HHS Public Access Author manuscript Author Manuscript
J Subst Use. Author manuscript; available in PMC 2017 January 01. Published in final edited form as: J Subst Use. 2016 ; 21(3): 237–243. doi:10.3109/14659891.2015.1005184.
The influence of family and social problems on treatment outcomes of persons with co-occurring substance use disorders and PTSD Elizabeth C. Saunders, BA1, Bethany M. McLeman, BA1, Mark P. McGovern, PhD2, Haiyi Xie, PhD3, Chantal Lambert-Harris, MA4, and Andrea Meier, MS4
Author Manuscript
1Dartmouth
Psychiatric Research Center, Geisel School of Medicine at Dartmouth, 85 Mechanic Street, Suite B4-1, Lebanon, NH, USA
2Department
of Psychiatry and of Community and Family Medicine, Geisel School of Medicine at Dartmouth, Lebanon, NH, USA
3Department
of Community & Family Medicine, Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire, USA
4Department
of Psychiatry, Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire,
USA
Abstract Author Manuscript
Objective—Family and social problems may contribute to negative recovery outcomes in patients with co-occurring substance use and psychiatric disorders, yet few studies have empirically examined this relationship. This study investigates the impact of family and social problems on treatment outcomes among patients with co-occurring substance use and posttraumatic stress disorder (PTSD). Method—A secondary analysis was conducted using data collected from a randomized controlled trial of an integrated therapy for patients with co-occurring substance use and PTSD. Substance use, psychiatric symptoms, and social problems were assessed. Longitudinal outcomes were analyzed using generalized estimating equations (GEE) and multiple linear regression.
Author Manuscript
Results—At baseline, increased family and social problems were associated with more severe substance use and psychiatric symptoms. Over time, all participants had comparable decreases in substance use and psychiatric problem severity. However, changes in family and social problem severity were predictive of PTSD symptom severity, alcohol use, and psychiatric severity at follow-up. Conclusions—For patients with co-occurring substance use and PTSD, family and social problem severity is associated with substance use and psychiatric problem severity at baseline and over time. Targeted treatment for social and family problems may be optimal.
Correspondence should be addressed to: Elizabeth Saunders, Dartmouth Psychiatric Research Center, 85 Mechanic Street, Suite B4-1, Lebanon, New Hampshire, 03766 USA. Tel: 603-448-0263; [email protected].
Saunders et al.
Page 2
Author Manuscript
Keywords family and social problems; posttraumatic stress disorder; substance use
INTRODUCTION
Author Manuscript
Social problems are common for patients in substance abuse treatment and are characterized by high levels of interpersonal conflict and violence, isolation and abandonment, and marital discord (Sugaya et al., 2011; Thompson & Bland, 1995; Whisman, 1999). Involvement in high risk social networks and unstable family situations contributes to stress and increases substance use vulnerability (Harris, Fallot, & Berley, 2005; McLellan, Cacciola, Alterman, Rikoon, & Carise, 2006). Research suggests that problems with family and social relationships may decrease addiction treatment benefit and contribute to high rates of relapse and re-hospitalization (Benda, 2001; Brewer, Catalano, Haggerty, Gainey, & Fleming, 1998; Kline-Simon et al., 2013; Sanchez-Hervas et al., 2012). For individuals in mental health treatment, family and social problems are likewise associated with high rates of anxiety, depression, and violent behavior (Jordan et al., 1996; Taft et al., 2009; Tracy, Munson, Peterson, & Floersch, 2010). Significant social problems contribute to worsening psychiatric symptoms (Bryant-Davis, Ullman, Tsong, & Gobin, 2011; Marsden, Gossop, Stewart, Rolfe, & Farrell, 2000; Tracy & Biegel, 2006). Additionally, family and social problems are predictors of recurrent depressive episodes and suicide attempts (Beach, Wamboldt, Kaslow, Heyman, & Reiss, 2006; Hooley & Teasdale, 1989; Vilhjalmsson, Kristjansdottir, & Sveinbjarnardottir, 1998).
