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Effective Treatments for PTSD in Women with SUD

Effective Treatments for PTSD in Women with SUD. Denise Hien, Ph.D., dhien@ccny.cuny.edu Professor and Adjunct Senior Research Scientist City University of New York, Subprogram in Clinical Psychology & Columbia University College of Physicians & Surgeons

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Effective Treatments for PTSD in Women with SUD

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  1. Effective Treatments for PTSD in Women with SUD Denise Hien, Ph.D., dhien@ccny.cuny.edu Professor and Adjunct Senior Research Scientist City University of New York, Subprogram in Clinical Psychology & Columbia University College of Physicians & Surgeons 138th American Public Health Association Annual Meeting November 10, 2010 | Denver, Colorado

  2. Presenter Disclosures Denise Hien, Ph.D. No relationships to disclose (1) The following personal financial relationships with commercial interests relevant to this presentation existed during the past 12 months:

  3. Scope: Trauma and Addiction • 1 in 2 women in the U.S. experience some type of traumatic event (Kessler, 1995) • Approximately 33% of females under age18 experience sexual abuse (Finkelhor, 1994; Wyatt, 1999) • 20% to 65% of individuals in treatment for SUD reporting assault histories (G. R. Brown & Anderson, 1991; P. J. Brown et al., 1995) • Prevalence rates of PTSD in community samples have ranged from 6% to 36% (Breslau, 1991; Kilpatrick, 1987; Norris, 1992; Resnick, 1993) • Studies have documented PTSD rates among substance using populations to be between 14%-60%(Brady, 2001; Donovan, 2001; Najavits, 1997; Triffleman, 2003)

  4. Pandora Problem Pandora, the first woman, created by the God of Fire and endowed with many gifts, was treacherously presented with a box containing the evils of humankind. When a naturally curious Pandora opens the box, the evils escape. Realizing what has happened, Pandora struggles to close the box, able to do so in time to keep Hope from escaping.

  5. Phases of Trauma Treatment Stabilize Process Affect Regulation Exposure Distress Tolerance Cognitive Somatosensory

  6. Combined Behavioral Treatments for Trauma and Addictions • ARTS: Assisted Recovery from Trauma and Substances(Triffleman et. al, 1999) • ATRIUM: Addictions and Trauma Recovery Integrated Model(Miller & Guidry, 2001) • COPE: Concurrent Treatment with Prolonged Exposure (Back and Kileen, in development) • CBT for PTSD (McGovern, in development) • Seeking Safety(Najavits, 1998; www.seekingsafety.org) • Transcend(Donovan et al., 2001)

  7. Overall Summary of Trauma/SUD Psychotherapy Studies • CBT shows promise in treating PTSD/SUD • PTSD treatments did not make patients worse, and improved PTSD, substance use and general psychiatric symptoms • Integrated counseling may be one of the key program features that impacts outcomes. • More research needed to examine the duration, scope, timing and combination of components to identify optimal model of PTSD/SUD treatment integration

  8. Limits of Randomized Controlled Trials for Patients with PTSD/SUD • Restricted participant characteristics • Heterogeneity in diagnosis and concurrent treatment • Inflexible treatment implementation • Practical guidelines regarding participant treatment participation • Therapist characteristics and training that do not reflect community practitioners • Using community clinicians in a train-the-trainer model Hien, DA, Cohen, LC & Campbell, A. In (2009). Methodological innovation in a clinical trial using hybrid models to increase the utility and efficiency of psychotherapy research for patients with comorbid mental health and substance disorders. Professional Psychology: Research and Practice, 32 (1), 48-55.

  9. NIDA Clinical Trials Network Trauma Group Study Sites Washington Node Residence XII Ohio Valley Node Maryhaven New England Node LMG Programs New York Node ARTC South Carolina Node Charleston Center Florida Node Gateway Community Florida Node The Village

  10. CTN Long Island Node Team Denise Hien, Lead Investigator Edward Nunes, Node PI Gloria Miele, Training Director Lisa Cohen, Protocol Manager Aimee Campbell, Project Director Jennifer Lima, Node Coordinator Huiping Jiang, Statistician Mei-Chen Hu, Statistician David Liu, NIDA Liaison

  11. Participating Nodes and CTPs

  12. Study Aims • Primary Analyses: • To assess the effectiveness of adding a trauma focused therapy to ongoing substance abuse treatment. • To evaluate the transportability of a 12- session group version of SS in community drug/alcohol treatment settings. • Secondary Analyses: • To identify for whom and how the trauma focused therapy worked best.

