National Drug and Alcohol Research Centre, University of New South Wales, Sydney, New South Wales, Australia 2052.
JAMA. 2012 Aug 15;308(7):690-9. doi: 10.1001/jama.2012.9071.
There is concern that exposure therapy, an evidence-based cognitive-behavioral treatment for posttraumatic stress disorder (PTSD), may be inappropriate because of risk of relapse for patients with co-occurring substance dependence.
To determine whether an integrated treatment for PTSD and substance dependence, Concurrent Treatment of PTSD and Substance Use Disorders Using Prolonged Exposure (COPE), can achieve greater reductions in PTSD and substance dependence symptom severity compared with usual treatment for substance dependence.
DESIGN, SETTING, AND PARTICIPANTS: Randomized controlled trial enrolling 103 participants who met DSM-IV-TR criteria for both PTSD and substance dependence. Participants were recruited from 2007-2009 in Sydney, Australia; outcomes were assessed at 9 months postbaseline, with interim measures collected at 6 weeks and 3 months postbaseline.
Participants were randomized to receive COPE plus usual treatment (n = 55) or usual treatment alone (control) (n = 48). COPE consists of 13 individual 90-minute sessions (ie, 19.5 hours) with a clinical psychologist.
Change in PTSD symptom severity as measured by the Clinician-Administered PTSD Scale (CAPS; scale range, 0-240) and change in severity of substance dependence as measured by the number of dependence criteria met according to the Composite International Diagnostic Interview version 3.0 (CIDI; range, 0-7), from baseline to 9-month follow-up. A change of 15 points on the CAPS scale and 1 dependence criterion on the CIDI were considered clinically significant.
From baseline to 9-month follow-up, significant reductions in PTSD symptom severity were found for both the treatment group (mean difference, -38.24 [95% CI, -47.93 to -28.54]) and the control group (mean difference, -22.14 [95% CI, -30.33 to -13.95]); however, the treatment group demonstrated a significantly greater reduction in PTSD symptom severity (mean difference, -16.09 [95% CI, -29.00 to -3.19]). No significant between-group difference was found in relation to improvement in severity of substance dependence (0.43 vs 0.52; incidence rate ratio, 0.85 [95% CI, 0.60 to 1.21), nor were there any significant between-group differences in relation to changes in substance use, depression, or anxiety.
Among patients with PTSD and substance dependence, the combined use of COPE plus usual treatment, compared with usual treatment alone, resulted in improvement in PTSD symptom severity without an increase in severity of substance dependence.
isrctn.org Identifier: ISRCTN12908171.
人们担心，对于同时患有物质依赖的创伤后应激障碍（PTSD）患者，暴露疗法（一种基于循证的认知行为治疗 PTSD 的方法）可能不适用，因为这可能会导致疾病复发。
确定 PTSD 和物质依赖的综合治疗（使用延长暴露治疗 PTSD 和物质使用障碍，即 COPE）是否可以比单独治疗物质依赖更能显著降低 PTSD 和物质依赖的严重程度。
设计、地点和参与者：这是一项在 2007 年至 2009 年期间在澳大利亚悉尼招募了 103 名同时患有 DSM-IV-TR 诊断标准的 PTSD 和物质依赖的患者的随机对照试验。参与者在基线后 9 个月进行评估，在基线后 6 周和 3 个月进行了中期测量。
参与者被随机分配接受 COPE 联合常规治疗（n=55）或单独常规治疗（对照组，n=48）。COPE 包括 13 次个体 90 分钟的治疗（即 19.5 小时），由临床心理学家进行。
使用临床医生管理的 PTSD 量表（CAPS；评分范围 0-240）评估 PTSD 严重程度的变化，以及使用复合国际诊断访谈版 3.0（CIDI；范围 0-7）评估物质依赖严重程度的变化，从基线到 9 个月的随访。CAPS 量表上的 15 分变化和 CIDI 上的 1 个依赖标准被认为具有临床意义。
从基线到 9 个月的随访，治疗组（平均差异，-38.24[95%置信区间，-47.93 至-28.54]）和对照组（平均差异，-22.14[95%置信区间，-30.33 至-13.95]）的 PTSD 严重程度都显著降低；然而，治疗组 PTSD 严重程度的降低更为显著（平均差异，-16.09[95%置信区间，-29.00 至-3.19]）。在改善物质依赖严重程度方面，治疗组与对照组之间没有显著差异（0.43 对 0.52；发病率比，0.85[95%置信区间，0.60 至 1.21]），在物质使用、抑郁或焦虑方面也没有显著差异。
在 PTSD 和物质依赖患者中，与单独常规治疗相比，COPE 联合常规治疗可改善 PTSD 严重程度，而不会增加物质依赖的严重程度。
国际标准随机对照试验号（ISRCTN）：ISRCTN8415431
