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Original Investigation
April 24, 2019

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

Author Affiliations
  • 1VA San Diego Healthcare System, San Diego, California
  • 2National Center for PTSD, White River Junction, Vermont
  • 3VA Center of Excellence for Stress and Mental Health, San Diego, California
  • 4Department of Psychiatry, University of California, San Diego, School of Medicine, La Jolla
  • 5James A. Haley Veterans’ Hospital, Tampa, Florida
  • 6Ralph H. Johnson VA Medical Center, Charleston, South Carolina
  • 7San Diego Joint Doctoral Program in Clinical Psychology, San Diego State University/University of California, San Diego
  • 8Department of Psychology, University of Texas, Austin
JAMA Psychiatry. 2019;76(8):791-799. doi:10.1001/jamapsychiatry.2019.0638
Key Points

Question  Is 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?

Findings  In 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.

Meaning  Integrated prolonged exposure therapy was well tolerated and had greater efficacy for reducing posttraumatic stress disorder symptoms than present-centered integrated coping skills therapy.


Importance  Co-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.

Objective  To 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 Participants  This 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.

Interventions  Veterans underwent I-PE (Concurrent Treatment of PTSD and Substance Use Disorder Using Prolonged Exposure) or I-CS (Seeking Safety) therapy.

Main Outcomes and Measures  A 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.

Results  A 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 (treatment × time interaction, −2.83; F3,233.1 = 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 (treatment × time interaction, 1.8%; F3,209.9 = 0.18; Cohen d = 0.04; P = .91).

Conclusions and Relevance  The 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 Registration  ClinicalTrials.gov identifier: NCT01601067