Denise A. Hien

Do Treatment Improvements in PTSD Severity Affect Substance Use Outcomes? A Secondary Analysis From a Randomized Clinical Trial in NIDA's Clinical Trials Network

OBJECTIVEnThe purpose of the analysis was to examine the temporal course of improvement in symptoms of posttraumatic stress disorder (PTSD) and substance use disorder among women in outpatient substance abuse treatment.nnnMETHODnParticipants were 353 women randomly assigned to 12 sessions of either trauma-focused or health education group treatment. PTSD and substance use assessments were conducted during treatment and posttreatment at 1 week and after 3, 6, and 12 months. A continuous Markov model was fit on four defined response categories (nonresponse, substance use response, PTSD response, or global response [improvement in both PTSD and substance use]) to investigate the temporal association between improvement in PTSD and substance use symptom severity during the studys treatment phase. A generalized linear model was applied to test this relationship over the follow-up period.nnnRESULTSnSubjects exhibiting nonresponse, substance use response, or global response tended to maintain original classification; subjects exhibiting PTSD response were significantly more likely to transition to global response over time, indicating maintained PTSD improvement was associated with subsequent substance use improvement. Trauma-focused treatment was significantly more effective than health education in achieving substance use improvement, but only among those who were heavy substance users at baseline and had achieved significant PTSD reductions.nnnCONCLUSIONSnPTSD severity reductions were more likely to be associated with substance use improvement, with minimal evidence of substance use symptom reduction improving PTSD symptoms. Results support the self-medication model of coping with PTSD symptoms and an empirical basis for integrated interventions for improved substance use outcomes in patients with severe symptoms.

Multisite Randomized Trial of Behavioral Interventions for Women With Co-Occurring PTSD and Substance Use Disorders

The authors compared the effectiveness of the Seeking Safety group, cognitive-behavioral treatment for substance use disorder and posttraumatic stress disorder (PTSD), to an active comparison health education group (Womens Health Education [WHE]) within the National Institute on Drug Abuses Clinical Trials Network. The authors randomized 353 women to receive 12 sessions of Seeking Safety (M = 6.2 sessions) or WHE (M = 6.0 sessions) with follow-up assessment 1 week and 3, 6, and 12 months posttreatment. Primary outcomes were the Clinician Administered PTSD Scale (CAPS), the PTSD Symptom Scale-Self Report (PSS-SR), and a substance use inventory (self-reported abstinence and percentage of days of use over 7 days). Intention-to-treat analysis showed large, clinically significant reductions in CAPS and PSS-SR symptoms (d = 1.94 and 1.12, respectively) but no reliable difference between conditions. Substance use outcomes were not significantly different over time between the two treatments and at follow-up showed no significant change from baseline. Study results do not favor Seeking Safety over WHE as an adjunct to substance use disorder treatment for women with PTSD and reflect considerable opportunity to improve clinical outcomes in community-based treatments for these co-occurring conditions.

The Impact of Cumulative Maternal Trauma and Diagnosis on Parenting Behavior

This study examines the relative contributions of cumulative maternal trauma, substance use, depressive and posttraumatic stress diagnoses on parental abuse potential, punitiveness, and psychological and physical aggression in a sample of 176 urban mothers. Participants were categorized into four groups: substance use (n = 41), depressed (n = 40), comorbid (n = 47), and control (n = 48). Participants in the three diagnostic groups reported significantly greater interpersonal trauma exposure than did controls. Hierarchical regressions reveal that cumulative trauma is a significant predictor of all parenting outcomes, even after controlling for demographic and diagnostic variables. Substance use and depression are significantly related to abuse potential, and PTSD is significantly negatively related to physical discipline, with no other significant associations between diagnostic status and parenting outcomes. These findings add to an important growing literature examining the impact of cumulative trauma on parental functioning. Implications for future research and parenting interventions are discussed.

