Transcript Prevalence of PTSD and Substance Use Disorders

Treating Trauma and Addiction:
The CTN Women and Trauma Study
Denise Hien, Ph.D.
Research Scholar, Columbia University School of Social Work
Executive Director, Women’s Health Project Treatment and Research Center,
Dept of Psychiatry, St. Luke’s\ Roosevelt Hospital Center
Gloria Miele, Ph.D.
Training Director, New York State Psychiatric Institue, Columbia University
Greg Brigham, Ph.D.
Chief Research Officer, Maryhaven
National Conference on Women, Addiction and Recovery: News You Can Use
Anaheim, CA, July 14, 2006
Overall Presentation Objectives
 Participants will gain an overview of specific treatment
approaches for women with trauma and substance use
disorders based upon our collective work with CTN’s Women
and Trauma Study.
 Participants will learn important descriptive characteristics of
women with trauma who attend outpatient substance abuse
treatment.
 Participants will gain knowledge about training and
supervision required when using empirical approaches to
treating women with trauma.
 Participants will learn the benefits and challenges to
implementing empirical approaches to treating women with
trauma in community treatment programs.
Historical Context for the Study of
Trauma and Addiction
 Women’s Movement and Grassroots Advocacy for Battered
Women in 1970’s.
 Crack/ Cocaine epidemic; DSM-IIIR broadens criteria for PTSD;
PTSD studies in Vets and Non Substance Abusers; Fullilove’s
Snowball Sample, Miller’s work with criminal justice population in
mid-late 1980’s.
 Surgeon General Koop declares Violence a Public Health
Epidemic in 1991.
 Judith Herman’s book Trauma and Recovery published in 1992.
Historical Context for the Study of
Trauma and Addiction (cont’d.)
 Epidemiology from cross-disciplinary research over the late
80’s and 90’s establishes high rates—surpassing normal
population estimates—for childhood abuse, domestic violence,
crime victimization and PTSD—especially for women.
 Chilcoat and Breslau identify support for self-medication model
in 1998; Kendler and colleagues publish first co-twin study
demonstrating causal link between childhood abuse and
substance use disorders in 2000.
 National consciousness of PTSD and addiction links following
September 11, 2001.
DSM-IV Criteria for
Posttraumatic Stress Disorder (PTSD)
A.
The person has been exposed to a traumatic event
• Event involved actual or threatened death or serious injury, or a threat to
the physical integrity of self or others
• The person’s response involved intense fear, helplessness, or horror
B.
C.
The traumatic event is persistently re-experienced
Avoidance of stimuli associated with the trauma and numbing of
general responsiveness
D.
Persistent symptoms of increased arousal, including difficulty
falling or staying asleep, irritability or outbursts of anger, difficulty
concentrating, hypervigilance, exaggerated startle response
(American Psychiatric Association, 1994)
PTSD vs. Complex Trauma
 PTSD typically develops from one incident, usually experienced
as an adult.
 Complex Trauma (DESNOS) is associated with repeated
incidents (domestic violence or ongoing childhood abuse).
Broader range of symptoms: self-harm, suicide, dissociation
(“losing time”); problems with relationships, memory, sexuality,
health, anger, shame, guilt, numbness, loss of faith and trust,
feeling damaged.
Pathways Between Trauma-related
Disorders and Substance Use
TRAUMA
PTSD
SUD
Clinical Challenges in the Treatment of
Traumatic Stress and Addiction
 Abstinence may not resolve
comorbid trauma-related disorders
 for many patients the PTSD
worsens
 Women with PTSD abuse the most
severe substances and are
vulnerable to relapse for both
conditions, as well as repeated
trauma
 Confrontational approaches typical
in addictions settings frequently
exacerbate mood and anxiety
disorders
 12-Step Models often do not
acknowledge the need for
pharmacologic interventions
 Treatment programs often do not
offer integrated treatments for
Substance Use and PTSD
 Treatments for only one
disorder—such as ExposureBased Approaches are often
marked by complications
 treatments developed for
PTSD alone may not be
advisable to treat women with
addictions
Pandora
The first woman, created by
Hephaestus (God of Fire)
endowed by the gods with all
the graces and treacherously
presented with a box in which
were confined all the evils that
could trouble mankind.
As the gods had anticipated,
Pandora opened the box,
allowing the evils to escape.
