Effective Treatments for PTSD in Women with SUD

1
Effective Treatments for PTSD in Women with SUD
Denise Hien, Ph.D., dhien_at_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.

• (1) The following personal financial
  relationships with commercial interests relevant
  to this presentation existed during the past 12
  months

No relationships to disclose
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 age 18
  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
New England Node LMG Programs
Ohio Valley Node Maryhaven
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
Node Node PI(s) Protocol PI CTP Site PI Location
Florida Jose Szapocznik Daniel Santisteban Lourdes Suarez-Morales The Village Michael Miller Miami, FL
Florida Jose Szapocznik Daniel Santisteban Lourdes Suarez-Morales Gateway Community Candace Hodgkins Jacksonville, FL
New England Kathleen Carroll Melissa Gordon LMG Programs Samuel Ball Stamford, CT
New York John Rotrosen Marion Schwartz Addiction Res TX Corporation Robert Sage Brooklyn, NY
Ohio Valley Gene Somoza Greg Brigham Maryhaven Greg Brigham Columbus, OH
South Carolina Kathleen Brady Therese Killeen Charleston Center Mark Cowell Charleston, SC
Washington Dennis Donovan Betsy Wells Residence XII Karen Canida Kirkland, WA
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
• Womens Health Education (WHE)
• Short term, manualized treatment
• Psychoeducational
• Focused on womens 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 N751 (38) No-show to Screen N671
(34)
Initial Eligibility Screen N1,963
Screening N541
Ineligible n171 (32)
Baseline N370
Randomized N353
Not Randomized N17 (5)
17
Sample Characteristics (N353)
18
Baseline PTSD Severity (N353)
19
Baseline Substance Use Disorders (N353)
Note not exclusive categories
20
PSS-SR Trauma Symptom Severity for ITT Sample
(N353)
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 (N353)
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
Improvement To Improvement To Improvement To Improvement To Improvement To
1 2 3 4 5
Improvement From None Drug Use PTSD Symptoms Global Drop Out
1 None 0.503 0.208 0.087 0.062 0.140
2 Drug Use 0.111 0.656 0.016 0.131 0.085
3 PTSD 0.149 0.081 0.310 0.367 0.093
4 Global 0.026 0.161 0.060 0.692 0.062
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
NIDAs 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?
• Transdisciplinary approaches.
• 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