Transcript Prevalence of PTSD and Substance Use Disorders

CTN 0015: Preliminary findings
from the “Women and Trauma”
Study
Denise Hien, Ph.D.
Research Scientist, Social Intervention Group,
Columbia University School of Social Work
Executive Director, Women’s Health Project Treatment and Research
Center, Addiction Institute of New York, St. Luke’s\Roosevelt Hospital
Center
St. Petersburg, Florida
December 7, 2006
PLEASE DO NOT CITE CONTENTS OF PRESENTATION WITHOUT PERMISSION OF THE AUTHOR
“The past isn’t dead,
it isn’t even past.”
-William Faulkner
Scope of the Problem
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)
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)
Neurobiological Changes in
Response to Traumatic Stress
Limbic System -Hippocampus and
Amygdala (Affect and
Memory, e.g, Ledoux, 2000; van der
Kolk, 1996)
Neurotransmitters and
Peptides (Numbing and
Depression, e.g., Pitman, 1991,
Southwick, 1999)
Changes in Hormonal
System (HPA axis)
(Arousal, e.g., Yehuda, 2000)
Historical Context for the Study of
Trauma & Addiction
Women’s
movement and
grassroots
advocacy for
battered women
1970
PTSD studies with
male veterans
with/out
substance use
Crack/
Cocaine
epidemic
1980
DSM-IIIR
broadens
criteria for
PTSD
Fullilove’s snowball
sample
1990
Miller’s work with
criminal justice
population
Historical Context for the Study of
Trauma & Addiction
Herman’s
Trauma
and
Recovery
published
1990
Chilcoat and
Breslau selfmedication
model
1995
Violence
declared
public health
epidemic
Kendler et al.
co-twin study
suggesting
causal link
between abuse
and SUD
2000
Manualized
integrated
trauma and
SUD tx
SAMSHA
findings
published
2006
National
awareness of
PTSD and
addiction
following
9/11/01
RCTs of
integrated
PTSD and
SUD tx
Differences between Co-morbid
PTSD vs. PTSD-only behavioral
treatments
Addition of components focused on coping and
cognitive restructuring related to substance use
(cravings and relapse triggers)
Concurrent Model : Additional components may be
integrated and delivered concurrently
Sequential Model: Initial phase may focus on
substance abuse related symptoms in preparation for
working on trauma related symptoms later
PTSD/SUD Behavioral Treatments
ATRIUM: Addictions and Trauma Recovery
Integrated Model (Miller & Guidry, 2001)
Seeking Safety (Najavits, 1998; www.seekingsafety.org)
TARGET - Trauma Affect Regulation: Guidelines
for Education and Therapy (Ford; www.ptsdfreedom.org)
Transcend (Donovan et al., 2001)
CTPCD - Concurrent Treatment of PTSD and
Cocaine Dependence (Back et al., 2001)
SDPT: Substance Dependence PTSD Therapy
(Triffleman et. al, 1999)
NIDA Clinical Trials Network
Women & Trauma Sites
Washington Node
Residence XII
Ohio Valley Node
Maryhaven
New England Node
LMG Programs
New York Node
ARTC
Long Island Node
Lead Node
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
Eva Petkova, Lead Statistician
Huiping Jiang, 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
Robert Sage
Brooklyn, NY
Florida
Jose
Szapocznik &
Daniel
Santisteban
Lourdes
SuarezMorales
New
England
Kathleen
Carroll
New York
John Rotrosen
Marion
Schwartz
Addiction
Research &
Treatment
Corporation
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
Betsy Wells
Residence XII
Karen Canida
Kirkland, WA
CTN Women & Trauma: A Unique
Opportunity
Chance to conduct a “practical” clinical trial
on SS while maintaining a rigorous control
Shorter treatment window and dose
Open-group, rolling admissions format
paralleling real world
Community treatment providers as
research clinicians
Treatment as usual while receiving
research intervention
Study Aims
To assess the effectiveness of adding Seeking
Safety (SS) and Women’s Health Education
(WHE) groups to ongoing substance abuse
treatment.
To evaluate the transportability of a 12- session
group version of SS in community drug/alcohol
treatment settings.