  13. Treatment Groups • Seeking Safety (SS) • Short term, manualized treatment • Cognitive Behavioral • Focused on addiction and trauma • Women’s Health Education (WHE) • Short term, manualized treatment • Psychoeducational • Focused on women’s health info and issues

  14. Pre-Post Control Group Design Pre-screen, Screening, Baseline, Randomization, Individual Session w/ Counselor Pre-Treatment 1 - 4 Weeks Treatment 6 Weeks 12 Twice Weekly Group Sessions (rolling admission) Post Treatment Follow-up 46 Weeks 1 Week 3 Month 6 Month 12 Month

  15. Assessment Measures • PTSD symptoms • PTSD Symptom Scale- Self-Report (PSS-SR) • Clinician Administered PTSD Scale (CAPS) • Substance use symptoms • Substance Use Inventory (SUI) • Addiction Severity Index (ASI) • Alcohol Composite • Drug Composite • Maximum number of days of use

  16. Study Enrollment Ineligible N=751 (38%) No-show to Screen N=671 (34%) Initial Eligibility Screen N=1,963 Screening N=541 Ineligible n=171 (32%) Baseline N=370 Randomized N=353 Not Randomized N=17 (5%)

  17. Sample Characteristics (N=353)

  18. Baseline PTSD Severity (N=353)

  19. Baseline Substance Use Disorders (N=353) Note: not exclusive categories

  20. PSS-SR Trauma Symptom Severity for ITT Sample (N=353) Hien, Wells, Jiang, Suarez-Morales, Campbell, Cohen, Miele, Kileen, Brigham, Robinson, Zhang (2009). Multi-site randomized trial of behavioral interventions for women with co-occurring PTSD and substance use disorders, Journal of Consulting and Clinical Psychology.

  21. Abstinence Rates for ITT Sample (N=353) Hien et al. (2009). Multi-site randomized trial of behavioral interventions for women with co-occurring PTSD and substance use disorders, Journal of Consulting and Clinical Psychology.

  22. Examining Functional Relationships is Criticalto understanding how and for whom the trauma treatments work best

  23. Temporality of Treatment Response Hien et. al, (2010). Do Treatment Improvements in PTSD Severity Affect Substance Use Outcomes? A Secondary Analysis from “Women and Trauma” Multi-Site Randomized Study. American Journal of Psychiatry.

  24. Alcohol Misuse • Stronger Seeking Safety treatment effects on PTSD hyperarousal symptoms (PSS-SR) compared with WHE over time were found for women with alcohol misuse at baseline. Hien, Campbell, Hu, et al. (In press). The role of alcohol misuse on PTSD outcomes for women in community treatment? A secondary analysis of NIDA’s Women and Trauma study, Drug and Alcohol Dependence

  25. Attendance Matters • Three consistent and distinct attendance patterns emerged: Completers, Droppers, and Titrators. • Titrators in Seeking Safety had lower rates of alcohol use from 1-week through 12 month follow-up compared to the health education group; cocaine results were similar but not statistically significant. Hien, Morgan-Lopez, Saavedre, et al. (submitted) Can Less be More?: A secondary analysis of CTN “Women and Trauma” study. Journal of Consulting and Clinical Psychology.

  26. Summary • PTSD changes found to impact SUD outcome/ No evidence substance use reduction improved PTSD. • Findings of all analyses consistent with a self-medication model of coping with PTSD. • Addressing trauma related symptoms did not negatively impact substance use recovery. Instead trauma-focused treatment can lead to improvements in SUD outcomes in the context of PTSD symptom reduction. • Clinicians working with alcohol misusers should attend to hyperarousal; those with cocaine/stimulant users may want to pay attention to avoidance/numbing cluster throughout treatment. • Empirical basis for recommending PTSD-focused and integrated interventions for improved substance use outcomes in patients with severe symptoms. • Attendance patterns and other contextual factors are important to consider in evaluating treatment outcomes.

  27. Implications for Dissemination • In order for psychotherapy research studies to inform and deepen our understanding of treatment and be relevant to the community, we must consider: • What are meaningful outcomes that tell us whether and how theories of psychotherapy map onto reality? • Transdisciplinaryapproaches. • Integrating mind/body: Physical Health, STD and HIV • Pharmacotherapies • Multimedia interventions for a wider audience • Need novel designs, innovative statistical methods, and broader yet more systematic criteria.

  28. Available from APA Press • Hands on guide for clinicians and providers seeking to treat women who suffer from trauma and the effects of substance abuse

  29. THANK YOU! • Participants and staff on the NIDA CTN Study: • 353 Participants; 28 Research Assistants, Assessors, and Coordinators; 39 Therapists and Supervisors; 11 Project Directors and Protocol Principal Investigators; 27 Quality Assurance Monitors and Data Managers • My wonderful colleagues: Nathilee Caldeira, Ph.D., Aimee Campbell, Ph.D., Lisa Cohen, Ph.D., Mei-Chen Hu, Ph.D., Huiping Jiang, Ph.D., Lisa Litt, Ph.D., Antonio Morgan-Lopez, Ph.D., Gloria Miele, Ph.D., Edward V. Nunes, MD, Lesia Ruglass Ph.D, and Lissette Saavedra, Ph.D. • ADD CTN GRANT NUMBER

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