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. 2024 Mar;150(3):319-353.
doi: 10.1037/bul0000409. Epub 2023 Nov 16.

Project harmony: A systematic review and network meta-analysis of psychotherapy and pharmacologic trials for comorbid posttraumatic stress, alcohol, and other drug use disorders

Denise A Hien  1 , Santiago Papini  2 , Lissette M Saavedra  3 , Alexandria G Bauer  1 , Lesia M Ruglass  4 , Chantel T Ebrahimi  1 , Skye Fitzpatrick  5 , Teresa López-Castro  4 , Sonya B Norman  6 , Therese K Killeen  7 , Sudie E Back  7 , Antonio A Morgan-López  3
Affiliations

Project harmony: A systematic review and network meta-analysis of psychotherapy and pharmacologic trials for comorbid posttraumatic stress, alcohol, and other drug use disorders

Denise A Hien et al. Psychol Bull. 2024 Mar.

Abstract

We conducted a systematic review and network meta-analyses (NMA) of psychotherapy and pharmacologic treatments for individuals with co-occurring posttraumatic stress disorder (PTSD) and alcohol or other drug use disorder (AOD). A comprehensive search spanning 1995-2019 yielded a pool of 39 studies for systematic review, including 24 randomized controlled trials for the NMA. Study interventions were grouped by target of treatment (PTSD + AOD, PTSD-only, and AOD-only) and approach (psychotherapy or medication). Standardized mean differences (SMD) from the NMA yielded evidence that at the end of treatment, integrated, trauma-focused therapy for PTSD + AOD was more effective at reducing PTSD symptoms than integrated, non-trauma-focused therapy (SMD = -0.30), AOD-focused psychotherapy (SMD = -0.29), and other control psychotherapies (SMD = -0.43). End-of-treatment alcohol use severity was less for AOD medication compared to placebo medication (SMD = -0.36) and trauma-focused therapy for PTSD + placebo medication (SMD = -0.67), and less for trauma-focused psychotherapy + AOD medication compared to PTSD medication (SMD = -0.53), placebo medication (SMD = -0.50), and trauma-focused psychotherapy + placebo medication (SMD = -0.81). Key limitations include the small number of studies in the NMA for pharmacologic treatments and the lack of demographic diversity apparent in the existing literature. Findings suggest room for new studies that can address limitations in study sample composition, sample sizes, retention, and apply new techniques for conducting comparative effectiveness in PTSD + AOD treatment. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

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Conflict of interest statement

Drs. Sudie Back and Therese Killeen disclose conflicts of interest as they are authors on the COPE therapy manuals published by Oxford University Press. All other authors report no conflicts of interest.