Pre-Post Control Group Design
Pre-Treatment
1 - 4 Weeks
Treatment
6 Weeks
Post Treatment
Follow-up
46 Weeks
Pre-screening, Screening,
Baseline, Randomization,
Individual Counselor Session
12 Twice Weekly Group
Sessions
1 Week
3 Month
6 Month
12 Month
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 information
and issues
Seeking Safety
Developed as a group treatment for PTSD/SUD women
Based on CBT models of SUDs, PTSD treatment,
women’s treatment and educational research
Educates patients about PTSD and SUD’s and their
interaction
Goals include abstinence and decreased PTSD
symptoms
Focuses on enhancing coping skills, safety and self-care
Active, structured treatment - therapist teaches,
supports and encourages
Case management
Najavits, 2002; www.seekingsafety.org
Women’s Health Education
Empowerment
Information is empowering
Self-care
Substance abuse and trauma interfere with ability to
care for oneself
Exposure to traumatic stress can affect people on many
different levels of functioning including:
emotional
behavioral
physical
There is significant overlap of PTSD and physical
symptoms
In the national comorbidity survey, use of medical care services
was highest in PTSD and panic disorder patients (Kessler, 1995)
Assessment Domains
Demographics
Substance Abuse/Dependence Diagnosis
CIDI – Composite International Diagnostic Interview
Substance Use
SUI – Substance Use Inventory (Primary)
Biological – Urine/Saliva Screen (Primary)
ASI – Addiction Severity Index
HIV Risk Behaviors: RBS – Risk Behavior
Survey
Health and Family Network (ASI; add-on
questions)
Assessment Domains
PTSD Diagnosis and Symptoms
CAPS – Clinician Administered PTSD Scale (Primary)
PSS-SR – Post Traumatic Stress Symptoms – Self
Report
Trauma Exposure: Lifetime Events Checklist
Psychiatric Symptoms: BSI – Brief Symptom
Inventory
Service Utilization: TSR – Treatment Services
Review (medication)
In-Treatment Measures
(baseline, weekly through treatment,1week post)
PTSD Symptoms (PSS-SR)
Biologically Confirmed Substance Abstinence
and Proportion of Days Used
Substance Use Inventory (SUI)
Urine Drug Screen (UDS)
Saliva Alcohol Screen (ST)
Participant Eligibility Criteria
Inclusion
female, 18 - 65 years old
used an illicit substance within the past six months and have
a current diagnosis of illicit drug/alcohol abuse or
dependence
PTSD or Sub-threshold PTSD
enrolled at participating community treatment program
Exclusion
advanced stage medical disease (AIDS, TB)
impaired mental status (MMSE: less than or equal to 21)
significant risk of suicidal/homicidal intent or behavior
history of schizophrenia-spectrum diagnosis
active psychosis (prior 2 months)
involved in PTSD-related litigation
refuses to be audio or videotaped
Enrollment
Initial Screen
N=1,963
Ineligible
N=751
Eligible for Baseline
N=1,212 (62%)
No Full Screen
N=751
Completed Baseline
N=541 (45%)
Ineligible
N=162
Eligible for Randomization
N=379 (70%)
Not Randomized
(multiple reasons)
Randomized
N=353 (93%)
N=26
Sample Characteristics (N=353)
Variable
percent or M (S.D.)
Age (years)
Race/ethnicity
39.2 (9.3)
Hispanic or Latino
Black/African American
White
Mixed
Other
6.5
34.0
45.6
13.3
0.6
Married
Widowed/Divorced
Never Married
33.3
29.3
37.4
Marital status
PTSD Diagnosis and Severity at
Baseline (N=353)
PTSD Diagnoses and Severity
Scores
Current Full PTSD
Current Subthreshold PTSD
CAPS Total Score
PSS-SR Severity
PSS-SR Frequency
percent or M (S.D.)
80.4
19.6
62.8 (19.4)
45.6 (10.8)
38.7 (15.3)
Substance Use Disorders at Baseline
(N=353)
Substance Use Diagnosis
percent
Current Alcohol Use Disorder Diagnosis
62.0
Current Marijuana Use Disorder Diagnosis
35.4
Current Opioid Use Disorder Diagnosis
33.1
Current Cocaine Use Disorder Diagnosis
72.8
Current Stimulant Use Disorder Diagnosis
8.2
Note: not exclusive categories
Lifetime Trauma Exposure (N=353)
Lifetime Traumatic Experiences
percent
Physical Assault
Childhood Physical Abuse
Lifetime Physical Abuse
58.7
93.8
Childhood Sexual Abuse
Lifetime Sexual Violence
70.1
89.5
40.3
19.3
39.8
72.7
53.1
Sexual Assault
Captivity
Sudden, Violent Death
Life-threatening Illness
Transportation Accident
Natural Disaster
Data Analytic Approach for In-Treatment
Outcomes
Mixed effect models were used to model the
outcome measures of interest as a function of
baseline levels, time, treatment, site and their
interactions.
