https://orcid.org/0000-0001-6298-1519
In the first part of our Special Issue focused on the intersection of trauma and substance misuse, we highlighted the complexities of heterogeneity in the etiology and treatment of related comorbidities (Roche & Foster, Citation2023). Specifically, the issue included investigations of heterogeneity related to their co-occurrence, including: (1) what sources and severities of trauma and related reactions modulate substance misuse onset, escalation, and prognosis (Jegede et al., Citation2023; Ferrie et al., Citation2023), (2) what individual-level characteristics and contexts catalyze risk for trauma and substance misuse comorbidity (Beck et al., Citation2023 Leonard et al., Citation2023, and North & Pfefferbaum Citation2023), (3) who should be screened for substance misuse and when following trauma exposure (North & Pfefferbaum Citation2023), and (4) which treatment integrations and adaptations would be most accessible and beneficial for implementation by which clinicians and for which patients (Ware et al., Citation2023; Vujanovic et al., Citation2023)? The second of our two-part Special Issue continues these lines of inquiry and the general themes of the first issue. Here, we present five additional studies addressing (1) person-to-person variation in dynamics between co-occurring post-traumatic stress disorder (PTSD) symptoms and substance misuse in vulnerable subpopulations (Moskal et al., Citation2024) and/or (2) considerations in the length, structure, targets, and outcomes for treatments of trauma symptoms comorbid with substance use disorder (SUD; Balderrama-Durbin et al., Citation2024; Watkins et al., Citation2024; Israel et al., Citation2024; Ralevski et al., Citation2024).
There is a need for novel, efficacious pharmacological and psychotherapeutic treatments to specifically target comorbid psychiatric disorders. Co-occurring disorders—like PTSD co-morbid with SUD and/or alcohol use disorder (AUD)—naturally amplify case complexity, heterogeneity, and severity relative to either condition alone. In particular, cross-diagnostic cascades and dynamics often warrant more extensive and prolonged psychotherapy. At the same time, treatment drop-out rates and engagement are typically worst for those with co-occurring conditions, signaling the challenges of administering the level of care often needed or administering treatment for each diagnosis sequentially.
Consequently, demand is high for development of concurrent, brief but potent psychotherapeutic interventions supporting rapid remediation of complex constellations of PTSD and SUD symptoms in this heterogeneous group. Two reports included in this special issue explore the use of brief intervention approaches to address bidirectional PTSD and SUD symptoms links among Veterans. First, Watkins and colleagues (Citation2024) report results from an effective short-term, concurrent treatment approach, noting that substance use improvement over the first post-treatment month varied as a function of trauma symptoms at the close of treatment. In a complementary investigation of cross-diagnostic symptom remediation across a brief, integrated treatment in primary care, Balderrama-Durbin and colleagues (Citation2024) detected yoked reductions in post-traumatic stress symptoms and heavy drinking. Severity in each problem predicted rates of decline in the other at both a granular timescale during treatment (i.e., from session-to-session) and at a protracted timescale following brief treatment (i.e., 8- and 14-weeks post-treatment). Overall these two reports suggest that, despite the inherent complexity, heterogeneity, and severity characteristic of co-morbid PTSD and SUD, shortened treatments can yield improvement in both symptom domains, with sustained gains likely dependent on the extent to which rapid reductions can be jointly achieved in both trauma and substance use domains by the end of treatment.
Alongside these studies of treatment integrations for addressing comorbid symptoms, Israel and colleagues (Citation2024) present a proposal for augmenting the classic phasic treatment for TRD via integrative deployment of harm reduction principles in what they coin a “prestabilization” phase of treatment for TRD + OUD. Phase 0 prestabilization is intended as a period of active, patient-centered outreach and engagement where treatment team members build positive rapport and flexibly adjust to the complex challenges and barriers present for the patient owing to the heterogeneity in their experiences of TRD + OUD comorbidity.
Despite the synergistic, deleterious consequences of co-occurring PTSD and SUD/AUD, there are no currently approved medications to treat this comorbidity; this lack of effective pharmacotherapies for this subpopulation has been attributed to both the complex, heterogeneous symptom presentation of the PTSD-SUD/AUD as well as the highly variable medication treatment responses observed across cases. Progesterone is a gonadal hormone that has direct and indirect effects on a variety of extra- and intra-cellular signaling systems, many of which are disrupted in AUD and PTSD. In this issue, a pilot laboratory study by Ralevski and colleagues (Citation2024) is the first to demonstrate that 3-days of progesterone (200 mg BID) treatment, vs. placebo, reduces trauma imagery-induced craving and negative mood in individuals with comorbid AUD and PTSD. When taken together, promising treatment findings from Watkins (Citation2024), Balderrama-Durbin (Citation2024), and Ralevski (Citation2024), as well as a new treatment framework provided by Israel (2024), signal advances in methodologies and approaches poised to capture treatment variability across settings and presenting problems (e.g., different primary substances of misuse). The multi-pronged treatment approaches showcased in this Special Issue are necessary to overcome the barriers presented by the heterogeneous clinical presentations and treatment needs of individuals with co-occurring PTSD and AUD, a complexity which is compounded by the current lack of available treatment options broadly effective for comorbid symptom remediation.
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The authors declare there is no competing interest at this study.
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References
- Balderrama-Durbin, C., Barden, E. P., Gates, M. V., Hill, J., Mastroleo, N. R., Possemato, K., King, P. R., & Rauch, S. A. M. (2024). Examining the temporal relation between posttraumatic stress symptoms and heavy drinking among veterans receiving mental health treatment in primary care. Journal of Dual Diagnosis, 20(1), 29–38. https://doi.org/10.1080/15504263.2023.2294985
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