Addressing Mental Health Comorbidities: Integrated CBT to Improve Functioning in Veterans with Co-Occurring Anxiety and Substance Use

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Background and significance: Co-occurring hazardous drinking and mental health disorders, particularly anxiety disorders, is an especially problematic combination experienced by deployed Veterans. Although VA is a leader in delivering evidence-based mental health treatment, gaps remain in our understanding of how to best promote psychosocial recovery for Veterans with co-occurring anxiety and hazardous drinking. Veterans who have been deployed are at particular risk for experiencing problems in functioning and reintegration related to mental health disorders and alcohol use. Co-occurring anxiety, posttraumatic stress disorder (PTSD), and hazardous drinking heavily impact psychosocial functioning (including occupational and relationship functioning) and quality of life. Cognitive behavior therapy (CBT) is an evidence-based psychotherapy (EBP) for anxiety disorders and hazardous drinking that can promote improvements in functioning and quality of life. However, many Veterans do not receive CBT for anxiety disorders and/or SUD. A significant challenge in treating an anxiety disorder or SUD with CBT is that providers most often treat each disorder separately, often in separate clinics. This results in an inefficient treatment process that leads to poor outcomes. The Unified Protocol (UP) is a transdiagnostic CBT protocol that effectively treats symptoms of multiple emotional disorders simultaneously. Adapting the UP to meet the needs of deployed Veterans with co- occurring anxiety, PTSD, and hazardous drinking has the potential to more efficiently and effectively improve functioning and reduce symptoms. Given the impact of anxiety, PTSD, and hazardous drinking among returning Veterans, the research goals of this RR&D CDA-2 proposal support the adaptation of the UP for use among deployed Veterans with hazardous drinking and examination of its feasibility, acceptability, and preliminary efficacy. Research Plan: Aim 1: Adapt the UP for treatment of anxiety disorders/PTSD and hazardous drinking among deployed Veterans (UP-A). This will be achieved using established iterative intervention development strategies, including incorporating stakeholder feedback in the development of the intervention. Feedback from stakeholders will include qualitative interviews key stakeholders (clinicians, Veterans). Aim 2: Evaluate deployed Veterans’ experience using UP-A through a non-randomized pilot trial (N = 10) and qualitative interviews with Veterans and revising the intervention based on findings to ensure Veteran-centricity, Veteran satisfaction, feasibility, and acceptability. Veterans will be recruited from VA treatment settings and provided UP-A by study clinicians. Veterans will complete measures of functioning and symptoms before and after receiving the intervention. Aim 3: Explore the feasibility, acceptability, and preliminary effect of UP-A on functioning outcomes, anxiety and PTSD symptoms, and alcohol use through a pilot randomized controlled trial. Deployed Veterans (N=40) will be randomized to receive UP-A or a problem solving therapy control. Outcomes will be collected at baseline, post-treatment, and three months post- treatment. Veterans will also complete qualitative interviews to obtain feedback on feasibility and acceptability. Career Plan: Dr. Ecker will receive training in conducting rehabilitation research among high-need Veteran populations (e.g., post-deployment health), clinical trial research, and training related to becoming an independently-funded VA researcher. These training objectives will be achieved through a multifaceted strategy that includes research with mentors, formal coursework, trainings/seminars/conferences, and consultation with the mentor team. Training will support the immediate goals of successfully conducting the proposed research and the long-term career goal of conducting research to improve functioning in Veterans with complex mental health care needs.