Article Review 2

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Substance abuse and posttraumatic stress disorders: Symptom interplay and effects on outcome

Summary

The above study examined the association between substance abuse disorder (SUD) and posttraumatic stress disorder (PTSD) and symptoms and mechanisms underlying those associations.  Participants of the study were assessed at the beginning of the study and six months following inpatient SUD treatment.  Since the treatment was necessary to conduct this study, it can be classified as interventionist.

Because SUD and PTSD occur together often, a more clear understanding of this dynamic may identify areas for intervention.  This also includes how different substances may be related to different PTSD symptom clusters.  For example, hyperarousal symptoms were associated with alcohol problems.  

Details of the study after the break…

At the study’s onset, 133 participants received inpatient SUD treatment at a psychiatric hospital.  51 percent were women, and 90 percent were white.  The average age was 37 years old.  Variables the study examined included sex [male, female], age [18-55], PTSD [yes, no], and SUD [alcohol, opioids, cocaine, cannabis, sedatives, stimulants].

Interviews and self-reports were conducted at the baseline and 6 months post-discharge.  90 percent of the participants completed follow-up assessments.  A PTSD Scale assessed PTSD, while the Life Stressor Checklist-Revised assessed traumatic exposure.  The number of symptoms endorsed indicated the PTSD and symptom cluster severity.  After six months, these same procedures were repeated. 

The study found that the most common SUD in this sample to be alcohol use disorder at 69 percent.  34 percent met the criteria for opioid use, 23 percent for cocaine abuse, 19 percent for cannabis use disorder, 15 percent for a sedative use disorder, 4 percent abusing hallucinogens, and 2 percent abusing stimulants.  

At the six month point, the majority of participants had used alcohol or other drugs at least once (67 percent).  38 patients were still suffering from PTSD, while only 14 reported no longer suffering from the disorder.  

Individuals with PTSD were more likely to meet the Diagnostic and Statistical Manual for Mental Disorders criteria for mood disorder than those who were not diagnosed as indicated on Table 1.

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Table 1. Rates of comorbid diagnoses by current PTSD

	PTSD		Non-PTSD
	n=55	%	n=78	%
Major depressive disorder (n=76)	43	78	33	42
Dysthymia (n=15)	9	16	6	8
Mania (n=9)	8	15	1	1
Panic disorder (n=41)	27	49	14	18
Agoraphobia without panic disorder (n=1)	0	0	1	1
Social phobia (n=18)	8	15	10	13
Simple phobia (n=10)	5	9	5	6
Obsessive-compulsive disorder (n=11)	6	11	5	6
Generalized anxiety disorder (n=25)	12	22	13	17

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Those with unremitted PTSD reported significantly more baseline re-experiencing symptoms than those with remitted PTSD as shown on Table 2.

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Table 2. Prediction of remission status

	PTSD status at follow-up
	PTSD remitted	PTSD unremitted
Baseline variables
Gender [no. (%)]
Male	6 (30)	14 (70)
Female	8 (25)	24 (75)
Substance use [M (S.D.)]
Percent days abstinent	41.0 (38.4)	48.2 (37.4)
Years of problematic use	18.9 (11.5)	17 (10.5)
PTSD severity [M (S.D.)]
Number of PTSD symptoms*	10.2 (1.6)	11.5 (2.2)
Criterion C symptoms	4.2 (1.2)	4.7 (0.99)
Criterion B symptoms*	2.8 (1.1)	7 (0.99)
Criterion D symptoms	3.2 (1.1)	3.3 (0.96)
General psychiatric distress SCL-90-R*	134.4 (50.7)	181.6 (68.2)
Follow-up variables
Substance use percent days abstinent [M (S.D.)]†	90 (14.7)	76 (31.1)
General psychiatric distress SCL-90-R [M (S.D.)]***	58.3 (47.6)	153.2 (77.6)

**P<.01.Values for baseline and follow-up percent days abstinent represent the nontransformed variables.

    *

P<.05.

              †

P=.08, marginally significant.

              ***

P<.001.

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Table 3 examines the effect of changes in PTSD status on substance use outcomes.

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Table 3. Prediction of follow-Up Percent Days Abstinent

Predictor	B	SEB	Beta	t-value	R2
Step 1					0.11
Baseline percent days Abstinent	0.24	0.09	0.24	2.77**
Sex	0.06	0.08	0.06	0.65
Contrast: No PTSD vs. Ever PTSD (Remitted and Unremitted)	−0.02	0.05	−0.05	−0.52
Contrast: Remitted vs. Unremitted	0.29	0.14	0.20	2.08*
Step 2					0.12
Baseline percent days Abstinent	0.25	0.09	0.25	2.78**
Sex	0.05	0.08	0.05	0.53
Contrast: No PTSD vs.Ever PTSD	−0.04	0.05	−0.09	−0.92
Contrast: Remitted vs. Unremitted	0.33	0.14	0.23	2.32*
Baseline SCL-90-R	0.01	0.01	0.13	1.33
Step 3					0.13
Baseline percent days abstinent	0.24	0.09	0.24	2.74**
Sex	0.03	0.09	0.03	0.29
Contrast: No PTSD vs. Ever PTSD	−0.04	0.05	−0.09	−0.91
Contrast: Remitted vs. Unremitted	0.32	0.14	0.22	2.23*
Baseline SCL-90-R	0.01	0.01	0.12	1.23
Baseline PTSD symptoms	−0.01	0.01	−0.08	−0.89
Step 4					0.19
Baseline percent days Abstinent	0.22	0.08	0.23	2.68*
Sex	0.04	0.09	0.04	0.41
Contrast: No PTSD vs. Ever PTSD	−0.02	0.05	−0.03	−0.34
Contrast: Remitted vs. Unremitted	0.16	0.15	0.11	1.06
Baseline SCL-90-R	0.01	0.01	0.25	2.28*
Baseline PTSD symptoms	−0.01	0.01	−0.09	−1.05
Follow-up SCL-90-R	−0.01	0.01	−0.35	−2.90**

       **

P<.01.

                   *

P<.05.

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After examining all of the variables, participants with alcohol use disorders reported a greater number of re-experiencing symptoms.  The results show that PTSD status did not predict substance abuse outcome, though a change in PTSD status after the follow-up predicted use outcomes as Table 2 shows.  These findings suggest that doctors should assess PTSD among those with SUD as well as monitoring other psychological symptoms that could become risk factors for relapse.

Discussion

This study wasn’t the best at evaluating my causal hypothesis, using cannabis helps to treat for stress and depression, although examining the effects of substance abuse and PTSD could be relevant.  I am finding it difficult to find a clear-cut interventionist study on the use of cannabis to treat stress and depression, however this study does give limited insight on cannabis users with PTSD.

Using only this data and the data from the previous article, my causal hypothesis would still not be supported.  Nonetheless, this is only to a certain degree, because I have yet to find an actual study that actually examines cannabis use in an experimental environment.

Limitations of the study include a mostly white participation rate.  Also, if only for my own hypothesis, I would have liked to have seen the study examine the actual effects of SUD and if any positive effects were noted.

Because of the studies limitations, it is increasingly apparent that I will need to find an interventionist study that specifically addresses my causal hypothesis.