Figures

Figure 1
Figure 1
PRISMA Flow Diagram
Figure 2
Figure 2
Networks of Comparisons at End of Treatment Note. The size of each node is proportional to the number of participants within each treatment category. The thickness of each edge is proportional to the number of comparisons between two categories, which is indicated by the numeral on each edge.
Figure 2
Figure 2
Networks of Comparisons at End of Treatment Note. The size of each node is proportional to the number of participants within each treatment category. The thickness of each edge is proportional to the number of comparisons between two categories, which is indicated by the numeral on each edge.
Figure 3
Figure 3
End-of-Treatment Outcomes for Each Treatment Category Note. Standardized mean differences (SMD) [95% CI] from the network meta-analyses. Estimates in the lower triangle (green) integrate direct and indirect evidence from all studies in the network, and estimates in the upper triangle (blue) are based on direct evidence from studies that included comparisons between treatment categories. Statistically significant differences are indicated in bold. Negative SMDs with 95% CIs that do not overlap with 0 indicate superiority of the category in the column vs row for the network meta-analysis and row vs column for the pairwise meta-analysis (positive SMDs indicate the reverse). AOD = alcohol and other drug use; Integrated = Non-Trauma Focused psychotherapy targeting both PTSD and AOD; PTSD = posttraumatic stress disorder; N = the number of studies used to estimate the effect; NA = not applicable because the two treatment categories were not directly compared in any studies.
Figure 3
Figure 3
End-of-Treatment Outcomes for Each Treatment Category Note. Standardized mean differences (SMD) [95% CI] from the network meta-analyses. Estimates in the lower triangle (green) integrate direct and indirect evidence from all studies in the network, and estimates in the upper triangle (blue) are based on direct evidence from studies that included comparisons between treatment categories. Statistically significant differences are indicated in bold. Negative SMDs with 95% CIs that do not overlap with 0 indicate superiority of the category in the column vs row for the network meta-analysis and row vs column for the pairwise meta-analysis (positive SMDs indicate the reverse). AOD = alcohol and other drug use; Integrated = Non-Trauma Focused psychotherapy targeting both PTSD and AOD; PTSD = posttraumatic stress disorder; N = the number of studies used to estimate the effect; NA = not applicable because the two treatment categories were not directly compared in any studies.
Figure 3
Figure 3
End-of-Treatment Outcomes for Each Treatment Category Note. Standardized mean differences (SMD) [95% CI] from the network meta-analyses. Estimates in the lower triangle (green) integrate direct and indirect evidence from all studies in the network, and estimates in the upper triangle (blue) are based on direct evidence from studies that included comparisons between treatment categories. Statistically significant differences are indicated in bold. Negative SMDs with 95% CIs that do not overlap with 0 indicate superiority of the category in the column vs row for the network meta-analysis and row vs column for the pairwise meta-analysis (positive SMDs indicate the reverse). AOD = alcohol and other drug use; Integrated = Non-Trauma Focused psychotherapy targeting both PTSD and AOD; PTSD = posttraumatic stress disorder; N = the number of studies used to estimate the effect; NA = not applicable because the two treatment categories were not directly compared in any studies.
Figure 3
Figure 3
End-of-Treatment Outcomes for Each Treatment Category Note. Standardized mean differences (SMD) [95% CI] from the network meta-analyses. Estimates in the lower triangle (green) integrate direct and indirect evidence from all studies in the network, and estimates in the upper triangle (blue) are based on direct evidence from studies that included comparisons between treatment categories. Statistically significant differences are indicated in bold. Negative SMDs with 95% CIs that do not overlap with 0 indicate superiority of the category in the column vs row for the network meta-analysis and row vs column for the pairwise meta-analysis (positive SMDs indicate the reverse). AOD = alcohol and other drug use; Integrated = Non-Trauma Focused psychotherapy targeting both PTSD and AOD; PTSD = posttraumatic stress disorder; N = the number of studies used to estimate the effect; NA = not applicable because the two treatment categories were not directly compared in any studies.
Figure 3
Figure 3
End-of-Treatment Outcomes for Each Treatment Category Note. Standardized mean differences (SMD) [95% CI] from the network meta-analyses. Estimates in the lower triangle (green) integrate direct and indirect evidence from all studies in the network, and estimates in the upper triangle (blue) are based on direct evidence from studies that included comparisons between treatment categories. Statistically significant differences are indicated in bold. Negative SMDs with 95% CIs that do not overlap with 0 indicate superiority of the category in the column vs row for the network meta-analysis and row vs column for the pairwise meta-analysis (positive SMDs indicate the reverse). AOD = alcohol and other drug use; Integrated = Non-Trauma Focused psychotherapy targeting both PTSD and AOD; PTSD = posttraumatic stress disorder; N = the number of studies used to estimate the effect; NA = not applicable because the two treatment categories were not directly compared in any studies.
Figure 3
Figure 3
End-of-Treatment Outcomes for Each Treatment Category Note. Standardized mean differences (SMD) [95% CI] from the network meta-analyses. Estimates in the lower triangle (green) integrate direct and indirect evidence from all studies in the network, and estimates in the upper triangle (blue) are based on direct evidence from studies that included comparisons between treatment categories. Statistically significant differences are indicated in bold. Negative SMDs with 95% CIs that do not overlap with 0 indicate superiority of the category in the column vs row for the network meta-analysis and row vs column for the pairwise meta-analysis (positive SMDs indicate the reverse). AOD = alcohol and other drug use; Integrated = Non-Trauma Focused psychotherapy targeting both PTSD and AOD; PTSD = posttraumatic stress disorder; N = the number of studies used to estimate the effect; NA = not applicable because the two treatment categories were not directly compared in any studies.
Figure 4
Figure 4
A. Forest plot for the pairwise meta-analyses of PTSD outcome across treatment categories included in the Psychotherapy Control NMA B. Forest plot for the pairwise meta-analyses of PTSD outcome across treatment categories included in the Placebo Control NMA C. Forest plot for the pairwise meta-analyses of alcohol outcome across treatment categories included in the Psychotherapy Control NMA D. Forest plot for the pairwise meta-analyses of alcohol outcome across treatment categories included in the Placebo Control NMA
Figure 4
Figure 4
A. Forest plot for the pairwise meta-analyses of PTSD outcome across treatment categories included in the Psychotherapy Control NMA B. Forest plot for the pairwise meta-analyses of PTSD outcome across treatment categories included in the Placebo Control NMA C. Forest plot for the pairwise meta-analyses of alcohol outcome across treatment categories included in the Psychotherapy Control NMA D. Forest plot for the pairwise meta-analyses of alcohol outcome across treatment categories included in the Placebo Control NMA
Figure 4
Figure 4
A. Forest plot for the pairwise meta-analyses of PTSD outcome across treatment categories included in the Psychotherapy Control NMA B. Forest plot for the pairwise meta-analyses of PTSD outcome across treatment categories included in the Placebo Control NMA C. Forest plot for the pairwise meta-analyses of alcohol outcome across treatment categories included in the Psychotherapy Control NMA D. Forest plot for the pairwise meta-analyses of alcohol outcome across treatment categories included in the Placebo Control NMA
Figure 4
Figure 4
A. Forest plot for the pairwise meta-analyses of PTSD outcome across treatment categories included in the Psychotherapy Control NMA B. Forest plot for the pairwise meta-analyses of PTSD outcome across treatment categories included in the Placebo Control NMA C. Forest plot for the pairwise meta-analyses of alcohol outcome across treatment categories included in the Psychotherapy Control NMA D. Forest plot for the pairwise meta-analyses of alcohol outcome across treatment categories included in the Placebo Control NMA
Figure 5
Figure 5
Risk of Bias (ROB) ratings
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