Author Manuscript
Social problems also add to treatment complications for individuals with co-occurring substance use and psychiatric disorders (Dutton, Adams, Bujarski, Badour, & Feldner, 2014; Peirce, Kindbom, Waesche, Yuscavage, & Brooner, 2008). For dually diagnosed patients, social problems appear to decrease quality of life and the chance of maintaining sobriety (Marsden et al., 2000; Nayback-Beebe & Yoder, 2011; Tracy & Biegel, 2006). Individuals with comorbid disorders have more family and social problems than individuals with only a single disorder (Peirce et al., 2008). Although substance use and psychiatric symptoms may impact levels of social problems, research shows that social problems also increase subjective distress and may negatively impact both psychiatric and addiction treatment outcomes (Alterman, McLellan, & Shifman, 1993; Moylan, Jones, Haug, Kissin, & Svikis, 2001; Peirce et al., 2008).
Author Manuscript
Family and social problems are particularly prevalent among patients with the specific comorbidity of posttraumatic stress disorder (PTSD) and substance use (Nayback-Beebe & Yoder, 2011). Individuals with social problems have increased risk for exposure to traumatic events and subsequent development of PTSD (Brewin, Andrews, & Valentine, 2000; Nayback-Beebe & Yoder, 2011; Ozer, Best, Lipsey, & Weiss, 2003). After experiencing a trauma, individuals with more significant social problems also have more severe PTSD symptoms than individuals with fewer social problems (Dutton et al., 2014; Golding, Wilsnack, & Cooper, 2002; Wright, Kelsall, Sim, Clarke, & Creamer, 2013). While social support appears to protect individuals against worsening PTSD symptoms, preliminary J Subst Use. Author manuscript; available in PMC 2017 January 01.
Saunders et al.
Page 3
Author Manuscript
evidence shows that social problems may contribute to increased PTSD symptom severity over time (Charuvastra & Cloitre, 2008; DiGangi et al., 2013; Ozer et al., 2003). Unfortunately, severe PTSD and substance use symptoms can also influence levels of social problems, contributing to a cycle of worsened mental health (Fontana, Rosenheck, & Desai, 2012). Past research suggests that having significant social problems negatively impacts treatment outcomes for patients with either a substance use or PTSD (Brewer et al., 1998; Charney, Zikos, & Gill, 2010; Evans, Cowlishaw, & Hopwood, 2009). Despite this, it’s unclear how social problems affect treatment outcomes for patients with comorbid substance use and PTSD. Therefore, the present study sought to evaluate the impact of social problems on treatment outcomes among patients with co-occurring PTSD and substance use disorders. This study aims to address the following questions:
Author Manuscript
1.
Are social problems associated with substance use outcomes?
2.
Are social problems associated with psychiatric symptom outcomes?
3.
Does improvement or deterioration in social problems predict change in substance use or psychiatric symptoms (or vice versa)?
METHODS Procedure
Author Manuscript
A secondary analysis was conducted using data from a randomized controlled trial investigating the efficacy of an integrated therapy for patients with co-occurring substance use and PTSD (McGovern et al., Under Review). All newly admitted substance use patients from seven community addiction treatment centers were screened at intake using the PTSD Checklist-Civilian (PCL-C). Those scoring 44 or above were eligible for a baseline assessment. At baseline, consenting participants were assessed for PTSD by research staff. To be eligible for randomization, participants had to meet current diagnostic criteria for PTSD. Participants were excluded if they had current acute psychotic symptoms, had attempted suicide in the past 30 days, or were under 18 years of age. Participants who consented and met eligibility requirements were randomized to receive one of three treatment options. Assessments were performed at baseline, 3-month, and 6-month followup intervals.