Spiral of Addiction and Recovery
(Covington, 1999)
Other Relevant Treatment Models
Linehan – Dialectical Behavioral Therapy (DBT)
Cloitre – Skills Training in Affective and
Interpersonal Regulation (STAIR/STAIR-PE)
TREM
Najavits,
1998
N
Comparison
of Existing
Trauma/
SUDFocused
Treatment
Research
27 women
17 (6 or more
sessions)
No Control
Length 24 group
of TX
Sessions, 3
months,
2x/wk, 90min/group
TX
Seeking
Content Safety: Cog
Behavioral
Interpersonal
coping skills
Follow
Up
Results
Triffleman,
2000
19 (10
women)
RCT
5 months (20
wks), 2x/wk,
individual
Brady,
2001
Donovan,
2001
39 (82%
women)
15 (10 or
more
sessions)
No Control
16 sessions,
individual, 90
min sessions
46 men
75 women
No Control
12 weeks,
partial hosp,
10 hrs/week
RCT
3 months,
individual
Exposure
Therapy &
CBT
CBT, RP &
peer social
support (2phase)
Seeking
Safety/CBT
vs RPT
6 mo post
6/12 mo post
6/9 mo post
Improvement
@ 6 mo,
diminished at
9 mo, no diff
b/t exp and
control
SU, PTSD,
Psych
Nonrandomized
TAU
3 mo post
SDPT
(Coping,
CBT, Stress
Inoc, In Vivo,
RP-2 phase)
vs 12 step
1 mo post
Improvement
on SU, PTSD,
Depression,
increase in
somatization
Improvement Improvement
on SU, PTSD, in SU, PTSD
psych, No
& Depression
gender
differences
Improvement
in PTSD, SU
SU, PTSD,
ASI psych
Small N,
Short FU
period
SU, PTSD
Variable SU, PTSD,
Psych, Cog
Limits Small N, No
Control, Did
not follow up
Drop-outs
Hien,
2004
SU, PTSD,
Depression
Small N, No
Control, large
drop out rate
Small N, No
Control, 30
day
abstinence
required, one
site
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
David Liu, NIDA Liaison
Participating Nodes and CTPs
Node
Node PI(s)
Protocol PI
CTP
Michael Miller
Miami, FL
Gateway
Community
Candace
Hodgkins
Jacksonville, FL
Samuel Ball
Stamford, CT
Addiction Research
& Treatment
Corporation
Robert Sage
Brooklyn, NY
Greg Brigham
Maryhaven
Greg Brigham
Columbus, OH
Kathleen Brady
Therese Killeen
Charleston Center
Mark Cowell
Charleston, SC
Dennis Donovan
& Betsy Wells
Betsy Wells
Residence XII
Karen Canida
Kirkland, WA
Lourdes
Suarez-Morales
Kathleen Carroll
Melissa Gordon LMG Programs
New York
John Rotrosen
Marion
Schwartz
Ohio Valley
Gene Somoza
South
Carolina
Washington
New England
Location
The Village
Jose Szapocznik
& Daniel
Santisteban
Florida
Site PI
Seeking Safety is in the Community
 In the CSAT study on Women and Violence, nine sites were
offered a choice of three treatment models for PTSD/SUD;
more chose SS than any other treatment model.
 The Veterans Affairs 10-site project on homeless women
veterans selected SS as the sole treatment to be compared
to “treatment-as-usual”.
 The State of Connecticut trauma initiative selected SS as
one of three trauma treatments. Seven agencies chose SS
for this year-long project.
Study Aims
 To assess the effectiveness of adding Seeking
Safety (SS) to standard substance abuse
treatment (TAU).
To evaluate the transportability of a 12- session group
version of SS in community drug/alcohol treatment
settings.
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
Focused on understanding women’s health issues
Stages of Healing
1. SAFETY: This is the phase you are in now. The goals are to free yourself from
substance abuse, stay alive, build healthy relationships, gain control over your
feelings, learn to cope with day-to-day problems, protect yourself from destructive
people and situations, not hurt yourself or others, increase your functioning, and
attain stability.
2. MOURNING: Once you are more safe, you may need to grieve about the past,
about what your trauma and substance abuse did to you. You may need to cry
deeply to get over the losses and pain you experienced: loss of innocence, loss of
trust, loss of time.
3. RECONNECTION: After letting yourself experience mourning, you will find yourself
more willing and able to reconnect with the world in joyful ways: thriving, enjoying
life, able to work and relate well to others. You will get to this stage if you can
establish safety now.
