Timing and type of posttraumatic stress disorder treatment in patients with co-occurring substance use disorder and posttraumatic stress disorder A randomized controlled trial

Introduction: Co-occurrence of posttraumatic stress disorder (PTSD) and substance use disorder (SUD) is common and difficult to treat. Understanding which timing and type of PTSD treatment is most effective for treating PTSD in patients with SUD and PTSD is important to improve treatment outcomes. This study compared effectiveness of simultaneous versus sequential SUD-PTSD-treatment and compared Prolonged Exposure (PE), Eye Movement Desensitization and Reprocessing (EMDR), and Imagery Rescripting (ImRs) head-to-head in patients with co-occurring SUD and PTSD.
Method: A single-blind 6-arm randomized controlled trial with 209 patients with co-occurring SUD and PTSD at two addiction treatment centers in the Netherlands, providing intra- and extramural care. Patients were allocated to simultaneous SUD + PE, SUD + EMDR or SUD + ImRs treatment or sequential SUD-PTSD-treatment (25% each). Next, sequential SUD + PTSD patients were randomly assigned to PE, EMDR, or ImRs (33% each). Data were collected at baseline, 3-month, 6-month, and 9-month follow-up. All analyses were intention-to-treat. Participants were randomized to receive 12 PTSD treatment sessions of simultaneous SUD + PE (n = 53), simultaneous SUD + EMDR (n = 50), simultaneous SUD + ImRs (n = 55), sequential SUD + PE (n = 17), sequential SUD + EMDR (n = 17) or sequential SUD + ImRs (n = 17). Standard protocols were used. Primary outcome was clinician-administered PTSD symptom severity. Secondary outcomes were treatment completion and SUD-severity. Additionally, loss of PTSD diagnosis and full remission of PTSD criteria were tested. Linear-Mixed-Models with a two-level structure (repeated measures, patients), were used to investigate treatment-effects.
Results: In the primary analyses including the 6-month and 9-month follow up, no significant differences in PTSD-severity were found between timing nor treatment-types. However, simultaneous treatment outperformed sequential treatment at 3-month follow-up and was preferred by most participants. ImRs was superior to PE and EMDR regarding PTSD-treatment completion. No between-group differences in SUD outcomes were found.
Conclusions: EMDR and ImRs are effective alternatives to the more established PE. These findings indicate that delaying PTSD treatment until after SUD treatment is not necessary.