Clinical challenges in the treatment of patients with posttraumatic stress disorder and substance abuse. Curr Opin Psychiatry

Department of Psychiatry and Psychotherapy, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.
Current Opinion in Psychiatry (Impact Factor: 3.94). 12/2007; 20(6):614-8. DOI: 10.1097/YCO.0b013e3282f0ffd9
Source: PubMed


The aim of this article is to review the current literature on co-occuring posttraumatic stress disorder and substance-use disorder, with an emphasis on clinical aspects and emerging treatments.
In clinical populations (focusing on either disorder), about 25-50% have a lifetime dual diagnosis of posttraumatic stress disorder and substance-use disorder. Patients with both disorders have a more severe clinical profile than those with either disorder alone, lower functioning, poorer well being, and worse outcomes across a variety of measures. In recent years, several promising treatment programs have been developed specifically for co-occuring posttraumatic stress disorder and substance-use disorder, with one model having been established as effective thus far.
Comorbid posttraumatic stress disorder/substance-use disorder is a frequent diagnosis in clinical populations that severely affects course and outcome. Treatment approaches appropriate for this vulnerable population need to be evaluated further and implemented in routine practice.

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    • "We believe that psycho-education about psychopathology and trauma should be an early part of detoxification for this subgroup in addition to information on integrated treatment possibilities for addiction and comorbid disorders. Subsequent addiction treatment should integrate psychotherapy components for comorbid disorders such as posttraumatic stress disorder [46]. This might prevent, reduce or reverse ‘bounceback’ developments and increase the patients’ hope that a change of behavior is possible. "
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    ABSTRACT: Motivation to change has been proposed as a prerequisite for behavioral change, although empirical results are contradictory. Traumatic experiences are frequently found amongst patients in alcohol treatment, but this has not been systematically studied in terms of effects on treatment outcomes. This study aimed to clarify whether individual Trauma Load explains some of the inconsistencies between motivation to change and behavioral change. Over the course of two months in 2009, 55 patients admitted to an alcohol detoxification unit of a psychiatric hospital were enrolled in this study. At treatment entry, we assessed lifetime Trauma Load and motivation to change. Mode of discharge was taken from patient files following therapy. We tested whether Trauma Load moderates the effect of motivation to change on dropout from alcohol detoxification using multivariate methods. 55.4% dropped out of detoxification treatment, while 44.6% completed the treatment. Age, gender and days in treatment did not differ between completers and dropouts. Patients who dropped out reported more traumatic event types on average than completers. Treatment completers had higher scores in the URICA subscale Maintenance. Multivariate methods confirmed the moderator effect of Trauma Load: among participants with high Trauma Load, treatment completion was related to higher Maintenance scores at treatment entry; this was not true among patients with low Trauma Load. We found evidence that the effect of motivation to change on detoxification treatment completion is moderated by Trauma Load: among patients with low Trauma Load, motivation to change is not relevant for treatment completion; among highly burdened patients, however, who a priori have a greater risk of dropping out, a high motivation to change might make the difference. This finding justifies targeted and specific interventions for highly burdened alcohol patients to increase their motivation to change.
    Substance Abuse Treatment Prevention and Policy 03/2013; 8(1):14. DOI:10.1186/1747-597X-8-14 · 1.16 Impact Factor
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    • "The last ten years of research has verified that mental disorders are associated with risk for later substance use conditions (Swendsen et al., 2010). There have been reviews of " comorbid " conditions over that time but most have focused on treatment of a particular non-substance condition and substance abuse, e.g., schizophrenia and substance abuse (Wobrock and Soyka, 2009), Attention Deficit Hyperactivity Disorder (ADHD) and SUD (Upadhyaya, 2007), Post Traumatic Stress Disorder (PTSD) and substance abuse (Schafer and Navajits, 2007). "
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    ABSTRACT: To update clinicians on the latest in evidence-based treatments for substance use disorders (SUD) and non-substance use disorders among adults and suggest how these treatments can be combined into an evidence-based process that enhances treatment effectiveness in comorbid patients. Articles were extracted from Pubmed using the search terms "dual diagnosis," "comorbidity" and "co-occurring" and were reviewed for evidence of effectiveness for pharmacologic and psychotherapeutic treatments of comorbidity. Twenty-four research reviews and 43 research trials were reviewed. The preponderance of the evidence suggests that antidepressants prescribed to improve substance-related symptoms among patients with mood and anxiety disorders are either not highly effective or involve risk due to high side-effect profiles or toxicity. Second generation antipsychotics are more effective for treatment of schizophrenia and comorbid substance abuse and current evidence suggests clozapine, olanzapine and risperidone are among the best. Clozapine appears to be the most effective of the antipsychotics for reducing alcohol, cocaine and cannabis abuse among patients with schizophrenia. Motivational interviewing has robust support as a highly effective psychotherapy for establishing a therapeutic alliance. This finding is critical since retention in treatment is essential for maintaining effectiveness. Highly structured therapy programs that integrate intensive outpatient treatments, case management services and behavioral therapies such as Contingency Management (CM) are most effective for treatment of severe comorbid conditions. Creative combinations of psychotherapies, behavioral and pharmacological interventions offer the most effective treatment for comorbidity. Intensity of treatment must be increased for severe comorbid conditions such as the schizophrenia/cannabis dependence comorbidity due to the limitations of pharmacological treatments.
    Addictive behaviors 01/2012; 37(1):11-24. DOI:10.1016/j.addbeh.2011.09.010 · 2.76 Impact Factor
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    ABSTRACT: Substance use disorders (SUD) and mental health disorders are often thought of as completely separate problems even though these disorders commonly co-occur. Among adolescents who seek treatment for substance use problems, co-occurring mental health problems (MHP) are common. This is concerning because co-occurring disorders among adults have been associated with more severe MHPs, relapsing to substance use sooner, being less likely to maintain abstinence, and other problems. Despite the awareness that co-occurring disorders are problematic for adolescents, few studies have been conducted to understand these problems with an adolescent sample. The purpose of this study was to understand if factors commonly related to co-occurring disorders among adults were the same for adolescents and to examine two measurement models for the dependent variable, substance use. This secondary analysis of data first examined characteristics that are related to MHPs among a sample of adolescents (N=801) who use substances. Factors in three domains were examined: demographics, substance use, social factors. The results indicated that among these adolescents, MHPs were common. Two key factors related to having a MHP were gender and the severity of the SUD. Females and adolescents with more severe SUDs, like dependence, were more likely to have MHPs. Furthermore, severity of the SUD partially mediated the relationship between several of the other factors and MHPs. The type of substance an adolescent reported using was also important. In addition, adolescents who had more peers and more family members who participated in deviant activities had more severe substance use problems and were more likely to have a MHP. In addition to examining the factors related to mental health problems among a substance using population, this study modeled the dependent variable in two different ways which had not been done before and allowed for variance in the measure to be accounted for in the model. MHPs were measured both continuously and categorically. The results of the comparison indicated that there were not major differences between the two models. Implications for social work practice, policy and research are discussed.
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