Psychotherapy for PTSD Among Veterans Also Receiving Drug or Alcohol Treatment (COMPASS)

Comparative Effectiveness of Trauma-Focused and Non-Trauma-Focused Treatment Strategies for PTSD Among Those With Co-Occurring SUD (COMPASS)

Many people who have posttraumatic stress disorder (PTSD) also struggle with problematic alcohol or drug use (substance use disorders [SUD]). Patients with both conditions prefer PTSD be treated alongside SUD. However, clinicians don't know if treatments that have been found to help those with PTSD work as well for people who also have SUD. This often leads to delaying PTSD treatment or using psychotherapies without research support. Trauma-focused psychotherapy (TFT) is the type of psychotherapy for PTSD that has been studied most often among people with both PTSD and SUD. It reduces symptoms of PTSD and substance use, although it might not work as well in those who have SUD as those who do not. Further, many patients with both PTSD and SUD do not complete TFT. Another strategy for treating PTSD is non-trauma-focused psychotherapy (NTFT). One NTFT, Present Centered Therapy, has been found to reduce symptoms of PTSD and more patients are able to complete NTFT than are able to finish TFT. However, no one has studied how well Present Centered Therapy works among patients who also have SUD.

We will test which approach (TFT of NTFT) is better for reducing symptoms of PTSD and which is more likely to be completed by patients with both PTSD and SUD at VA healthcare facilities. We will also test to see whether some participants did better than others, so we can learn how to individualize treatment recommendations to patients. Participants will be assigned by chance to either TFT of NTFT. Patients assigned to TFT will receive either Prolonged Exposure or Cognitive Processing Therapy; both are weekly psychotherapies focused on addressing thoughts and/or memories related to their trauma. Those assigned to NTFT will receive Present Centered Therapy, a weekly psychotherapy in which patients learn about how PTSD relates to their current difficulties and problem solve current life difficulties. All participants will also receive SUD treatment. Participants will answer questions about their symptoms and experience with treatment before, right after they finish, and three and six months after they finish PTSD treatment. At the end of the study we will compare which treatment approach worked better to decrease PTSD symptom severity and which treatment patients were better able to complete. We will also track other outcomes that are important to patients (e.g., how they are doing in their relationships).

Study Overview

• Status: Active, not recruiting
• Conditions: Stress Disorders, Post-Traumatic; Substance Use Disorders
• Intervention / Treatment: Behavioral: Prolonged Exposure Therapy; Behavioral: Cognitive Processing Therapy; Behavioral: Present Centered Therapy

Detailed Description

Background and Significance: Posttraumatic stress disorder (PTSD) and substance use disorder (SUD) comorbidity is common. The Veterans Affairs (VA)/Department of Defense Clinical Practice Guideline for PTSD strongly recommends providing guideline-concurrent care for PTSD alongside SUD treatment, but there is insufficient evidence about which guideline-recommended treatments for PTSD work best in this population. Trauma-focused therapy (TFT) is a frontline treatment approach; yet its effectiveness is less well-established among patients with co-occurring SUD, and TFT dropout rates are uniquely high in this population. Multiple guidelines suggest non-trauma-focused treatment (NTFT) as a second-line treatment approach for PTSD; higher completion rates for some NTFT (e.g., Present Centered Therapy) may make this strategy particularly effective for those with comorbid SUD. Despite providers' desire for an NTFT option for patients with PTSD/SUD, no guideline-recommended NTFTs have been evaluated in those with the comorbidity

Study Aims: Our long-term objective is to improve the lives of patients with co-occurring PTSD and SUD. To meet this objective, we will conduct a pragmatic randomized clinical trial that will yield decisive data regarding the comparative effectiveness of two evidence-based approaches for the treatment of PTSD in this understudied patient population: trauma-focused and non-trauma-focused psychotherapy. The major aims are: (1) Determine whether TFT differs at a clinically-meaningful magnitude from NTFT in its effects on posttreatment PTSD symptoms among patients with co-occurring PTSD and SUD (2) Determine whether patients with co-occurring PTSD and SUD randomized to TFT drop out of PTSD treatment more often than those randomized to NTFT, and (3) Determine if TFT differs at a clinically-meaningful level from NTFT in PTSD symptom reduction and number of PTSD therapy sessions attended in patients with varying (a) levels of baseline SUD severity, (b) classes of misused substances, and (c) treatment preferences.

