Clinical Interview (SCID) DSM-IV. Participants on stable pharmacotherapy for depression or alcohol dependence were eligible, as were participants who needed and completed alcohol withdrawal. Participants were excluded if they were younger than 18 years of age, had current psychosis, severe suicide risk, significant cognitive impairment, limited English comprehension or severe substance dependence.

Of the 154 participants screened by telephone, 90 met the study criteria. The 62 who agreed to participate were randomized to either the IT group (n = 33) or the Alcohol Support (AS) group (n = 29). All available participants were re-assessed at follow-up without regard to treatment attendance.

The mean age was 42 in the IT group and 40 in the AS group. The IT group was 58% female; the AS group was 48% female.

Thirty participants (91%) in the IT group and 29 (100%) in the AS group were alcohol-dependent.

The authors held 12 weekly individual sessions with IT patients consisting of IT for PTSD and AUD, and with the AS group consisting of CBT for AUD plus supportive counseling. They conducted blind assessments at baseline, at the end of the treatment period, and again five months later.

Outcomes included changes in alcohol consumption, PTSD severity on CAPS, alcohol dependence and problems, and depression and anxiety.

Forty-eight participants (77%) completed two or more follow-ups, 56 patients (90%) completed at least one, and six (10%) were lost to follow-up.

The authors found reductions in PTSD severity in both groups. On adjusted analysis, IT participants who received one or more sessions of exposure therapy showed a two-fold greater rate of clinically significant change in CAPS severity at follow-up than AS participants (60% vs 39%, odds ratio OR 2.31).

AS participants, who received more treatment from other services during follow-up, showed even larger reductions than IT participants in alcohol consumption, dependence and problems, and by nine months post-treatment the rate of diagnosis of AUD among participants was down to 48%.

"We found that individuals with complex presentations of alcohol problems and post-traumatic stress disorders can benefit significantly from effective treatment of alcohol use disorders, with greater benefit associated with exposure therapy for psychological trauma," Dr. Sannibale said in an email.

"This study confirms data that many people with PTSD and other anxiety disorders have co-morbid substance use disorders, particularly alcohol misuse. Exposure therapy also is crucial for treating PTSD, even in the context of alcohol misuse," said Dr. Raymond J. Kotwicki, Chief Medical Officer of Skyland Trail and Associate Professor of Psychiatry and Behavioral Sciences of the Emory University School of Medicine in Atlanta, Georgia, in an email.

"It suggests, though, that perhaps exposure therapy may increase alcohol use in patients who participate in re-experiencing of their traumas," he added. Dr. Kotwicki was not involved in the study.

Dr. Benjamin Druss, Rosalynn Carter Chair in Mental Health of the Department of Health Policy and Management at the Rollins School of Public Health, also at Emory, told Reuters Health in an email, "Comorbidity between mental disorders such as PTSD and substance use disorders is the rule rather than the exception. This is one of the very few studies that has looked at the benefits of treating both types of conditions in an integrated fashion."

"The findings suggest that, for patients with comorbid conditions, treating both conditions at once may result in important benefits over just treating one at a time. We need to build systems of care that are able to deliver these sorts of integrated interventions for people living with substance use and mental conditions," he added. Dr. Druss was not involved in the study.

Dr. Kotwicki observed, "There seems to be suggestive evidence that alcohol use disorders maintain symptoms of PTSD and may be causally related. I don't believe that the evidence from this study is sufficient to make that assertion. The key for me is that substance use disorders MUST be treated concurrently with PTSD and other mental illnesses in order for either to maximally improve."

"Integrating exposure-based CBT psychotherapy into out-patient treatment for PTSD in patients with co-morbid alcohol use disorders may be a wise clinical choice," he added.

He also noted that the study didn't address alcohol use disorders in family members. "We know that alcohol dependence runs in families as its own genetically-based illness unrelated to PTSD or trauma history. Rates of continued alcohol misuse may be more related to that genetic diathesis rather than a part of participants' PTSD," he said.

Dr. Kotwicki also thought the rates of pharmacotherapy for depression and alcohol treatment were "quite low" in this study. "We know from many other studies that combined medication and psychotherapy are symbiotic and yield superior clinical outcomes. If study participants who were not currently on pharmacotherapy for either PTSD or alcohol misuse were started on appropriate medication, perhaps general treatment results may have been different for the entire cohort," he said.

Going forward, Dr. Sannibale said, researchers need to learn what baseline characteristics predict greater treatment responses, and how to improve treatment retention.

"I believe it is important for clinicians to encourage people with these complex problems to remain hopeful about treatment and to persevere with it even when the problems seem insoluble or if it takes several attempts before engaging successfully. Treatment does work!" she said.


Addiction 2013.

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