Author Manuscript
Information on substance use, PTSD, psychiatric symptoms, and family and social problems was collected at all three assessments. Demographic data were obtained using the ASI and chart review. Substance use was assessed using the Timeline Follow Back (TLFB), Addiction Severity Index (ASI), and toxicology screens. The Clinician Administered PTSD Scale (CAPS) and ASI were administered to collect data on psychiatric symptoms. Family and social problems were assessed using the ASI. Study design, maintenance, and consent procedures were all monitored and approved by the Trustees of Dartmouth College Committee for the Protection of Human Subjects (CPHS). All research was conducted in accordance with CPHS protections and good clinical practice.
J Subst Use. Author manuscript; available in PMC 2017 January 01.
Saunders et al.
Page 4
Participants and sampling
Author Manuscript
Participants were recruited from seven community-based addiction treatment programs in Vermont and New Hampshire between December 1, 2010 and January 31, 2013. Threehundred fifty-eight participants were assessed for eligibility, 75 of whom did not meet inclusion criteria, primarily due to failure to meet diagnostic criteria for a current PTSD diagnosis. Two-hundred eighty-three participants were randomized to the study. Of the 283, 3- and 6-month follow-up data were obtained from 78.5% and 71.9%, respectively. Treatment interventions
Author Manuscript
All study participants were enrolled in intensive outpatient programs (IOP) for substance abuse. The recruitment sites were state-funded and used the American Society of Addiction Medicine criteria for Level II Intensive Outpatient services (9–12 hours per week), and Level I Outpatient services (at least one hour per month) (American Society of Addiction Medicine, 2013). IOP and aftercare services included both group and individual modalities. The seven programs did vary on several factors, including organizational and staff stability, leadership, access to mental health services and medications, provision of instrumental support, expertise of clinical staff, and finances. Though the sites were heterogeneous, utilizing multiple IOP programs for recruitment enhanced generalizability and external validity.
Author Manuscript
Randomized participants received one of three treatments: Integrated Cognitive Behavioral Therapy (ICBT) plus treatment-as-usual (TAU), Individual Addiction Counseling (IAC) plus TAU, or TAU only. ICBT is a manual-guided individual therapy for co-occurring PTSD and substance use. IAC is a manual-guided individual therapy adapted from the Individual Drug Counseling treatment used in the NIDA Cocaine Collaborative Study. Standard care (TAU) consisted of participation in an addiction-focused intensive outpatient treatment program and aftercare following program completion. Measures PTSD Checklist - Civilian (PCL-C)—The PCL-C is a 27-item, self-report screening measure used to indicate a probable PTSD diagnosis (Weathers, Litz, Herman, Huska, & Keane, 1993). A score of 44 or greater on the PCL-C indicates probable PTSD (Weathers, Litz, Huska, & Keane, 1994).
Author Manuscript
Self-Administered Addiction Severity Index (SA-ASI)—The SA-ASI is a standardized questionnaire assessing problem severity across seven dimensions: medical, employment, alcohol, drug, legal, family/social, and psychiatric (McLellan et al., 1985; Rosen, Henson, Finney, & Moos, 2000). Problem severity scores for the SA-ASI are computed using the same algorithms as the interviewer-administered ASI (McGahan, Griffin, Parente, & McLellan, 1986). The SA-ASI has acceptable validity and internal consistency and was administered at all three assessment periods (Denis, Cacciola, & Alterman, 2013). The ASI family/social problem severity score is comprised of five questions on relationship satisfaction, and conflicts with family and friends. The baseline ASI family/social problem
J Subst Use. Author manuscript; available in PMC 2017 January 01.
Saunders et al.
Page 5
Author Manuscript
severity score was used to split participants into terciles of family and social problem severity. Participants were categorized as having low, moderate, or high severity of social problems. Toxicological data—Both urine drug screen and breathalyzer data were collected at all three assessment periods to confirm active substance use. The AlcoHawk ABI breathalyzer was used to test for recent alcohol use. The One Step Multi-Drug Screen Test Card with Integrated iCup was used to test for recent cannabis, cocaine, benzodiazepine, amphetamine, methamphetamine, and opiate use.