Study Description: We propose a prospective, pragmatic randomized comparative effectiveness trial at 14 VA Medical Center sites (11 confirmed). Randomization will occur at the patient level and will assign participants to either (1) TFT (Prolonged Exposure or Cognitive Processing Therapy) or 2) NTFT (Present Centered Therapy). All participants will also receive concurrent SUD treatment-as-usual. Participants will complete self-report measures and a clinician-administered interview pretreatment, posttreatment, and six-months posttreatment. 420 participants (210 per arm) will be veterans seeking outpatient SUD treatment in an enrolled clinic who meet DSM-5 criteria for a current SUD and PTSD. The sample will be diverse in sex, race, age, and geography. Main outcomes will be PTSD symptom severity measured by the Clinician Administered PTSD Scale for DSM-5 (CAPS-5), and PTSD treatment dropout (dichotomous indicator of completion of all PTSD treatment sessions). Major Aim 1 will be tested using a linear mixed model using study intervention, assessment point, and their interaction as fixed effects and including random effects for participant, clinician, and study site. Major Aim 2 will be testing using a random effects logistic regression of therapy retention on intervention and baseline CAPS incorporating random effects for clinician and site.

• Study Type: Interventional
• Enrollment (Anticipated): 420
• Phase: Not Applicable

Contacts and Locations

• Study Contact: Name: Doris Clancy; Phone Number: 833-741-0667; Email: Doris.Clancy@va.gov

Study Locations

• United States
  • California
    • San Diego, California, United States, 92161
      • San Diego VA Healthcare System
  • Florida
    • Tampa, Florida, United States, 33612
      • Tampa VA Medical Center
  • Georgia
    • Atlanta, Georgia, United States, 30033
      • Atlanta VA Medical Center
  • Illinois
    • Hines, Illinois, United States, 60141
      • Edward Hines, Jr. VA Hospital
  • Louisiana
    • New Orleans, Louisiana, United States, 70119
      • Southeast Louisiana Veterans Health Care System
  • Minnesota
    • Minneapolis, Minnesota, United States, 55417
      • Minneapolis VA Medical Center
  • New York
    • Syracuse, New York, United States, 13210
      • Syracuse VA Medical Center
  • North Carolina
    • Durham, North Carolina, United States, 27705
      • Durham VA Medical Center
  • Ohio
    • Cincinnati, Ohio, United States, 45220
      • Cincinnati VA Healthcare System
    • Cleveland, Ohio, United States, 44106
      • Louis Stokes Cleveland VA Medical Center
  • Pennsylvania
    • Philadelphia, Pennsylvania, United States, 19104
      • Philadelphia VA Medical Center
  • Utah
    • Salt Lake City, Utah, United States, 84148
      • Salt Lake City VA Healthcare System
  • Washington
    • Seattle, Washington, United States, 98108
      • Puget Sound VA Healthcare System
  • Wisconsin
    • Madison, Wisconsin, United States, 53705
      • Madison VA Medical Center

Participation Criteria

Eligibility Criteria

• Ages Eligible for Study: 18 years and older (Adult, Older Adult)
• Accepts Healthy Volunteers: No
• Genders Eligible for Study: All

Description

INCLUSION CRITERIA:

1. Initiate an episode of outpatient SUD treatment at an enrolled facility.
2. meet DSM-5 criteria for a current SUD (Tobacco Use Disorder alone is not sufficient for inclusion).
3. Report substance use in the past 30 days (or in the 30 days prior to entering a controlled environment if exiting said controlled environment at time of enrollment)
4. meet DSM-5 criteria for PTSD
5. provide informed consent and be willing to be randomized to PTSD treatment condition
6. agree to not receive non-study, active psychotherapy for PTSD during study treatment

EXCLUSION CRITERIA:

1. Severe cognitive impairment
2. Current suicidal or homicidal intent with a specific plan
3. Unstable psychotic or manic symptoms not attributable to SUD
4. More than 30 days between index outpatient SUD intake/treatment planning appointment & consent or more than 90 days between the index outpatient SUD visit and the first PTSD psychotherapy session

Study Plan

How is the study designed?

