PTSD and SUD Among Returning Veterans: A Study

Comorbidity of posttraumatic stress disorder (PTSD) and substance use disorders (SUD) create unique problems in the treatment of both disorders. Current knowledge suggests that SUD must be treated prior to the treatment of PTSD. Veterans returning from current conflicts in the Middle East are particularly vulnerable to the comorbidity of these disorders. Evidence based treatments are beginning to show that the current practice of treating SUD before PTSD may not be the most effective model of treatment. Research is showing that treating both disorders concurrently could be the most effective model.

Individuals diagnosed with Post Traumatic Stress Disorder (PTSD) have a high comorbidity with SUD (Substance Use Disorder). (Henslee and Coffrey, 2010.) stated that between 25 and 45% of patients seeking substance abuse treatment, also satisfy criteria for PTSD. A study of veterans conducted by (Najavits, Norman, Kihlahan, and Kosten, 2010) found that 20% of Veterans Affairs (VA) patients diagnosed with PTSD also had SUD. Souza and Spates (2008) provided evidence that approximately 50% of individuals in inpatient treatment can also meet the criteria of PTSD.

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Individuals with both PTSD and SUD indicate having more substance related issues, including greater psychological distress, and lower levels of social support from peers and family members.

This is true even when compared to substance abusers with other psychiatric disorders. (McDevitt-Murphy, 2011). Empirical research continually adds to the growing evidence that the comorbidity of PTSD and SUD is a continuing problem that must be addressed when treating individuals that present with either disorder. A study by (Elbogen, Beckham, Butterfield, Swartz, & Swanson, 2008) also addresses the increased risk of violence from veterans with severe mental illness.

“PTSD appears to be one of the most difficult comorbid disorders to treat with SUD due to the intensification of PTSD symptoms while withdrawing from substances.” (Suza and Spates, 2008).

Seeking Safety is a cognitive-behavioral psychotherapy designed for treatment of individuals with PTSD and SUD is designed with 25 modules designed to address the significant challenges that comorbidity of PTSD/SUD bring to treatment providers. The 25 modules contain diverse content that addresses life choices and building health relationships, honesty/integrating the split self healing from anger, and other topics that effect individuals with PTSD/SUD. A pilot study was conducted specifically designed for OIF/OEF (Operation Iraqi Freedom and Operation Enduring Freedom) veterans. The study had a high dropout rate of 42%, but those who remained in treatment for the full study showed promise for engagement and reducing symptoms of PTSD/SUD in the population (Norman et al., 2010).

Protocol was developed at the University of Memphis and the Memphis VA Medical Center (McDevitt-Murphy, 2010) to address cognitive-behavioral therapy. The protocol involved returning OIF/OEF veterans and their significant others. The developed treatment was named Project VALOR (Veterans and Loved Ones Readjusting). One of the additional challenges faced by veterans returning from a combat zone is the attempt to reconnect with their loved ones. “Patients with comorbid PTSF and SUD tend to rely on maladaptive coping styles more than other alcohol abusers with other psychiatric disorders” (p. 41). Project Valor used cognitive-behavioral coping skills treatment (CST) and includes patients significant other to provide reinforcement for changing the maladaptive behavior that is incompatible with substance abuse. The early research suggests that this approach holds promise in successful intervention of returning OIF/OEF veterans.

Although not directed specifically towards returning OIF/OEF veterans, prolonged exposure (PE) therapy shows promise in treating patients in residential substance use treatment facilities (Henslee, Coffey, 2010). The role that avoidance plays in PTSD highlights how effective PE can be used in treatment. PE is an effective treatment that can be implemented with slight modifications so that it can be developed to target specific populations, including returning OIF/OEF veterans.

Although not directed specifically towards returning OIF/OEF veterans, prolonged exposure (PE) therapy shows promise in treating patients in residential substance use treatment facilities (Henslee & Coffey, 2010). The role that avoidance plays in PTSD highlights how effective PE can be used in treatment. PE is an effective treatment that can be implemented with slight modifications so that it can be developed to target specific populations, including returning OIF/OEF veterans.

Veterans who have served in combat supporting Operation Iraqi Freedom (OIF) and Operation Enduring Freedom (OEF) have a comorbidity rate of 11 to 20% for PTDS and SUD (Norman, Wilkins, Tapert, Lang, and Najavits, 2010). SUD is estimated in 21% of veterans seeking treatment with the Veterans Administration. PTDS is estimated in 20% in members of the military and 11% of veterans (Najavits et al., 2010). The researcher stated that veterans with PTSD were more likely to receive opioids for pain management than veterans without a mental health issue.

This places them at high risk of misuse due to the comorbidity of PTSD and SUD. A Department of Defense study of substance use and mental health trends showed that heavy alcohol use was higher among members who had been deployed when compared to those who had not been deployed (Bray, Pemberton, Lane, Hourani, Mattiko, & Babeu, 2010). Co- occurring conditions like PTSD are known to increase the misuse of alcohol (Bray, Pemberton, Lane, Hourani, Mattiko, & Babeu, 2010). National Guard veterans returning from deployment for OIF/OEF are at an increased risk of mental health problems. They are also at a higher risk than their Active Duty counterparts and diagnosis and symptoms increased over time following deployments (Erbes, Kaler, Shultz, Poulsny, & Arbisi, 2011). Findings in current substance abuse literature have shown that individuals with comorbid PTSD and SUD are lower functioning than individuals with a single diagnosis (McDevitt-Murphy, 2011).

Combined treatment for PTSD and SUD poses several barriers to effective treatment. Conventional wisdom has been that the SUD must be addressed before work can begin on the symptoms of PTSD. This follows the belief that exposure to traumatic events will lead to increased substance use so the symptoms of PTSD cannot be addressed until the patient has shown improvement with SUD. (Suza and Spates, 2008) show that current lore suggests three pathways that comorbidity can occur. The first pathway suggests that PTSD is a secondary disorder due to the high risk behaviors created by those with a SUD. The second pathway suggests that PTSD is the primary disorder and SUD is created due to individuals using substances to reduce the negative effects created by PTSD. The third pathway is increased reciprocal vulnerability created from early childhood trauma. “The Pandora’s Box hypothesis states that any attempts to address trauma related material in the incipient stages of substance dependence treatment would severely interfere with treatment effectiveness” (p. 17).

There is growing empirical evidence that runs contrary to the current wisdom and lore that SUD must be treated before the symptoms of PTSD can be addressed. The current studies of Seeking Safety, Significant Other and Project VALOR, and Prolonged Exposer all show promising results that treating patients with comorbidity of PTSD and SUD simultaneously could be the best path to treatment. “Individuals who receive PTSD treatment in addition to SUD treatment in the first three months of intervention are 3.7 times more likely to be free of substances at a 5-year follow up than individuals who receive only SA treatment” (Suza and Spates, 2008).

Special attention must be paid to returning OIF/OEF veterans due to their high rate of comorbidity of PTSD and SUD. The stress and traumatic events that result from serving in a combat zone, compounded with the difficulties many veterans face while attempting to reintegrate back into normal society, place them at higher risk to develop mental health disorders they did not have prior to deployment. Survey results from treatment of OIF/OEF veterans concurs that simultaneous treatment is proving effective. Further research needs to be conducted to strengthen the primary findings of simultaneous treatment in this population and to also determine which method of treatment shows the best results.