A systematic review and meta-analysis of psychological interventions for comorbid post-traumatic stress disorder and substance use disorder
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Background: The psychological treatment of comorbid post-traumatic stress disorder (PTSD) and substance use disorder (SUD) is clinically challenging, and outcomes are often poor. Objective: This paper describes a systematic review and meta-analysis which sought to establish the current efficacy for a number of established psychological approaches for adults and adolescents, in comparison to interventions for SUD alone, or other active approaches, following a pre-registered protocol. Method: This review followed PRISMA and Cochrane Collaboration guidelines. Data extraction and risk of bias judgements using Cochrane criteria were undertaken by all authors. Primary outcomes were PTSD severity and substance use post-treatment. The quality of findings was assessed using GRADE. Following a comprehensive search, conducted to 13 September 2021, 27 studies were included. Results: We found a relatively high level of dropout across studies. In our main comparisons, we found no benefits for present-focused treatment approaches aimed at improving coping skills beyond those for SUD-only interventions. We found modest benefits for trauma-focused intervention plus SUD intervention post-treatment for PTSD (standardized mean difference (SMD) = -0.36, 95% confidence interval (CI) -0.64, -0.08), and at 6-13 months for PTSD (SMD = -0.48, 95% CI -0.81, -0.15) and alcohol use (SMD = -0.23, 95% CI -0.44, -0.02). There were no benefits for cognitive restructuring interventions as a group, but we found a modest effect for integrated cognitive behavioural therapy (ICBT) for PTSD post-treatment (SMD = -0.33, 95% CI -0.62, -0.04). There was evidence of some benefit for trauma-focused intervention over present-focused intervention for PTSD from a single study and for reduction in dropout for incentivized attendance for trauma-focused intervention from another single study. Most findings were of very low quality. Conclusion: There is evidence that trauma-focused therapy and ICBT can improve PTSD for some individuals, but many patients do not fully engage with treatment and average treatment effects are modest. HIGHLIGHTS: For PTSD, evidence was strongest for trauma-focused CBT-based approaches, but effects were modest.There was little evidence of any added benefit on substance use, beyond that of standard addiction treatments, for any included intervention.Dropout from treatment was high.
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Non-trauma-focused treatments are less effective than trauma-focused treatments and generally have lower effect sizes for PTSD, including in PTSD+SUD samples.
“However, non-TF treatments are less effective than TF treatments and generally have lower effect sizes for the treatment of PTSD (e.g., V A/DoD PTSD Guideline, 2023), including in PTSD+SUD samples (Roberts et al., 2015; Roberts et al., 2022).”
From Cannabis use and trauma-focused treatment for co-occurring posttraumatic stress disorder and substance use disorders: A meta-analysis of individual patient data (2024) · cites this paper as Roberts et al., 2022
In the Results (page unavailable), the review reports no PTSD benefit for present-focused treatments over SUD-only treatment, while trauma-focused treatment showed modest benefits. The Discussion (page unavailable) also reports one direct study favouring trauma-focused over present-focused treatment for PTSD severity. That supports the direction of the claim in PTSD+SUD samples, but a single direct comparison and very-low-quality findings do not establish that non-trauma-focused treatments generally have lower effect sizes. (LLM, conf=0.82)
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- Back, S. E., Foa, E. B., Killeen, T. K., Mills, K. L., Teesson, M., Carroll, K. M., et al. (2014). Concurrent treatment of PTSD and substance use disorders using prolonged exposure (COPE): Therapist manual. New York: Oxford University Press.
- NICE. (2007). Drug misuse in over 16s: psychosocial interventions. National Institute for Health and Care Excellence. Retrieved from www.nice.org.uk/guidance/cg51 39480985
- NICE. (2018). Post-traumatic stress disorder. National Institute for Health and Care Excellence. Retrieved from www.nice.org.uk/guidance/ng116 31211536
- Review Manager (RevMan) [Computer program]. Version 5.4.1 Copenhagen: The Nordic Cochrane Centre, The Cochrane Collaboration. (2020).