Author Manuscript
Clinician Administered PTSD Scale (CAPS)—The CAPS is a structured diagnostic interview for PTSD (Blake et al., 2000; Weathers, Keane, & Davidson, 2001). A total score of 44 or greater indicates a positive PTSD diagnosis. CAPS total scores between 44 and 64 indicate moderate PTSD. Any CAPS score of 65 or greater is considered severe (Blake et al., 2000). For this study, we focused on current PTSD symptoms (past 30 days). CAPS data were gathered at all three assessment periods. Systematic chart review—Demographic, medication, hospitalization, and treatment services data were extracted from the agencies’ patient records based on common federal requirements for the U.S. Substance Abuse and Mental Health Services Administration Treatment Episode Data Set (TEDS) reporting.
Author Manuscript
90-day Timeline Follow Back (TLFB)—The TLFB is a structured interview surveying frequency and amount of alcohol and illicit substance use over the past 90 days (Sobell, Maisto, Sobell, & Cooper, 1979). The TLFB was administered at all three assessment periods. Data analyses Descriptive statistics were used to examine baseline demographic, substance use, and psychiatric characteristics. Analyses of variance (ANOVA) and chi-square tests compared baseline demographics, substance use, and psychiatric characteristics between the three levels of family/social problem severity. A Tukey HSD post-hoc test of tercile group differences was used for significant ANOVAs. To investigate study attrition, t-tests and chisquared tests were used to compare baseline demographic, substance use, and psychiatric characteristics between participants who attended and did not attend the 6-month follow-up.
Author Manuscript
The longitudinal relationships between family and social problem severity, substance use, and psychiatric outcomes were investigated using generalized estimation equation (GEE) models. To control for potentially confounding group differences at baseline, initial CAPS score, ASI drug severity, gender, age, and psychiatric problem severity score were added to the GEE model as covariates. Although some participants were randomized to receive one of two individual study therapies, the proportions of participants receiving these therapies did not significantly differ by family/social severity tercile. Therefore analyses were not adjusted for treatment type. SPSS version 22.0 was used to complete these data analyses (IBM Corporation, 2012).
J Subst Use. Author manuscript; available in PMC 2017 January 01.
Saunders et al.
Page 6
Author Manuscript
Multiple linear regression analyses were used to determine whether changes in social problem severity predicted substance use and psychiatric outcomes at 6 months. Change in substance use and psychiatric outcomes were included as dependent variables, while change in family and social problems was included as the independent variable. Change scores for family and social problems, PTSD severity, psychiatric severity, and days of substance use were calculated by subtracting scores at the 6-month follow-up from baseline scores. Potentially confounding demographic and clinical variables, such as baseline alcohol severity, drug use severity, psychiatric severity, and CAPS total score, were added to the models as covariates, using a forward selection method. Although race and ethnicity were initially included in the models, these variables were excluded due to high standard error values because of sample homogeneity. Regression analyses were conducted using Stata version 13 (StataCorp, 2013).
Author Manuscript
RESULTS Participant demographics and clinical characteristics Most participants were in their mid-30s, female, Caucasian, not Hispanic or Latino and had never been married (Table 1). The sample endorsed significant social, psychological, and alcohol problems at baseline. All participants met criteria for a substance use disorder diagnosis. At baseline, 21.8% (61) of participants had a positive urine drug or breathalyzer screen. Participants experienced an average of 6.13 (SD=3.42) traumatic events in their lifetime, and 71% (201) had severe PTSD symptoms at baseline.
Author Manuscript
Demographic characteristics including age, gender, race, and ethnicity were similar across the terciles of social problem severity (Table 2). Current marital status was significantly different between the three groups. A greater proportion of participants with high problem severity were either separated or married; this group was also more dissatisfied with their current marital status. Baseline demographic, substance use, and psychiatric characteristics were also compared between participants who attended the 6-month follow-up and participants who did not attend. Study completers were significantly older (m=36.23 years, SD=11.09, versus m=30.62 years, SD=7.47; t(281)=4.08, p
J Subst Use. Author manuscript; available in PMC 2017 January 01. Published in final edited form as: J Subst Use. 2016 ; 21(3): 237–243. doi:10.3109/14659891.2015.1005184.
