Evaluating the Impact of Supplementing Residential Substance Use Treatment with Written Exposure Therapy for Veterans with Co-Occurring PTSD and Substance Use Disorders

创伤后应激障碍（PTSD）和物质使用障碍（SUD）高度共病， 合并症增加了功能结局不良的风险。SUD与不良功能结局相关 例如生活质量，社区参与和自杀（Teeters，兰开斯特，Brown & Back，2017）。风险 对于那些同时患有PTSD和SUD诊断的人来说，生活质量差和自杀率进一步增加， 与单独的任何一种情况相比，使用酒精的退伍军人的自杀企图率高出三倍 障碍和PTSD（诺曼，哈勒，汉布伦，Southwick & Pietrzak，2018）。对于PTSD-SUD患者， 有证据表明PTSD症状的严重程度更高和SUD治疗结果更差（例如，Back等人， 2000年），以及无家可归和残疾的比例较高（Bowe & Rosenheck，2015年）。PTSD-SUD 治疗已经显示出PTSD和SUD症状有希望的减少（Flanagan，Korte，基林和Back， 2016）。然而，在广泛实施同时或单一目标金本位制方面仍然存在重大挑战 对这一人群的治疗，特别是对农村退伍军人的治疗，他们的治疗可能有限（例如，弗拉纳根 例如，2016）。书面暴露疗法（WET）是PTSD的一线，简短和有效的治疗方法， 解决了其他黄金标准治疗所带来的一些挑战。该项目旨在 检查向退伍军人提供书面暴露疗法（WET）的可行性和可接受性， 共患PTSD-SUD，同时完成28天的住院SUD计划（DOM SUD）。的 在项目期间，以及在1个月和3个月的随访期内， 还应进行审查，特别注意药物使用率、无家可归率、治疗出勤率， 治疗完成、生活质量、自杀倾向、创伤后应激障碍和抑郁症状。退伍军人参加了 将招募PTSD自评量表-5（PCL-5）评分超过33分的DOM SUD患者进行进一步筛选。 那些通过使用临床医生管理的创伤后应激障碍量表（DSM）确认符合创伤后应激障碍标准的患者- 5例（CAPS-5）受试者将被随机分配至两个治疗组之一：口服治疗（DOM SUD）和书面治疗 住宅SUD计划（resWET）中的暴露疗法。随机化将按性别分层， 将对妇女和少数族裔参与者进行过度抽样。TAU对照组的人将参加 在DOM SUD治疗计划中，而resWET组中的患者也将接受五次单独治疗 湿的会议。参与者将完成每周症状的测量，除了对对 物质使用。还将编制DOM SUD和resWET的治疗完成率。参与者 将通过视频亲自完成治疗前、治疗后、1个月和3个月随访措施， 或通过电话，这些措施，沿着从治疗记录中获得的数据，将使用 描述性分析以寻找关于两种症状反应的重要趋势（例如，创伤后应激障碍，抑郁症） 治疗，以及行为和功能结果（如自杀企图，无家可归， 治疗出勤率、治疗完成率、药物使用、残疾）。这些初步数据将用于 为将来使用这种治疗方法的研究提供信息。此外，DOM SUD中的提供程序将完成 治疗的可行性和可接受性措施以及重点小组，以提供关于 为采用治疗方法需要解决的执行障碍， 治疗的可及性。所有退伍军人还将通过调查提供有关其治疗的反馈 当治疗完成后，以及焦点小组的参与。定性和定量结果 数据将用于改善治疗和评估方法，并确定关键的 措施（WHO-DAS、PCL、PHQ-9），以准备一项全面的RCT，系统地评价resWET。

Posttraumatic Stress Disorder (PTSD) and Substance Use Disorder (SUD) are highly comorbid, and comorbidity increases risk for poor functional outcomes. SUDs are associated with poor functional outcomes such as quality of life, community engagement, and suicide (Teeters, Lancaster, Brown & Back, 2017). Risks for poor quality of life and suicide increase further for those with co-occurring PTSD and SUD diagnoses as compared to either condition alone, with suicide attempt rates three times higher for Veterans with alcohol use disorder and PTSD (Norman, Haller, Hamblen, Southwick & Pietrzak, 2018). For patients with PTSD-SUD, there is evidence of greater PTSD symptom severity and poorer SUD treatment outcomes (e.g., Back et al., 2000), as well as higher rates of homelessness and disability (Bowe & Rosenheck, 2015). PTSD-SUD treatments have shown promising reductions in PTSD and SUD symptoms (Flanagan, Korte, Killeen & Back, 2016). Yet, there are still major challenges in widely implementing concurrent or single-target gold-standard treatments for this population, especially with rural veterans where care access may be limited (e.g., Flanagan et al., 2016). Written Exposure Therapy (WET) is a front-line, brief and effective treatment for PTSD that addresses some of the challenges posed by other gold-standard treatments. This project is designed to examine the feasibility and acceptability of Written Exposure Therapy (WET) delivered to Veterans with comorbid PTSD-SUD while they are completing a 28 day-residential SUD program (DOM SUD). The preliminary effects of the treatment during the program, and at one month and 3 month follow-up periods will also be examined, with particular attention to rates of substance use, homelessness, treatment attendance, treatment completion, quality of life, suicidality, and PTSD and depression symptoms. Veterans enrolled in the DOM SUD with PTSD Checklist-5 (PCL-5) scores over 33 will be recruited for further screening into the study. Those that meet criteria for PTSD through confirmation using the Clinician Administered PTSD Scale for DSM- 5 (CAPS-5) will be randomized into one of two treatment arms: Treatment as Usual (DOM SUD) and Written Exposure Therapy in a residential SUD program (resWET). Randomization will be stratified by gender and oversampling for women and minority participants will be used. Those in the TAU control group will participate in the DOM SUD treatment program, while those in the resWET group will also have five individual treatment sessions of WET. Participants will complete weekly measures of symptoms, in addition to rating cravings for substance use. Treatment completion rates will also be compiled for both DOM SUD and resWET. Participants will complete pre-treatment, post-treatment, 1 month, and 3 month follow-up measures in person, over video, or by phone, and these measures, along with data available from the treatment record, will be examined using descriptive analyses to look for important trends regarding both symptom responses (e.g., PTSD, depression) to treatment, as well as behavioral and functional outcomes (such as suicide attempts, homelessness, treatment attendance, treatment completion, substance use, disability). This preliminary data will be used to inform future studies using this treatment approach. Additionally, providers in the DOM SUD will complete treatment feasibility and acceptability measures and focus groups to provide essential information about implementation barriers that need to be addressed for the uptake of the treatment approach and to enhance the accessibility of the treatment. All Veterans will also provide feedback about their treatment, through survey when the treatment is complete, and focus group participation. Findings from both qualitative and quantitative data will be used to improve the treatment and assessment approach and to determine effect sizes of key measures (WHO-DAS, PCL, PHQ-9) to prepare for a fully powered RCT to systematically evaluate resWET.