Interpersonal partner violence and women in the United States: An overview of prevalence rates, psychiatric correlates and consequences and barriers to help seeking

Intimate partner violence Battered females At risk populations Mental disorders Help seeking behavior Epidemiology

The Impact of Trauma-Focused Group Therapy upon HIV Sexual Risk Behaviors in the NIDA Clinical Trials Network “Women and Trauma” Multi-Site Study

Women in drug treatment struggle with co-occurring problems, including trauma and post-traumatic stress disorder (PTSD), which can heighten HIV risk. This study examines the impact of two group therapy interventions on reduction of unprotected sexual occasions (USO) among women with substance use disorders (SUD) and PTSD. Participants were 346 women recruited from and receiving treatment at six community-based drug treatment programs participating in NIDA’s Clinical Trials Network. Participants were randomized to receive 12-sessions of either seeking safety (SS), a cognitive behavioral intervention for women with PTSD and SUD, or women’s health education (WHE), an attention control psychoeducational group. Participants receiving SS who were at higher sexual risk (i.e., at least 12 USO per month) significantly reduced the number of USO over 12-month follow up compared to WHE. High risk women with co-occurring PTSD and addiction may benefit from treatment addressing coping skills and trauma to reduce HIV risk.

Trauma and trauma-related disorders for women on methadone: prevalence and treatment considerations.

There is a growing recognition of the strong association between psychoactive substance abuse and violence. Repeated exposure to violent trauma is particularly salient for women. Moreover, violent trauma may play a role in the etiologies of depression, substance abuse, and trauma-related disorders, such as posttraumatic stress disorder (PTSD). For the female methadone patient, an untreated trauma-related disorder can be a hidden factor that hinders treatment response and leads to treatment complications, such as depression, polysubstance abuse, or treatment drop out. This article reviews the prevalence of trauma and violence for women on methadone, comparing low-income, inner-city female drug abusers with males in methadone treatment on childhood and adulthood exposure to violent trauma and PTSD. Because women are in a minority in methadone maintenance treatment programs, standard treatment approaches have generally not focused on their particular issues and needs. Two alternative models are presented for group treatment of trauma and trauma-related disorders in female methadone patients; potential benefits of each in reducing symptomatology and improving interpersonal functioning are examined. Modification of standard approaches and the typical barriers to engagement in treatment for this special population are also addressed.

The role of alcohol misuse in PTSD outcomes for women in community treatment: A secondary analysis of NIDA's Women and Trauma Study

BACKGROUNDnIndividuals with comorbid substance use and posttraumatic stress disorder may differentially benefit from integrated trauma-focused interventions based on specific presenting characteristics such as substance use type and PTSD severity. The current study is a secondary analysis of a NIDA Clinical Trials Network study exploring the effectiveness of two interventions for women with comorbid PTSD and substance use disorders.nnnMETHODnGeneralized estimating equations were used to examine the association of baseline alcohol misuse with PTSD outcome measures over time for all randomized participants.nnnRESULTSnWomen entering treatment with baseline alcohol misuse had higher Post Traumatic Stress Disorder Symptom Scale (PSS-SR) total scores (t=2.43, p<.05), cluster C (avoidance/numbing) scores (t=2.63, p<.01), and cluster D (hyper-arousal) scores (t=2.31, p<.05). For women with alcohol misuse, after treatment week 1, PSS-SR scores were significantly lower in the Seeking Safety intervention during treatment (chi(2)(1)=4.00, p<.05) and follow-up (chi(2)(1)=4.87, p<.05) compared to those in the health education intervention. Alcohol misusers in the Seeking Safety group who had higher baseline hyper-arousal severity improved more quickly than those with lower baseline hyper-arousal severity during treatment (chi(2)(1)=4.06, p<.05).nnnCONCLUSIONSnThese findings suggest that the type of substance abuse at treatment entry may inform treatment selection, predict treatment response among those with co-occurring PTSD and substance use disorders, and indicate a more severe clinical picture.