The influence of family and social problems on treatment outcomes of persons with co-occurring substance use disorders and PTSD Elizabeth C. Saunders, BA1, Bethany M. McLeman, BA1, Mark P. McGovern, PhD2, Haiyi Xie, PhD3, Chantal Lambert-Harris, MA4, and Andrea Meier, MS4
Author Manuscript
1Dartmouth
Psychiatric Research Center, Geisel School of Medicine at Dartmouth, 85 Mechanic Street, Suite B4-1, Lebanon, NH, USA
2Department
of Psychiatry and of Community and Family Medicine, Geisel School of Medicine at Dartmouth, Lebanon, NH, USA
3Department
of Community & Family Medicine, Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire, USA
4Department
of Psychiatry, Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire,
USA
Abstract Author Manuscript
Objective—Family and social problems may contribute to negative recovery outcomes in patients with co-occurring substance use and psychiatric disorders, yet few studies have empirically examined this relationship. This study investigates the impact of family and social problems on treatment outcomes among patients with co-occurring substance use and posttraumatic stress disorder (PTSD). Method—A secondary analysis was conducted using data collected from a randomized controlled trial of an integrated therapy for patients with co-occurring substance use and PTSD. Substance use, psychiatric symptoms, and social problems were assessed. Longitudinal outcomes were analyzed using generalized estimating equations (GEE) and multiple linear regression.
Author Manuscript
Results—At baseline, increased family and social problems were associated with more severe substance use and psychiatric symptoms. Over time, all participants had comparable decreases in substance use and psychiatric problem severity. However, changes in family and social problem severity were predictive of PTSD symptom severity, alcohol use, and psychiatric severity at follow-up. Conclusions—For patients with co-occurring substance use and PTSD, family and social problem severity is associated with substance use and psychiatric problem severity at baseline and over time. Targeted treatment for social and family problems may be optimal.
Correspondence should be addressed to: Elizabeth Saunders, Dartmouth Psychiatric Research Center, 85 Mechanic Street, Suite B4-1, Lebanon, New Hampshire, 03766 USA. Tel: 603-448-0263; [email protected].
Saunders et al.
Page 2
Author Manuscript
Keywords family and social problems; posttraumatic stress disorder; substance use
INTRODUCTION
Author Manuscript
Social problems are common for patients in substance abuse treatment and are characterized by high levels of interpersonal conflict and violence, isolation and abandonment, and marital discord (Sugaya et al., 2011; Thompson & Bland, 1995; Whisman, 1999). Involvement in high risk social networks and unstable family situations contributes to stress and increases substance use vulnerability (Harris, Fallot, & Berley, 2005; McLellan, Cacciola, Alterman, Rikoon, & Carise, 2006). Research suggests that problems with family and social relationships may decrease addiction treatment benefit and contribute to high rates of relapse and re-hospitalization (Benda, 2001; Brewer, Catalano, Haggerty, Gainey, & Fleming, 1998; Kline-Simon et al., 2013; Sanchez-Hervas et al., 2012). For individuals in mental health treatment, family and social problems are likewise associated with high rates of anxiety, depression, and violent behavior (Jordan et al., 1996; Taft et al., 2009; Tracy, Munson, Peterson, & Floersch, 2010). Significant social problems contribute to worsening psychiatric symptoms (Bryant-Davis, Ullman, Tsong, & Gobin, 2011; Marsden, Gossop, Stewart, Rolfe, & Farrell, 2000; Tracy & Biegel, 2006). Additionally, family and social problems are predictors of recurrent depressive episodes and suicide attempts (Beach, Wamboldt, Kaslow, Heyman, & Reiss, 2006; Hooley & Teasdale, 1989; Vilhjalmsson, Kristjansdottir, & Sveinbjarnardottir, 1998).
