Transcript Open slides - CTN Dissemination Library

Effective Treatments
for PTSD in Women
with SUD
Denise Hien, Ph.D., [email protected]
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
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
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)
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.
Phases of Trauma Treatment
Stabilize
Process
Affect Regulation
Exposure
Distress Tolerance
Cognitive
Somatosensory
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)
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
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.
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
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
Participating Nodes and CTPs
Node
Node PI(s)
Protocol PI
CTP
Site PI
Location
The Village
Michael
Miller
Miami, FL
Gateway
Community
Candace
Hodgkins
Jacksonville,
FL
Melissa
Gordon
LMG Programs
Samuel Ball
Stamford,
CT
John Rotrosen
Marion
Schwartz
Addiction Res &
Robert Sage
TX Corporation
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
Florida
Jose
Szapocznik &
Daniel
Santisteban
Lourdes
SuarezMorales
New
England
Kathleen
Carroll
New York
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.
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
Pre-Post Control Group
Design
Pre-Treatment
1 - 4 Weeks
Treatment
6 Weeks
Post
Treatment
Follow-up
46 Weeks
Pre-screen, Screening, Baseline,
Randomization, Individual
Session w/ Counselor
12 Twice Weekly Group
Sessions (rolling admission)
1
Week
3
Month
6
Month
12
Month
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
Study Enrollment
Initial Eligibility Screen
N=1,963
Screening N=541
Ineligible
N=751 (38%)
No-show to Screen
N=671 (34%)
Ineligible
n=171 (32%)
Baseline N=370
Randomized N=353
Not Randomized
N=17 (5%)
Sample Characteristics
(N=353)
Variable
Age (years)
Race/ethnicity
Hispanic or Latina
Black/African American
White
Mixed
Other
Marital status
Married
Widowed/Divorced
Never Married
Education
Years
% or M (SD)
39.2 (9.3)
6.5
34.0
45.6
13.3
0.6
33.3
29.3
37.4
12.5 (2.4)
Baseline PTSD Severity (N=353)
Variable
PTSD Diagnosis
Full
Subthreshold
percent or M (S.D.)
80.4
19.6
CAPS Total Score
62.8 (19.4)
PSS-SR Severity
45.6 (10.8)
PSS-SR Frequency
38.7 (15.3)
Baseline Substance Use Disorders
(N=353)
Current Substance Use Diagnosis
percent
Alcohol
62.0
Marijuana
35.4
Opiates
33.1
Cocaine
72.8
Stimulant
8.2
Note: not exclusive categories
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.
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.
Examining Functional
Relationships is Critical
to understanding how and for whom the
trauma treatments work best
Temporality of Treatment Response
Improvement To
1
2
3
4
5
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
Improvement From
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.
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
Attendance Matters
•Three consistent and distinct
attendance patterns emerged:
Completers, Droppers, and Titrators.
•Titrators in Seeking Safety had
lower rates of alcohol use from 1week 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.
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.
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.
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
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.
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