Survey of eating disorder symptoms among women in treatment for substance abuse.

A strong association between substance use disorders (SUDs) and eating disorders (EDs) in women has been established. Yet, little is known about the rates and impact of ED symptoms in women presenting to addiction treatment. The current investigation assessed the prevalence of ED symptoms and their effect on treatment outcomes in a sample of substance abusing women with co-occurring posttraumatic stress disorder (PTSD) enrolled in outpatient substance use programs. Participants were 122 women who participated in a multisite clinical trial comparing two behavioral treatments for co-occurring SUD and PTSD. The Eating Disorder Examination-self report, and measures of PTSD and SUD symptoms were administered at baseline, during treatment and at four follow-up points. Two subgroups emerged; those reporting binge eating in the 28 days prior to baseline (Binge group; n = 35) and those who reported no binge eating episodes (No Binge group; n = 87). Women in the Binge group endorsed significantly higher ED, PTSD, and depression symptoms at baseline than those in the No Binge group. Although all participants showed significant reductions in PTSD symptoms and improvements in abstinence rates during the study period, the improvements for the Binge group were significantly lower. These findings suggest that a subgroup of women with co-occurring PTSD and SUDs, who endorsed binge ED symptoms, responded differently to SUD/PTSD group treatment. Identification of ED symptoms among treatment-seeking women with SUDs may be an important element in tailoring interventions and enhancing treatment outcomes.

Child Maltreatment and Adulthood Violence: The Contribution of Attachment and Drug Abuse

This study examined the association between child maltreatment and adult violence in a high-risk sample of women with and without a history of cocaine abuse and the contribution of working models of childhood attachment relationships in understanding this association. Results indicated that whereas childhood physical abuse was associated with adult sexual victimization for cocaine-abusing women, sexual abuse was associated with both partner violence victimization and perpetration for comparison women. Insecure working models of attachment were associated with partner violence victimization for comparison women, independent of the effect of sexual abuse. These findings suggest the importance of research focused on understanding the processes by which child maltreatment may lead to later violence and that examines both childhood and adulthood experiences in understanding pathways to adult violence.

Intimate Partner Violence Outcomes in Women with PTSD and Substance Use: A Secondary Analysis of NIDA Clinical Trials Network “Women and Trauma” Multi-Site Study

Studies have shown strong associations between intimate partner violence (IPV) and both posttraumatic stress disorder (PTSD) and substance use disorders (SUD). Despite these linkages, research on the dual diagnosis of PTSD-SUD and its relationship to IPV is in an early stage, and little is known about how PTSD-SUD treatment might influence IPV outcomes. The current study is a secondary analysis of a larger NIDA Clinical Trials Network study exploring the effectiveness of two behavioral interventions for women with comorbid PTSD-SUD. Participants (n=288) were randomly assigned to Seeking Safety (SS), a cognitive-behavioral treatment that focuses on trauma and substance abuse symptoms, or to Womens Health Education, a psychoeducational group. Logistic regressions were used to examine how treatment condition, identified risk factors and their interactions were related to IPV. Results showed that participants who were abstinent at baseline were significantly less likely to experience IPV over the 12-month follow-up period, whereas participants living with someone with an alcohol problem were significantly more likely to experience IPV over follow-up. Findings also showed that at a trend level participants with recent interpersonal trauma at baseline and higher total of lifetime trauma exposures were more likely to report IPV during follow-up. Although there was no main effect for treatment condition, a significant interaction between treatment condition and baseline abstinence was found. Participants who were abstinent at baseline and in the SS condition were significantly less likely to report IPV over follow-up. These findings indicate that an integrated treatment for PTSD and SUD was associated with significantly better IPV outcomes for a subset of individuals. The possibility that women with PTSD-SUD may differentially benefit from SS has important clinical implications. Further research examining the intersection of PTSD, SUD and IPV, and the impact of treatment on a range of outcomes is needed.