Author Manuscript
Social problems also add to treatment complications for individuals with co-occurring substance use and psychiatric disorders (Dutton, Adams, Bujarski, Badour, & Feldner, 2014; Peirce, Kindbom, Waesche, Yuscavage, & Brooner, 2008). For dually diagnosed patients, social problems appear to decrease quality of life and the chance of maintaining sobriety (Marsden et al., 2000; Nayback-Beebe & Yoder, 2011; Tracy & Biegel, 2006). Individuals with comorbid disorders have more family and social problems than individuals with only a single disorder (Peirce et al., 2008). Although substance use and psychiatric symptoms may impact levels of social problems, research shows that social problems also increase subjective distress and may negatively impact both psychiatric and addiction treatment outcomes (Alterman, McLellan, & Shifman, 1993; Moylan, Jones, Haug, Kissin, & Svikis, 2001; Peirce et al., 2008).
Author Manuscript
Family and social problems are particularly prevalent among patients with the specific comorbidity of posttraumatic stress disorder (PTSD) and substance use (Nayback-Beebe & Yoder, 2011). Individuals with social problems have increased risk for exposure to traumatic events and subsequent development of PTSD (Brewin, Andrews, & Valentine, 2000; Nayback-Beebe & Yoder, 2011; Ozer, Best, Lipsey, & Weiss, 2003). After experiencing a trauma, individuals with more significant social problems also have more severe PTSD symptoms than individuals with fewer social problems (Dutton et al., 2014; Golding, Wilsnack, & Cooper, 2002; Wright, Kelsall, Sim, Clarke, & Creamer, 2013). While social support appears to protect individuals against worsening PTSD symptoms, preliminary J Subst Use. Author manuscript; available in PMC 2017 January 01.
Saunders et al.
Page 3
Author Manuscript
evidence shows that social problems may contribute to increased PTSD symptom severity over time (Charuvastra & Cloitre, 2008; DiGangi et al., 2013; Ozer et al., 2003). Unfortunately, severe PTSD and substance use symptoms can also influence levels of social problems, contributing to a cycle of worsened mental health (Fontana, Rosenheck, & Desai, 2012). Past research suggests that having significant social problems negatively impacts treatment outcomes for patients with either a substance use or PTSD (Brewer et al., 1998; Charney, Zikos, & Gill, 2010; Evans, Cowlishaw, & Hopwood, 2009). Despite this, it’s unclear how social problems affect treatment outcomes for patients with comorbid substance use and PTSD. Therefore, the present study sought to evaluate the impact of social problems on treatment outcomes among patients with co-occurring PTSD and substance use disorders. This study aims to address the following questions:
Author Manuscript
1.
Are social problems associated with substance use outcomes?
2.
Are social problems associated with psychiatric symptom outcomes?
3.
Does improvement or deterioration in social problems predict change in substance use or psychiatric symptoms (or vice versa)?
METHODS Procedure
Author Manuscript
A secondary analysis was conducted using data from a randomized controlled trial investigating the efficacy of an integrated therapy for patients with co-occurring substance use and PTSD (McGovern et al., Under Review). All newly admitted substance use patients from seven community addiction treatment centers were screened at intake using the PTSD Checklist-Civilian (PCL-C). Those scoring 44 or above were eligible for a baseline assessment. At baseline, consenting participants were assessed for PTSD by research staff. To be eligible for randomization, participants had to meet current diagnostic criteria for PTSD. Participants were excluded if they had current acute psychotic symptoms, had attempted suicide in the past 30 days, or were under 18 years of age. Participants who consented and met eligibility requirements were randomized to receive one of three treatment options. Assessments were performed at baseline, 3-month, and 6-month followup intervals.
