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Integrated exposure-based therapy effective for comorbid PTSD and substance dependence

Clinical Question:
Is exposure-based therapy combined with standard substance abuse treatment effective for adults with co-occurring posttraumatic stress disorder and substance dependence?

Bottom Line:
The combined use of prolonged exposure therapy with standard substance dependence treatment is more effective for reducing posttraumatic stress disorder (PTSD) severity scores than substance dependence therapy only in the management of adults with co-occurring PTSD and substance dependence. (LOE = 1b-)

Mills KL, Teesson M, Back SE, et al. Integrated exposure-based therapy for co-occurring posttraumatic stress disorder and substance dependence. A randomized controlled trial. JAMA 2012;308(7):690-699.  [PMID:22893166]

Study Design:
Randomized controlled trial (single-blinded)



Outpatient (specialty)

Although exposure therapy, a cognitive-behavioral therapy that exposes patients to memories of past trauma, is effective in the treatment of PTSD, there is concern that it may increase the risk of relapse in patients with co-occurring substance dependence. These investigators identified adults (N = 103), 18 years or older, meeting standard diagnostic criteria for both PTSD and substance dependence. Patients randomly received assignment (uncertain allocation concealment) to either (1) treatment consisting of a standardized integrated treatment program, including prolonged exposure therapy plus usual treatment for substance dependence; or (2) a control group consisting only of usual treatment for substance dependence. The intervention group consisted of 13 individual 90-minute sessions with trained clinical psychologists. Ten percent of treatment sessions were randomly evaluated to assess compliance with the therapy manual. Usual treatment for substance dependence included available community counseling, detoxification programs, and residential rehabilitation. Individuals conducting evaluation interviews who used standard rating tools for PTSD and substance dependence severity remained masked to treatment group assignment. Complete follow-up interviews at 6 weeks, 3 months, and 9 months occurred for only 55.3% of participants, but 90.3% completed at least 1 of the 3 follow-up interviews. Drugs of concern included heroin, cannabis, amphetamines, benzodiazepines, alcohol, cocaine, and other opiates and hallucinogens. Using intention-to-treat analysis, the treatment group demonstrated a significant reduction in Clinician-Administered PTSD Scale scores compared with the control group (mean difference = -16.09; 95% CI, -29.00 to -3.19; range = 0 to 240, higher scores indicating more severe PTSD). The authors state that a difference of 15 points on the standardized PTSD symptom severity evaluation tool is considered clinically significant. There were no significant between-group differences in severity of substance dependence, substance use, depression, anxiety, or suicide attempts.


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