Treatment of post-traumatic stress disorder and substance use disorder in adults with a history of adverse childhood experiences: A systematic review of psychological interventions

Abstract

Background: Adverse childhood experiences (ACEs) have long-term effects on adult health, including unresolved trauma and substance use disorder (SUD). There are hypotheses of a mediating role of emotion regulation. This systematic literature review and narrative synthesis assessed the effectiveness of psychological interventions on emotion regulation, PTSD and SUD symptoms.

Methods: Searches were conducted using the Cochrane Handbook for Systematic Reviews methodology. Eligible studies were randomised controlled trials (RCTs) and quasi-experimental psychological interventions published between 2009 and 2019. Study characteristics, results and methodological quality were systematically analysed.

Results: Thirteen studies, including nine RCTs, were selected. Integrated SUD and PTSD treatments consisted of Seeking Safety, exposure-based treatment, Trauma Recovery and Empowerment Model, and integrated cognitive behavioural therapy. Two studies reported emotion regulation. Five studies found a small to medium positive effect size of psychological interventions on PTSD outcomes. Two studies had a small positive effect size on SUD outcomes and two a small negative effect size. Attrition was high across most studies. Characteristics likely to affect the applicability of the review were described.

Conclusion: The review found some evidence of a small inconsistent positive effect of psychological interventions on PTSD outcomes, and no evidence of effect on SUD outcomes. The range of theoretical models was narrow. Overall quality was low with high clinical heterogeneity and missing key information, particularly on emotion regulation, an important transdiagnostic feature. Further research is required to establish interventions that can treat these multiple conditions with a focus on effectiveness, acceptability, and implementation in real life clinical practice.

Keywords: ACEs, adverse childhood experiences; AEs, adverse events; ATREM, Attachment-informed TREM; CBT, Cognitive–Behavioural Therapy; CI, confidence intervals; CPTSD, complex PTSD; DERS, Difficulties in Emotion Regulation Scale; EMDR, eye movement desensitisation and reprocessing; ER, emotion regulation; FSP, family and social problems; ICBT, Integrated CBT; M, mean; OR, odds ratio; PRISMA, Preferred Reporting Items for Systematic Reviews and Meta-Analyses; PTSD, post-traumatic stress disorder; RCT, randomised control trial; SD, standard deviation; SS, Seeking Safety; SUD, substance use disorder; SWiM, Synthesis Without Meta-Analysis; TREM, Trauma Recovery and Empowerment Model; adverse childhood experiences; emotion regulation; posttraumatic stress disorder; psychological interventions; substance use disorder; systematic review.

Fig. 1

Adapted preferred reporting items for systematic reviews and meta-analyses (PRISMA) study flow diagramMoher et al., 2009.

Fig. 2

Risk of bias graph.

Fig. 3

Forest plot of comparison: 1 IT, outcome: PTSD Severity post treatment. Ordered by lowest attrition bias and then biggest sample size.

Fig. 4

Forest plot of comparison: 1 IT, outcome: SUD severity post treatment. Ordered by lowest attrition bias and then biggest sample size.