Efficacy of Integrated Exposure Therapy vs Integrated Coping Skills Therapy for Comorbid Posttraumatic Stress Disorder and Alcohol Use Disorder: A Randomized Clinical Trial

This randomized clinical trial of veterans compares the efficacy of integrated prolonged exposure therapy with present-centered integrated coping skills therapy in reducing posttraumatic stress disorder (PTSD) symptoms and alcohol use. Key PointsQuestionIs integrated prolonged exposure therapy tolerable and more efficacious than present-centered integrated coping skills therapy for reducing posttraumatic stress disorder symptoms and alcohol use in patients with comorbid posttraumatic stress disorder and alcohol use disorder? FindingsIn this randomized clinical trial of 119 patients, exposure therapy reduced posttraumatic stress disorder symptoms significantly more than coping skills therapy after treatment and at 3- and 6-month follow-ups. Participants in both treatment arms had reductions in heavy drinking days over time. MeaningIntegrated prolonged exposure therapy was well tolerated and had greater efficacy for reducing posttraumatic stress disorder symptoms than present-centered integrated coping skills therapy. ImportanceCo-occurrence of posttraumatic stress disorder (PTSD) and alcohol use disorder (AUD) is common and associated with psychiatric and functional problems. Understanding whether exposure therapy is tolerable and efficacious for treating PTSD and AUD is critical to ensure that best practice treatments are available. ObjectiveTo compare the efficacy of integrated (ie, targeting both PTSD and alcohol use) prolonged exposure (I-PE) therapy with present-centered integrated coping skills (I-CS) therapy, a more commonly available treatment, in reducing PTSD symptoms and alcohol use. Design, Setting, and ParticipantsThis prospective randomized clinical trial with masked assessments considered 186 veterans seeking Veterans Affairs mental health services. A total of 119 veterans with PTSD and AUD were randomized. Data were collected from February 1, 2013, to May 31, 2017, before treatment, after treatment, and at 3- and 6-month follow-ups. Intention-to-treat analyses were performed. InterventionsVeterans underwent I-PE (Concurrent Treatment of PTSD and Substance Use Disorder Using Prolonged Exposure) or I-CS (Seeking Safety) therapy. Main Outcomes and MeasuresA priori planned outcomes were PTSD symptoms (Clinician Administered PTSD Scale for DSM-5) and percentage of heavy drinking days (Timeline Follow-Back) before treatment, after treatment, and at 3- and 6-month follow-ups. ResultsA total of 119 veterans (mean [SD] age, 41.6 [12.6] years; 107 [89.9%] male) were randomized. Linear mixture models found that PTSD symptoms decreased in both conditions, with a significantly greater decrease for I-PE treatment compared with I-CS treatment (treatmentxtime interaction, -2.83; F-3,F-233.1=4.92; Cohen d=0.41; P=.002). The percentage of heavy drinking days improved in both conditions but was not statistically different between I-PE and I-CS treatment (treatmentxtime interaction, 1.8%; F-3,F-209.9=0.18; Cohen d=0.04; P=.91). Conclusions and RelevanceThe I-PE arm had a greater reduction in PTSD symptoms than the I-CS arm and comparable drinking decreases. The study provides evidence that exposure therapy is more efficacious in treating PTSD than a more commonly available integrated treatment without exposure for comorbid PTSD and AUD. Trial RegistrationClinicalTrials.gov identifier: NCT01601067