Adapted from Herman, Trauma and Recovery, 1992
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
Key Treatment Concepts
Safety first
From substances and harmful situations
“Safe Coping Skills”
Anticipating dangerous situations
“Red Flags/Green Flags”
Setting boundaries
Anger management
Affect regulation skills
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
 cognitive
 characterological
 somatic
 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
CTP Criteria for Study Inclusion
 Outpatient Program
 Length of program stay at least 10 weeks
 Average 2-3 new female intakes per week
 At least 4 interested counselors/therapists
 Ability to accommodate 2 groups conducting twice
weekly sessions over 1 year
Pre-Post Control Group Design
Pre-Treatment
1 - 4 Weeks
Pre-screening, Screening, Baseline,
Randomization, Individual Counselor
Session
Treatment
6 Weeks
Post Treatment
Follow-up
46 Weeks
12 Twice Weekly Group Sessions
1 Week
3 Month
6 Month
12 Month
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 CTP
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
Assessment Measures









Demographics
Substance Abuse/Dependence Diagnosis
Substance Use (past 7, past 30 days/biological)
PTSD Symptoms (CAPS, PSS-SR)
Psychiatric Symptoms (BSI)
Other Service Utilization (medication)
Health Related Questions
HIV Risk Behaviors
Child/Adult Physical/Sexual Violence
Primary Outcomes
(baseline, 1week post, 3-, 6-, 12-month follow-up)
 PTSD Symptoms (CAPS)
 Biologically Confirmed Substance Abstinence
Substance Use Inventory (SUI)
Urine Drug Screen (UDS)
Saliva Alcohol Screen (ST)
Secondary Analyses
 Site characteristics
Frequency and length of TAU
Group sizes
Type of treatment and modality
Proportion of patients on medication
Gender/Trauma specific interventions
 Individual baseline characteristics
Severity, type, duration of substance use/PTSD
Psychotropic medication use
Drug use and PTSD symptoms over time
Enrollment
Initial Screen
1,963 Completed
1,212 (62%) Eligible
Screening Interviews
541 Completed
379 (70%) Eligible
353 (93%) Eligible Pts. Randomized
Eligibility of Screened Sample (N=541)*
Randomization (N=353)
Sample Characteristics (N=353)
Variable
Agea
Race: White (%)
Yrs Educationb
Marriedc: (%)
Lifetime Convictions
M (SD) / %
38.9 (9.8)
56.0
12.5 (2.5)
15.0
5.2 (9.3)
Range Across Sites
32.3 – 46.4
8.8 – 97.1
11.6 – 13.2
0 – 40.0
1.6 – 11.8
Chronic Medical Problemsd: % yes
Mental Health Visits 30de
12-Step Attendancef
45
10.4 (9.6)
16.1 (12.7)
26 – 86
5.4 – 19.1
4.7 – 24.4
CAPS Total Scoreg
BSI Depression Subscaleh
56.4 (17.5)
6.7 (5.1)
45.6 – 66.9
4.1 – 8.1
a
b
c
d
Chi-sq=73.9(6), p-value<0.001; Chi-sq =48.1(6), p-value<0.001; Chi-sq=73.7(30), p-value<0.001;
;e
f
g
Chi-sq=20.1(6), p-value=0.003 Chi-sq =96.2(6), p-value<0.001; Chi-sq =57.7(6), p-value<0.001; Chih
sq =31.8(6), p-value<.001; Chi-sq=18.9(6), p-value<0.001
ASI Alcohol & Drug Composite Scores
(N=353)
Trauma Characteristics (N=353)
 Partner Violence
261 (73.9)
 Partner Sexual Violence
117 (33.1)
 Childhood Physical Abuse
205 (58.1)
 Childhood Sexual Abuse
244 (69.1)
*Taken from the Life Events Checklist
 Traumatic Events*
 Physical Assault 91.8%
 Sexual Assault 89.2%
 Other Unwanted Sexual
Experience 81.9%
 Sudden Unexpected Death
79.0%
 Transportation Accident 72.5%
 Assault with Weapon 71.7%
Trauma Exposure (N=353)*
PTSD Diagnosis – Full vs Subthreshold
(N=353)*
PTSD Symptom Severity (CAPS Subscales)
(N=353)*
Summary
Consistent across sites:
 High levels of multiple trauma exposure with clinically significant PTSD
symptoms.
 High percentage of sexual assaults (range=85%-100%).
 High rates of service utilization (i.e. 12 step, medical and mental health
visits).
 Low overall depression levels, but with clinically significant subgroup
with higher depression scores.
Differences across sites:
 Types of other traumatic experiences reported.
 Types of drugs used and drug diagnosis.
 Recruitment success linked to type of CTP population and number of
available intakes.
Implications
 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.
 Clinicians and researchers need to be aware of the potential
for such differences when developing or delivering
treatment interventions so as to best meet needs of this
heterogeneous group.
Implementation Issues
 Intervention Delivery
Weeks in treatment
Number and type of sessions received
Number of participants in each group session
Session length
 Therapist
Characteristics
Adherence Levels
Race/Ethnicity
Alliance
 Treatment as Usual
Gender/Trauma services
Additional Challenges



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

Training and re-training replacements
Varied levels of experience and education
Slow start up
Slow recruitment
Adherence levels (Seeking Safety)
Multi-site communication
Overview of Stage of Science
 Treatment outcome research which examines longer-term
interventions is urgently needed.
 Improving retention remains a clinical challenge.
 Studies are needed which test effects of elements such as:
 timing of sessions in the context of substance abuse treatment,
optimal dose,
combination psychopharmacology and behavioral interventions,
mechanisms/mediators of treatment outcomes (i.e., emotion
regulation)
how and when to add other behavioral approaches such as
exposure therapy.
Support
Participation in this study made possible by:
 NIDA CTN Long Island Regional Node
 NIDA/NIH Grant U10 DA13035
We would like to acknowledge all of the staff
and participants who made this study possible.