A non-randomized sample of naturalisticallyoccurring “wait list” controls was examined with
baseline as the pre-test and assessment during 1st
week of treatment as the post-test.
Additional analyses on the impact of treatment
attendance on outcomes were conducted.
PTSD In-Treatment Outcomes: PSS-SR severity
modeled from pre-treatment to post-treatment weekly
by treatment group
PTSD In-Treatment Outcomes: PSS-SR frequency
modeled from pre-treatment to post-treatment weekly
by treatment group
SUD In-Treatment Outcomes: Abstinence rates
modeled from pre-treatment to post-treatment weekly
by treatment group
SUD In-Treatment Outcomes: Days of use modeled
from pre-treatment to post-treatment weekly by
treatment group
Secondary Analyses: Six Week Pre- “Post”
Changes for Non-Randomized Naturalistic Wait
Group (N=20)
Wait List
Secondary Analyses: Treatment
Attendance Rates
Treatment
Group*
N
Mean (sd)
Median
SS
170
6.3 (4.4)
7
WHE
172
5.9 (4.3)
6.5
*No significant differences between groups
Secondary Analyses: Effects of treatment
attendance on post-treatment abstinence
rates
DF
2
p-value
Baseline Abstinence
1
48.07
<.001
Race
3
2.39
n.s.
Site
5
48.95
<.001
Age
1
0.27
n.s.
Education
1
0.00
n.s.
Time
1
4.33
<.05
Treatment
1
0.04
n.s.
Treatment Attendance
1
7.47
<.001
Source
Secondary Analyses: Effects of treatment
attendance on post-treatment days of use
DF
2
p-value
Baseline Use
1
24.09
<.001
Race
3
1.48
n.s.
Site
5
14.20
0.01
Age
1
0.85
n.s.
Education
1
1.28
n.s.
Time
6
11.78
n.s.
Treatment
1
0.05
n.s.
Baseline Use*Time
6
24.89
<.001
Treatment Attendance
1
7.07
<.01
Source
Comments
Though all participants met PTSD and SUD diagnoses as per study
inclusion criteria, findings show that within this sample population
there was substantial variability across sites in terms of types of
trauma exposure, types of drugs used and specific drug use
diagnoses.
Despite such differences in site characteristics, overall, both SS and
WHE groups led by community substance abuse counselors can
reduce PTSD symptoms at a statistically significant level.
Although SUD outcomes were not statistically significant by the end
of six weeks of treatment, they were reduced from baseline and the
number of sessions received did significantly predict lowered levels
of SUD symptoms.
We speculate that the reductions observed in PTSD symptoms
during treatment, particularly in the SS group, may be more
pronounced over the follow up period and lead to greater reductions
in SUD symptoms over time.
Project Directors/Protocol PIs
Frankie Kropp
Agatha Kulaga
Melissa Gordon
Chanda Brown
Silvia Mestre
Nadja Schreiber
Mary Hatch-Maillette
Chris Neuenfeldt
Cheri Hansen
Karen Esposito
Sharon Chambers
CTN-0015 Research Staff
Brianne O’Sullivan
Ileana Graf
Melissa Chu
Nishi Kanukollu
Treneane Salisbury
Rebecca Krebs
Ann Whetzel
Stella Resko
Carol Hutchinson
Chanda Brown
Janice Ayuda
Pamela Bernard
Jessica Ucha
Nicole Moodie
Allison Kristman-Valente
Lynette Wright
Melanie Spear
Lisa Johnson
Catherine Williams
Calonie Gray
Michele DiBono
Rachel Hayon
Barbara Bettini
Barbara Thomas
Lisa Markiewicz
Elizabeth Cowper
Rosaline King
Lara Reichert