Design Details

• Primary Purpose: Treatment
• Allocation: Randomized
• Interventional Model: Parallel Assignment
• Masking: Single

Number of Arms

2

Arms and Interventions

Participant Group / Arm	Intervention / Treatment
Experimental: Trauma-Focused Therapy; Patients randomized to Trauma Focused Therapy will receive either Prolonged Exposure (PE) or Cognitive Processing Therapy (CPT). According to standard VA practice, assignment will be determined according to which trauma-focused therapy the assigned provider is verified to provide; if the assigned therapist is verified in both PE and CPT, the provider will decide which treatment to deliver. PE and CPT are both recommended as frontline treatments by all published PTSD guidelines. The standard treatment length will be 12 weekly sessions; however, patients and providers can collaboratively agree to early completion or extension as warranted.	Behavioral: Prolonged Exposure Therapy; Prolonged Exposure Therapy is an individually-delivered treatment for PTSD that includes in vivo exposure to trauma reminders and imaginal exposure to the trauma memory delivered in 90-minute weekly sessions.; Behavioral: Cognitive Processing Therapy; Cognitive Processing Therapy is an individually-delivered treatment for PTSD that focuses on challenging and modifying maladaptive beliefs related to the trauma, with an optional written trauma account during weekly 60-minute sessions
Experimental: Non-Trauma-Focused Therapy; Those randomized to non-trauma-focused therapy will receive present centered therapy (PCT). Originally designed as a strong comparator for psychotherapy research that included the components of "good therapy," PCT is now a bona-fide PTSD treatment suggested at the second tier in multiple clinical practice guidelines. The standard treatment length will be 12 weekly sessions; however, patients and providers can collaboratively agree to early completion or extension as warranted.	Behavioral: Present Centered Therapy; Present Centered Therapy is an individually-delivered treatment for PTSD that focuses on "current life problems as manifestations of PTSD" in weekly 60-minute sessions. It includes psychoeducation and normalization of responses to trauma, problem solving related to current life difficulties and stress identified by patients, and emotional support and validation

What is the study measuring?

Primary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Clinician Administered Scale for PTSD -5 (CAPS-5) Severity Score	PTSD Symptom Severity - Clinician Assessed; range 0-80; higher scores = greater severity.	Immediately after ending treatment
PTSD Treatment Non-completion	Proportion of veterans who do not complete a full course of assigned PTSD treatment	Immediately after ending treatment

