Combinatorial Treatments for PTSD and Substance Use Have Favorable Outcomes

A systematic review and meta-analysis published in the American Journal of Psychiatry found that combinatorial treatment approaches that addressed comorbid posttraumatic stress disorder (PTSD) and substance use disorder led to favorable outcomes.

Investigators from Rutgers University, New Brunswick, New Jersey in the United States searched publication databases through December 2020 for studies targeting PTSD, substance use disorders, or both. A total of 36 studies comprising 4046 patients were included in this analysis.

The study population had a mean age of 39.0 (SD, 11.2) years, 53% were men, 65% were White, and 25% were Black. The target study populations were a mixture of veteran and civilian populations. A variety of interventions were employed in the studies, including seeking safety therapy, integrated cognitive-behavioral therapy, and pharmacotherapies for substance use.

Compared with treatment-as-usual, at the end of treatment, symptoms of PTSD were reduced by treatment overall (d, -0.61; 95% CI, -0.72 to -0.52). Stratified by treatment, the largest comparative effect was observed for trauma-focused therapies plus pharmacotherapy for substance use disorder (d, -0.92; 95% CI, -1.57 to -0.30), followed by behavioral therapies for substance use disorder (d, -0.60; 95% CI, -0.80 to -0.38) and pharmacotherapy for substance use disorder (d, -0.32; 95% CI, -0.53 to -0.12). These comparisons had significant cross-study heterogeneity in latent PTSD symptoms (τ², 0.116; P <.001).

At the 12-month follow-up, symptoms of PTSD remained significantly reduced after treatment compared with usual care (d, -1.16; 95% CI, -1.40 to -0.92). The most favored approach was combined trauma-focused therapy plus pharmacotherapy for substance use disorder (d, -2.00; 95% CI, -3.38 to -0.68), followed by pharmacotherapy for substance use disorder (d, -1.37; 95% CI, -2.15 to -0.63) and placebo (d, -0.57; 95% CI, -1.08 to -0.01).

For alcohol severity outcomes, interventions were favored over usual care at 12 months (d, -0.36; 95% CI, -0.50 to -0.22). The most effective interventions were combined trauma-focused therapy plus pharmacotherapy for substance use disorder (d, -1.24; 95% CI, -2.03 to -0.40) and pharmacotherapy for substance use disorder (d, -0.84; 95% CI, -1.30 to -0.41). Similarly, interventions were superior to usual care at 12 months for the outcome of drug use severity (d, -0.63; 95% CI, -0.78 to -0.47). However, no intervention strategies alone were favored over usual care.

The limitations of this study included the significant heterogeneity between studies and the various interventions and treatment durations that were pooled.

Study authors concluded, “Our findings support the contention that there are no wrong doors regarding the delivery of substance use intervention services that integrate PTSD treatment alongside them, as opposed to isolating approaches to substance use and PTSD in distinct services. However, as the findings provide clearer support for trauma-focused interventions, alcohol-targeted pharmacotherapy, and their combination, it does appear that some doors are better than others.”