CTN-0015 Clinicians
Lisa Cohen
Dawn Baird-Taylor
Lisa Litt
Martha Schmitz
Karen Tozzi
Darlene Franklin
Kathleen Estlund
Molly McHenry-Whalen
Erin Demirjian
Anslie Stark
Karen Bowes
Metris Batts
Felisha Lyons
Kathy McPherson
Victoria Johnson
Denese Lewis
Sharon Anderson-Goss
Merilee Perrine
Angela Waldrop
Leslie Lobel-Juba
Maria Mercedes Giol
Lourdes Barrios
Lisa Mandelman
Jeanette Suarez
Danielle Macri
Maria Hurtado
Tina Klem
Nancy Magnetti
Anne Marie Sales
Renee Sumpter
Michelle Melendez
Ida Landers
Regina Morrison
Clare Tyson
Mary Hodge-Moen
Sandra Free
Goldie Galloway
Karen Canida
Katie Revenaugh
CTN-0015 QA and Data Management
Jim Robinson
JP Noonan
Connie Klein
Karen Loncto
Chris Hutz
Lauren Fine
Michelle Cordner
Melissa Gordon
Maura Weber
Kristie Smith
Catherine Dillon
Donna Bargoil
Jurine Lewis
Girish Gurnani
Inna Logvinsky
Peggy Somoza
Sharon Pickrel
Katie Weaver
Molly Carney
Catherine Otto
Rebecca Defevers
Emily DeGarmo
Royce Sampson
Stephanie Gentilin
Clare Tyson
Anthony Floyd
Nathilee Francois
Appendices: Summary Data Tables
Comparison of
Existing Trauma
/ SUD- Focused N
Treatment
Research
Design
Sessions,
Timeframe
& Modality
Najavits,
1998
Triffleman,
2000
Brady et.
al., 2001
Donovan,
2001
Hien et al.,
2004
27
Women
19
Mixed
39
Mixed
46
Men
107
Women
No Control
RCT
No Control
No Control
RCT
24,
3 mos.,
group
40,
5 mos.,
individual
60
3 mos.,
group
24
3 mos.,
individual
16
4 mos.,
individual
Tx
Content
SS
SDPT, 12Step
CTPSD,
CBT,
Exposure
CBT, RPT,
Soc
Support
SS, RPT,
TAU
Follow Up
3 mos.
1 mo.
6 mos.
6/12 mos.
6/9 mos.
Results
 SU,
 SU,
PTSD &
PTSD,
Depression Psych SXs
SXs
 SU,
PTSD &
Depression
SXs
 SU,
PTSD SXs
 SU,
PTSD,
Psych SXs
at 6 mos
Summary Statistics for Post-treatment PSS-SR Severity Modeled by
Baseline PTSD Severity, Demographics, Treatment Group, Time, Site,
and their Interactions
DF
2
p-value
PSS-SR Baseline
1
71.73
<.001
Race
3
1.34
n.s.
Site
5
24.19
<.001
Age
1
0.68
n.s.
Education
1
4.97
<.05
Time
1
1.08
n.s.
Treatment
1
6.81
<.01
Time*Treatment
1
4.96
<.05
Time* PSS-SR
Baseline
1
12.35
<.001
Parameter
Summary Statistics for Post-treatment PSS-SR Frequency Modeled by
Baseline PTSD Frequency, Demographics, Treatment Group, Time, Site,
and their Interactions
DF
2
p-value
PSS-SR Baseline
1
76.74
<.001
Race
3
0.64
n.s.
Site
5
27.60
<.001
Age
1
0.95
n.s.
Education
1
5.07
<.05
Time
1
1.47
n.s.
Treatment
1
8.55
<.01
Time*Treatment
1
5.28
<.05
1
15.32
<.001
Parameter
Time* PSS-SR Baseline
Summary Statistics for Post-treatment Days of Use Modeled by Baseline
Days of Use, Demographics, Treatment Group, Time, Site, and their
Interactions
DF
2
p-value
Baseline Days of Use
1
21.66
<.001
Race
3
1.26
n.s.
Site
5
18.37
<.01
Age
1
0.50
n.s.
Education
1
0.95
n.s.
Time
6
11.90
<.10
Treatment
1
0.01
n.s.
Baseline Days of
Use*Time
6
20.80
<.01
Parameter
Summary Statistics for Post-treatment Abstinence Rates Modeled by
Baseline Abstinence, Demographics, Treatment Group, Time, Site, and
their Interactions
DF
2
p-value
Baseline Abstinence
1
51.12
<.001
Race
3
2.10
n.s.
Site
5
44.18
<.001
Age
1
0.18
n.s.
Education
1
0.00
n.s.
Time
1
0.02
n.s.
1
0.12
n.s.
Parameter
Treatment