Secondary Outcome Measures

Outcome Measure	Measure Description	Time Frame
PTSD Checklist-5 (PCL-5)	PTSD Symptom Severity - Self-Reported; Range = 0-80; higher scores = more severe symptoms	Immediately after ending treatment
PTSD Checklist-5 (PCL-5)	PTSD Symptom Severity - Self-Reported; Range = 0-80; higher scores = more severe symptoms	3-months after ending treatment
PTSD Checklist-5 (PCL-5)	PTSD Symptom Severity - Self-Reported; Range = 0-80; higher scores = more severe symptoms	6-months after ending treatment
% Days with drug use or heavy drinking over prior 28 days	Substance use as measured by the Timeline Follow-Back Interview (TLFB)	Immediately after ending treatment
% Days with drug use or heavy drinking over prior 28 days	Substance use as measured by the Timeline Follow-Back Interview (TLFB)	3 months after ending treatment
% Days with drug use or heavy drinking over prior 28 days	Substance use as measured by the Timeline Follow-Back Interview (TLFB)	6 months after ending treatment
Clinician Administered Scale for PTSD -5 (CAPS-5) Severity Score	PTSD Symptom Severity - Clinician Assessed; range 0-80; higher scores = greater severity.	3 months after treatment
Clinician Administered Scale for PTSD -5 (CAPS-5) Severity Score	PTSD Symptom Severity - Clinician Assessed; range 0-80; higher scores = greater severity.	6 months after treatment
Short Inventory of Problems, Revised (SIP-R)	Problems associated with drug or alcohol use; range = 0-51, higher scores = more severe	Immediately after treatment
Short Inventory of Problems, Revised (SIP-R)	Problems associated with drug or alcohol use; range = 0-51, higher scores = more severe	3-months after treatment
Short Inventory of Problems, Revised (SIP-R)	Problems associated with drug or alcohol use; range = 0-51, higher scores = more severe	6-months after treatment
Brief Inventory of Psychosocial Functioning (BIPF)	PTSD-related psychosocial functioning; higher scores = more severe	Immediately after treatment
Brief Inventory of Psychosocial Functioning (BIPF)	PTSD-related psychosocial functioning; higher scores = more severe	3 months after treatment
Brief Inventory of Psychosocial Functioning (BIPF)	PTSD-related psychosocial functioning; higher scores = more severe	6 months after treatment
Insomnia Severity Index	Self-reported sleep disturbances; range 0-28; higher scores = more severe	Immediately after treatment
Insomnia Severity Index	Self-reported sleep disturbances; range 0-28; higher scores = more severe	3 months after treatment
Insomnia Severity Index	Self-reported sleep disturbances; range 0-28; higher scores = more severe	6 months after treatment
Dimensions of Anger Reactions (DAR)	Self-reporter anger; range = 2-25; higher scores = more severe	Immediately after treatment
Dimensions of Anger Reactions (DAR)	Self-reporter anger; range = 2-25; higher scores = more severe	3 months after treatment
Dimensions of Anger Reactions (DAR)	Self-reporter anger; range = 2-25; higher scores = more severe	6 months after treatment
WHO Quality of Life, Brief (WHOQOL-BREF)	Self-reported quality of life; higher score = better quality of life	Immediately after treatment
WHO Quality of Life, Brief (WHOQOL-BREF)	Self-reported quality of life; higher score = better quality of life	3 months after treatment
WHO Quality of Life, Brief (WHOQOL-BREF)	Self-reported quality of life; higher score = better quality of life	6 months after treatment
Patient Health Questionnaire-9 (PHQ-9)	Self-reported depression; range = 0-27; higher scores = more severe symptoms	Immediately after treatment
Patient Health Questionnaire-9 (PHQ-9)	Self-reported depression; range = 0-27; higher scores = more severe symptoms	Three months after treatment
Patient Health Questionnaire-9 (PHQ-9)	Self-reported depression; range = 0-27; higher scores = more severe symptoms	Six months after treatment
Client Satisfaction Questionnaire - 8 (CSQ-8)	Treatment satisfaction; range = 8-32; higher scores = more severe symptoms	Immediately after treatment

Collaborators and Investigators

• Sponsor: Center for Veterans Research and Education
• Collaborators: Patient-Centered Outcomes Research Institute; Minneapolis Veterans Affairs Medical Center

Publications and helpful links

General Publications

• Kehle-Forbes SM, Nelson D, Norman SB, Schnurr PP, Shea MT, Ackland PE, Meis L, Possemato K, Polusny MA, Oslin D, Hamblen JL, Galovski T, Kenny M, Babajide N, Hagedorn H. Comparative effectiveness of trauma-focused and non-trauma-focused psychotherapy for PTSD among veterans with comorbid substance use disorders: Protocol & rationale for a randomized clinical trial. Contemp Clin Trials. 2022 Sep;120:106876. doi: 10.1016/j.cct.2022.106876. Epub 2022 Aug 18.

Study record dates

Study Major Dates

• Study Start (Actual): December 8, 2020
• Primary Completion (Anticipated): February 1, 2024
• Study Completion (Anticipated): February 1, 2024

Study Registration Dates

• First Submitted: September 29, 2020
• First Submitted That Met QC Criteria: October 5, 2020
• First Posted (Actual): October 9, 2020

Study Record Updates

• Last Update Posted (Actual): April 3, 2023
• Last Update Submitted That Met QC Criteria: March 31, 2023
• Last Verified: March 1, 2023

More Information

Terms related to this study

• Keywords: PTSD; Psychotherapy; Randomized Clinical Trial; Comparative Effectiveness; Substance Use Disorders
• Additional Relevant MeSH Terms: Mental Disorders; Chemically-Induced Disorders; Pathologic Processes; Trauma and Stressor Related Disorders; Stress Disorders, Traumatic; Substance-Related Disorders; Disease; Stress Disorders, Post-Traumatic
• Other Study ID Numbers: #PTSD-2019C1-16009

Plan for Individual participant data (IPD)

• Plan to Share Individual Participant Data (IPD)?: YES

Drug and device information, study documents

• Studies a U.S. FDA-regulated drug product: No
• Studies a U.S. FDA-regulated device product: No