Author Manuscript
Information on substance use, PTSD, psychiatric symptoms, and family and social problems was collected at all three assessments. Demographic data were obtained using the ASI and chart review. Substance use was assessed using the Timeline Follow Back (TLFB), Addiction Severity Index (ASI), and toxicology screens. The Clinician Administered PTSD Scale (CAPS) and ASI were administered to collect data on psychiatric symptoms. Family and social problems were assessed using the ASI. Study design, maintenance, and consent procedures were all monitored and approved by the Trustees of Dartmouth College Committee for the Protection of Human Subjects (CPHS). All research was conducted in accordance with CPHS protections and good clinical practice.
J Subst Use. Author manuscript; available in PMC 2017 January 01.
Saunders et al.
Page 4
Participants and sampling
Author Manuscript
Participants were recruited from seven community-based addiction treatment programs in Vermont and New Hampshire between December 1, 2010 and January 31, 2013. Threehundred fifty-eight participants were assessed for eligibility, 75 of whom did not meet inclusion criteria, primarily due to failure to meet diagnostic criteria for a current PTSD diagnosis. Two-hundred eighty-three participants were randomized to the study. Of the 283, 3- and 6-month follow-up data were obtained from 78.5% and 71.9%, respectively. Treatment interventions
Author Manuscript
All study participants were enrolled in intensive outpatient programs (IOP) for substance abuse. The recruitment sites were state-funded and used the American Society of Addiction Medicine criteria for Level II Intensive Outpatient services (9–12 hours per week), and Level I Outpatient services (at least one hour per month) (American Society of Addiction Medicine, 2013). IOP and aftercare services included both group and individual modalities. The seven programs did vary on several factors, including organizational and staff stability, leadership, access to mental health services and medications, provision of instrumental support, expertise of clinical staff, and finances. Though the sites were heterogeneous, utilizing multiple IOP programs for recruitment enhanced generalizability and external validity.
Author Manuscript
Randomized participants received one of three treatments: Integrated Cognitive Behavioral Therapy (ICBT) plus treatment-as-usual (TAU), Individual Addiction Counseling (IAC) plus TAU, or TAU only. ICBT is a manual-guided individual therapy for co-occurring PTSD and substance use. IAC is a manual-guided individual therapy adapted from the Individual Drug Counseling treatment used in the NIDA Cocaine Collaborative Study. Standard care (TAU) consisted of participation in an addiction-focused intensive outpatient treatment program and aftercare following program completion. Measures PTSD Checklist - Civilian (PCL-C)—The PCL-C is a 27-item, self-report screening measure used to indicate a probable PTSD diagnosis (Weathers, Litz, Herman, Huska, & Keane, 1993). A score of 44 or greater on the PCL-C indicates probable PTSD (Weathers, Litz, Huska, & Keane, 1994).
Author Manuscript
Self-Administered Addiction Severity Index (SA-ASI)—The SA-ASI is a standardized questionnaire assessing problem severity across seven dimensions: medical, employment, alcohol, drug, legal, family/social, and psychiatric (McLellan et al., 1985; Rosen, Henson, Finney, & Moos, 2000). Problem severity scores for the SA-ASI are computed using the same algorithms as the interviewer-administered ASI (McGahan, Griffin, Parente, & McLellan, 1986). The SA-ASI has acceptable validity and internal consistency and was administered at all three assessment periods (Denis, Cacciola, & Alterman, 2013). The ASI family/social problem severity score is comprised of five questions on relationship satisfaction, and conflicts with family and friends. The baseline ASI family/social problem
J Subst Use. Author manuscript; available in PMC 2017 January 01.
Saunders et al.
Page 5
Author Manuscript
severity score was used to split participants into terciles of family and social problem severity. Participants were categorized as having low, moderate, or high severity of social problems. Toxicological data—Both urine drug screen and breathalyzer data were collected at all three assessment periods to confirm active substance use. The AlcoHawk ABI breathalyzer was used to test for recent alcohol use. The One Step Multi-Drug Screen Test Card with Integrated iCup was used to test for recent cannabis, cocaine, benzodiazepine, amphetamine, methamphetamine, and opiate use.
