Cardiff & Vale University Health Board, Cardiff, UK.
Division of Psychological Medicine and Clinical Neurosciences, Cardiff University, Cardiff, UK.
Eur J Psychotraumatol. 2022 May 3;13(1):2041831. doi: 10.1080/20008198.2022.2041831. eCollection 2022.
The psychological treatment of comorbid post-traumatic stress disorder (PTSD) and substance use disorder (SUD) is clinically challenging, and outcomes are often poor.
This paper describes a systematic review and meta-analysis which sought to establish the current efficacy for a number of established psychological approaches for adults and adolescents, in comparison to interventions for SUD alone, or other active approaches, following a pre-registered protocol.
This review followed PRISMA and Cochrane Collaboration guidelines. Data extraction and risk of bias judgements using Cochrane criteria were undertaken by all authors. Primary outcomes were PTSD severity and substance use post-treatment. The quality of findings was assessed using GRADE. Following a comprehensive search, conducted to 13 September 2021, 27 studies were included.
We found a relatively high level of dropout across studies. In our main comparisons, we found no benefits for present-focused treatment approaches aimed at improving coping skills beyond those for SUD-only interventions. We found modest benefits for trauma-focused intervention plus SUD intervention post-treatment for PTSD (standardized mean difference (SMD) = -0.36, 95% confidence interval (CI) -0.64, -0.08), and at 6-13 months for PTSD (SMD = -0.48, 95% CI -0.81, -0.15) and alcohol use (SMD = -0.23, 95% CI -0.44, -0.02). There were no benefits for cognitive restructuring interventions as a group, but we found a modest effect for integrated cognitive behavioural therapy (ICBT) for PTSD post-treatment (SMD = -0.33, 95% CI -0.62, -0.04). There was evidence of some benefit for trauma-focused intervention over present-focused intervention for PTSD from a single study and for reduction in dropout for incentivized attendance for trauma-focused intervention from another single study. Most findings were of very low quality.
There is evidence that trauma-focused therapy and ICBT can improve PTSD for some individuals, but many patients do not fully engage with treatment and average treatment effects are modest.
For PTSD, evidence was strongest for trauma-focused CBT-based approaches, but effects were modest.There was little evidence of any added benefit on substance use, beyond that of standard addiction treatments, for any included intervention.Dropout from treatment was high.
共病创伤后应激障碍（PTSD）和物质使用障碍（SUD）的心理治疗具有临床挑战性，治疗效果往往不佳。
本文描述了一项系统评价和荟萃分析，旨在根据预先注册的方案，确定多种已确立的心理方法对成年人和青少年的当前疗效，与仅针对 SUD 的干预措施或其他有效方法进行比较。
本综述遵循 PRISMA 和 Cochrane 协作组指南进行。所有作者均进行了数据提取和使用 Cochrane 标准进行偏倚风险判断。主要结局为治疗后 PTSD 严重程度和物质使用情况。使用 GRADE 评估研究结果的质量。在 2021 年 9 月 13 日之前进行了全面检索，共纳入 27 项研究。
我们发现研究中存在较高的脱落率。在我们的主要比较中，我们发现针对改善应对技能的以当下为重点的治疗方法，并没有比仅针对 SUD 的干预措施带来额外的益处。我们发现创伤聚焦干预加 SUD 干预在 PTSD 治疗后（标准化均数差（SMD）=-0.36，95%置信区间（CI）-0.64，-0.08）和 PTSD 治疗后 6-13 个月（SMD=-0.48，95%CI-0.81，-0.15）和酒精使用（SMD=-0.23，95%CI-0.44，-0.02）方面有适度益处。认知重构干预作为一个整体没有益处，但我们发现整合认知行为疗法（ICBT）在 PTSD 治疗后有适度效果（SMD=-0.33，95%CI-0.62，-0.04）。一项研究表明创伤聚焦干预优于当下聚焦干预对 PTSD 有一定效果，另一项研究表明针对创伤聚焦干预的激励性参与可以降低脱落率。大多数研究结果的质量都很低。
有证据表明，创伤聚焦疗法和 ICBT 可以改善某些个体的 PTSD，但许多患者无法完全参与治疗，且平均治疗效果较为温和。
对于 PTSD，基于 CBT 的创伤聚焦方法的证据最强，但效果温和。对于任何纳入的干预措施，在物质使用方面，除了标准成瘾治疗之外，没有任何证据表明有任何额外的益处。治疗脱落率较高。
