Trauma, Technology, and Routine Outcome Measures

This issue of the Journal highlights four issues: trauma, technology, routine outcome measurement, and cognitive remediation. We comment on the articles in that order.

Tuliao, Jaffe, and McChargue (2016) examined the relationships between posttraumatic stress disorder symptoms, alcohol expectancies, and severity of alcohol outcomes among college students with a trauma history using mediation analyses. The results did not support the hypothesized mediation role of general tension reduction, but other pathways were significant. Cui, Haller, Skidmore, Goldsteinholm, Norman, and Tate (2016) studied treatment attendance among veterans with co-occurring depression, substance dependence, and posttraumatic stress disorder who were randomly assigned to two forms of psychotherapy. Group assignment and most other variables did not predict attendance.

Sullivan, Weiss, Flanagan, Willie, Armeli, and Tennen (2016) examined posttraumatic stress disorder and the use of alcohol and drugs by adult women who had recently experienced intimate partner violence. A diagnosis of posttraumatic stress disorder was strongly related to alcohol and drug use. Ham, Wiersma-Mosley, Feldner, Melkonian, Milner, and Lewis (2016) studied college students with a trauma history by examining their nonmedical prescription drug use (using a medication without a prescription or in ways for which it was not prescribed). The key finding was that frequent posttraumatic stress symptoms correlated with hazardous nonmedical prescription drug use. We suggest a brief note on terminology: “Medications” are substances approved and prescribed to treat specific conditions; the term “drugs” is often used to refer to substances that are not approved for medical uses but are used and abused for other purposes. Some substances fall into both categories of course, but attention to the distinction may improve clarity in the substance abuse literature.

Chuang, Chan, and Leventhal (2016) studied anxiety, depression, and other negative psychological states in relation to lifetime substance use among ninth-grade students. Lifetime use of alcohol and/or other drugs correlated with symptoms of anxiety, depression, and other negative psychological states and traits. The study measured vulnerability rather than psychiatric disorders but clearly showed that psychological vulnerability was related to early use of substances. Although posttraumatic symptoms were not measured explicitly, the findings suggest underlying background issues, such as trauma.

These articles (plus another in McGurk's special section on cognitive interventions) address co-occurring posttraumatic symptoms and substance use. We suspect that other articles in the issue could have fruitfully measured trauma history as well. Civilian and military trauma and substance use comorbidity have been common in the U.S. for some time, and trauma has typically preceded the abuse of substances (Jacobsen, Southwick, and Kosten, 2011).

The particular relationships between posttraumatic symptoms and substance use probably vary considerably from one population to another, as some of the studies in this issue illustrate, and are also undoubtedly related to individual psychological, social, and environmental factors. Perhaps the specific correlations are less important than the message that we should expect this co-occurrence and concentrate on developing and implementing effective treatments. As Chuang, Chan, and Leventhal (2016) point out, these relationships often develop early, based on the timing of childhood traumas, and should stimulate efforts to identify vulnerability and provide some form of preventive interventions.

The painful internal states that result from trauma often stimulate attempts to escape (a central feature of posttraumatic stress disorder), including through using psychoactive substances. We suggest another note on terminology: The term “self-medication” in the literature does not align with the standard definition and aims of medications (Mueser, Drake, and Wallach, 1998). We suggest that attempts to suppress negative cognitive and emotional experiences with psychoactive drugs differ fundamentally from medical treatments for these painful internal states and should not be termed self-medication.

Aschbrenner, Naslund, Gill, Bartels, and Ben-Zeev (2016) examined transcripts of text messages between clinicians and clients with schizophrenia and substance use, which were exchanged as part of a 12-week illness management intervention. Thematic analysis revealed several major themes related to mental health symptoms: mental health coping strategies, mental health treatment and management, lifestyle behaviors, social relationships and leisure activities, motivation and goal setting, and independent living. Overall, the clients were interested in using text messaging to get help with coping strategies. This study follows a special section on technology tools in the Journal (Marsch & Ben-Zeev, 2012) and adds to increasing evidence regarding the future potential of these tools to increase access, efficacy, and cost-effectiveness (Ben-Zeev, 2014; Marsch & Gustafson, 2013; Ben-Zeev et al., 2013).

Noel, Woods, Routhier, and Drake (2016) reported on a clinical inventory to assess recovery among young men with co-occurring serious mental and substance use disorders. The inventory was used to assess progress on specific program goals and to stimulate shared decision making. Routine outcome measurement in mental health has proliferated around the world despite controversies (Bilsker & Goldner, 2002). A recent special issue of the International Journal of Psychiatry documented the heterogeneous approaches in nine high-income countries around the world (Roe, Drake, & Slade, 2015). International efforts show slow but steady progress, emphasizing some of the same themes that Noel and colleagues discuss, including the involvement of stakeholders, alignment with program goals and culture, use of technology, and timely feedback.

Researchers often mistakenly believe that routine outcome measurement is simple: They say, “Just use the relevant research measures.” Nothing could be further from the reality. Research measures are rarely administered and used appropriately for clinical purposes. The amount, timing, and use of routine outcome measurement depend on the target population, treatment setting, expected rate of change, specific program goals, and many other factors. The current state of routine outcome measurement is inchoate; meanwhile, emerging technologies are rapidly changing the possibilities for collection, analysis, and feedback of results. Routine outcome measurement presents an opportunity for meaningful research.

Finally, McGurk (2016) has organized a special section on cognitive remediation and provided a separate editorial on the three articles in the section. We appreciate her excellent contribution to the Journal.

Disclosures

Dr. Drake reports no financial relationships with commercial interests. Dr. Green reports research grant support over the past three years from Janssen and Novartis. He currently serves as a consultant to Otsuka and Alkermes (unpaid) and on a data safety monitoring board for Eli Lilly studies, and he is the co-inventor in one patent (and the co-inventor of a pending patent) on the treatment of substance abuse. During the past three years he has owned shares of stock in Johnson & Johnson, Pfizer, and Mylan.