Author Manuscript
Clinician Administered PTSD Scale (CAPS)—The CAPS is a structured diagnostic interview for PTSD (Blake et al., 2000; Weathers, Keane, & Davidson, 2001). A total score of 44 or greater indicates a positive PTSD diagnosis. CAPS total scores between 44 and 64 indicate moderate PTSD. Any CAPS score of 65 or greater is considered severe (Blake et al., 2000). For this study, we focused on current PTSD symptoms (past 30 days). CAPS data were gathered at all three assessment periods. Systematic chart review—Demographic, medication, hospitalization, and treatment services data were extracted from the agencies’ patient records based on common federal requirements for the U.S. Substance Abuse and Mental Health Services Administration Treatment Episode Data Set (TEDS) reporting.
Author Manuscript
90-day Timeline Follow Back (TLFB)—The TLFB is a structured interview surveying frequency and amount of alcohol and illicit substance use over the past 90 days (Sobell, Maisto, Sobell, & Cooper, 1979). The TLFB was administered at all three assessment periods. Data analyses Descriptive statistics were used to examine baseline demographic, substance use, and psychiatric characteristics. Analyses of variance (ANOVA) and chi-square tests compared baseline demographics, substance use, and psychiatric characteristics between the three levels of family/social problem severity. A Tukey HSD post-hoc test of tercile group differences was used for significant ANOVAs. To investigate study attrition, t-tests and chisquared tests were used to compare baseline demographic, substance use, and psychiatric characteristics between participants who attended and did not attend the 6-month follow-up.
Author Manuscript
The longitudinal relationships between family and social problem severity, substance use, and psychiatric outcomes were investigated using generalized estimation equation (GEE) models. To control for potentially confounding group differences at baseline, initial CAPS score, ASI drug severity, gender, age, and psychiatric problem severity score were added to the GEE model as covariates. Although some participants were randomized to receive one of two individual study therapies, the proportions of participants receiving these therapies did not significantly differ by family/social severity tercile. Therefore analyses were not adjusted for treatment type. SPSS version 22.0 was used to complete these data analyses (IBM Corporation, 2012).
J Subst Use. Author manuscript; available in PMC 2017 January 01.
Saunders et al.
Page 6
Author Manuscript
Multiple linear regression analyses were used to determine whether changes in social problem severity predicted substance use and psychiatric outcomes at 6 months. Change in substance use and psychiatric outcomes were included as dependent variables, while change in family and social problems was included as the independent variable. Change scores for family and social problems, PTSD severity, psychiatric severity, and days of substance use were calculated by subtracting scores at the 6-month follow-up from baseline scores. Potentially confounding demographic and clinical variables, such as baseline alcohol severity, drug use severity, psychiatric severity, and CAPS total score, were added to the models as covariates, using a forward selection method. Although race and ethnicity were initially included in the models, these variables were excluded due to high standard error values because of sample homogeneity. Regression analyses were conducted using Stata version 13 (StataCorp, 2013).
Author Manuscript
RESULTS Participant demographics and clinical characteristics Most participants were in their mid-30s, female, Caucasian, not Hispanic or Latino and had never been married (Table 1). The sample endorsed significant social, psychological, and alcohol problems at baseline. All participants met criteria for a substance use disorder diagnosis. At baseline, 21.8% (61) of participants had a positive urine drug or breathalyzer screen. Participants experienced an average of 6.13 (SD=3.42) traumatic events in their lifetime, and 71% (201) had severe PTSD symptoms at baseline.
Author Manuscript
Demographic characteristics including age, gender, race, and ethnicity were similar across the terciles of social problem severity (Table 2). Current marital status was significantly different between the three groups. A greater proportion of participants with high problem severity were either separated or married; this group was also more dissatisfied with their current marital status. Baseline demographic, substance use, and psychiatric characteristics were also compared between participants who attended the 6-month follow-up and participants who did not attend. Study completers were significantly older (m=36.23 years, SD=11.09, versus m=30.62 years, SD=7.47; t(281)=4.08, p