Cited by
Sorted by citations
MDMA-assisted therapy for moderate to severe PTSD: A randomized, placebo-controlled phase 3 trial
Mitchell, J. M., Ot’alora G., M., van der Kolk, B., Shannon, S., Bogenschutz, M., Gelfand, Y., Paleos, C., Nicholas, C. R., Quevedo, S., Balliett, B., et al. (2023) · Nature Medicine · doi:10.1038/s41591-023-02565-4 · Cited by 455 · see citing works
Kearney, B. E., Corrigan, F. M., Frewen, P. A., Nevill, S., Harricharan, S., Andrews, K., Jetly, R., McKinnon, M. C., & Lanius, R. A. (2023) · European Journal of Psychotraumatology · doi:10.1080/20008066.2023.2240691 · Cited by 23 · see citing works
Hill, M. L., Kline, A. C., Saraiya, T. C., Gette, J., Ruglass, L. M., Norman, S. B., Back, S. E., Saavedra, L. M., Hien, D. A., & Morgan-López, A. A. (2024) · Journal of Anxiety Disorders · doi:10.1016/j.janxdis.2024.102827 · Cited by 11 · see citing works
Nardi, W. R., Kelly, P., Roy, A., Becker, S., Brewer, J., & Sun, S. (2024) · Journal of Substance Use and Addiction Treatment · doi:10.1016/j.josat.2024.209442 · Cited by 11 · see citing works
- Authors
- Roberts, N. P., Lotzin, A., & Schäfer, I.
- Affiliations
- Cardiff and Vale University Health Board (GB)
- University Medical Center Hamburg-Eppendorf (DE)
- Corresponding author
- Roberts, Neil P.
- Venue
- European Journal of Psychotraumatology
- Publisher
- Informa UK Limited
- Published
- 2022-05-03
- Volume
- 13
- Issue
- 1
- Pages
- 2041831-2041831
- ISSN
- 2000-8066 (ISSN-L)
- PMC
- PMC9090345
- OpenAlex
- W4225331155
- Cited by
- 120
- References
- 89
- Citations by year
- 2026: 29 · 2025: 31 · 2024: 24 · 2023: 20 · 2022: 16
- FWCI
- 3.79
- Type
- journal article
- Language
- en
- Open access
- gold
- doi.org
- Licence
- Locations
- European Journal of Psychotraumatology (publishedVersion, cc-by-nc)
- PubMed Central (publishedVersion, cc-by-nc)
- PubMed (publishedVersion)
- ORCA Online Research @Cardiff (Cardiff University) (acceptedVersion)
- DOAJ (DOAJ: Directory of Open Access Journals) (submittedVersion, cc-by-sa)
- Topics
- Social Sciences › Psychology › Clinical Psychology › Posttraumatic Stress Disorder Research
- Social Sciences › Psychology › Clinical Psychology › Psychotherapy Techniques and Applications
- Health Sciences › Medicine › Epidemiology › Substance Abuse Treatment and Outcomes
- Keywords
- post-traumatic stress disorder, substance use disorders, comorbidities, psychological intervention, trauma-focused cognitive behavioral therapy, cognitive restructuring, treatment discontinuation, alcohol consumption, adolescents, treatment efficacy
- MeSH terms
- Psychosocial Intervention, Adolescent, Adult, Humans, Psychotherapy, Stress Disorders, Post-Traumatic, Cognitive Behavioral Therapy, Substance-Related Disorders
About these checks
Registry, retraction, Cites and statistics results are computed, not judged, with one exception: a printed reference that no index lists is read once by a model before it counts as a citation error. Claims are extracted by a model and kept only when their quote appears verbatim in the text; each cited source is then checked, with a model’s help, for whether it says what the claim relies on. Those verdicts can be wrong — read the claim’s quote and the cited source before relying on one.
Statistics and arithmetic are recomputed, not judged.
Confidence bands are shown only for fields calibrated on our annotated test set. None is calibrated yet, so no band is shown.
What counts as a claim ›How we measure confidence ›How we check this ›
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