Psychological therapies for post‐traumatic stress disorder and comorbid substance use disorder

Neil P Roberts; Pamela A Roberts; Neil Jones; Jonathan I Bisson

doi:10.1002/14651858.CD010204.pub2

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Figure 1

Study flow diagram.

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Figure 2

Risk of bias graph: review authors' judgements about each risk of bias item presented as percentages across all included studies.

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Figure 3

Risk of bias summary: review authors' judgements about each risk of bias item for each included study.

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Analysis 1.1

Comparison 1 Trauma‐focused psychological therapy vs control therapy, Outcome 1 PTSD severity following treatment completion.

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Analysis 1.2

Comparison 1 Trauma‐focused psychological therapy vs control therapy, Outcome 2 PTSD severity 3‐4 months following treatment completion.

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Analysis 1.3

Comparison 1 Trauma‐focused psychological therapy vs control therapy, Outcome 3 PTSD severity 5‐7 months following treatment completion.

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Analysis 1.4

Comparison 1 Trauma‐focused psychological therapy vs control therapy, Outcome 4 Drug or alcohol use, or both following treatment completion.

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Analysis 1.5

Comparison 1 Trauma‐focused psychological therapy vs control therapy, Outcome 5 Drug or alcohol use, or both 3‐4 months following treatment completion.

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Analysis 1.6

Comparison 1 Trauma‐focused psychological therapy vs control therapy, Outcome 6 Drug or alcohol use, or both 5‐7 months following treatment completion.

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Analysis 1.7

Comparison 1 Trauma‐focused psychological therapy vs control therapy, Outcome 7 Treatment completers.

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Analysis 1.8

Comparison 1 Trauma‐focused psychological therapy vs control therapy, Outcome 8 PTSD diagnosis following treatment completion.

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Study
Individual intervention
Coffey 2006	Not reported
Coffey submitted	Not reported
Foa 2013	Twelve participants were removed from the study because of serious adverse events (serious suicidal ideation, n = 7; serious medical illness, n = 3; psychotic symptoms, n = 1; death, n = 1; however, none of these events was determined to be related to the study).
Mills 2012	Two participants from the treatment group (3.6%) and 5 participants from the control group (10.4%) attempted suicide during the study (OR, 0.32 [95% CI, 0.06‐1.76]). Although it is possible that these attempts were related to participation in the study, all 7 individuals reported that this was not the case and elected to remain involved with the study. Additionally, 1 participant from the treatment group (1.8%) died as a result of a preexisting medical condition.

Analysis 1.9

Comparison 1 Trauma‐focused psychological therapy vs control therapy, Outcome 9 Adverse events.

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Analysis 1.10

Comparison 1 Trauma‐focused psychological therapy vs control therapy, Outcome 10 Adverse events.

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Study	Mean number sessions attended by intervention group (& SD)	Number sessions available	Percentage attended
Studies including intervention for SUD
Coffey submitted	8.16 (3.26) approximated	12	68.0%
Foa 2013	6.33 (5.31)	18	35.2%
Mills 2012	5.83 (4.94)	13	44.9%

Analysis 1.11

Comparison 1 Trauma‐focused psychological therapy vs control therapy, Outcome 11 Mean number of sessions attended for intervention group.

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Analysis 1.12

Comparison 1 Trauma‐focused psychological therapy vs control therapy, Outcome 12 Sensitivity analysis: PTSD severity following treatment completion.

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Analysis 2.1

Comparison 2 Trauma‐focused psychological therapy vs active psychological therapy for SUD only, Outcome 1 PTSD severity following treatment completion.

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Analysis 2.2

Comparison 2 Trauma‐focused psychological therapy vs active psychological therapy for SUD only, Outcome 2 PTSD severity 5‐7 months following treatment completion.

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Analysis 2.3

Comparison 2 Trauma‐focused psychological therapy vs active psychological therapy for SUD only, Outcome 3 PTSD severity 8‐10 months following treatment completion.

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Analysis 2.4

Comparison 2 Trauma‐focused psychological therapy vs active psychological therapy for SUD only, Outcome 4 Drug or alcohol use, or both following treatment completion.

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Analysis 2.5

Comparison 2 Trauma‐focused psychological therapy vs active psychological therapy for SUD only, Outcome 5 Drug or alcohol use, or both 5‐7 months following treatment completion.

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Analysis 2.6

Comparison 2 Trauma‐focused psychological therapy vs active psychological therapy for SUD only, Outcome 6 Drug or alcohol use, or both 8‐10 months following treatment completion.

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Analysis 2.7

Comparison 2 Trauma‐focused psychological therapy vs active psychological therapy for SUD only, Outcome 7 Treatment completers.

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Analysis 2.8

Comparison 2 Trauma‐focused psychological therapy vs active psychological therapy for SUD only, Outcome 8 PTSD diagnosis following treatment completion.

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Analysis 2.9

Comparison 2 Trauma‐focused psychological therapy vs active psychological therapy for SUD only, Outcome 9 SUD diagnosis following treatment completion.

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Analysis 3.1

Comparison 3 Non‐trauma‐focused psychological therapy for PTSD and SUD or PTSD only vs control therapy, Outcome 1 PTSD severity following treatment completion.

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Analysis 3.2

Comparison 3 Non‐trauma‐focused psychological therapy for PTSD and SUD or PTSD only vs control therapy, Outcome 2 PTSD severity 3‐4 months following treatment completion.

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Analysis 3.3

Comparison 3 Non‐trauma‐focused psychological therapy for PTSD and SUD or PTSD only vs control therapy, Outcome 3 PTSD severity 5‐7 months following treatment completion.

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Analysis 3.4

Comparison 3 Non‐trauma‐focused psychological therapy for PTSD and SUD or PTSD only vs control therapy, Outcome 4 PTSD severity 12 months following treatment completion.

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Analysis 3.5

Comparison 3 Non‐trauma‐focused psychological therapy for PTSD and SUD or PTSD only vs control therapy, Outcome 5 Drug or alcohol use, or both following treatment completion.

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Analysis 3.6

Comparison 3 Non‐trauma‐focused psychological therapy for PTSD and SUD or PTSD only vs control therapy, Outcome 6 Drug or alcohol use, or both 3‐4 months following treatment completion.

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Analysis 3.7

Comparison 3 Non‐trauma‐focused psychological therapy for PTSD and SUD or PTSD only vs control therapy, Outcome 7 Drug or alcohol use, or both 5‐7 months following treatment completion.

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Analysis 3.8

Comparison 3 Non‐trauma‐focused psychological therapy for PTSD and SUD or PTSD only vs control therapy, Outcome 8 Drug or alcohol use, or both 12 months following treatment completion.

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Study
Individual intervention
Mueser 2008	12/16 (70.6%)
Group intervention
Frisman 2008	39/141 (28%)

Analysis 3.9

Comparison 3 Non‐trauma‐focused psychological therapy for PTSD and SUD or PTSD only vs control therapy, Outcome 9 Treatment completers.

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Analysis 3.10

Comparison 3 Non‐trauma‐focused psychological therapy for PTSD and SUD or PTSD only vs control therapy, Outcome 10 Treatment completers.

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Analysis 3.11

Comparison 3 Non‐trauma‐focused psychological therapy for PTSD and SUD or PTSD only vs control therapy, Outcome 11 PTSD diagnosis following treatment completion.

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Study
Group intervention
Boden 2012	No harmful or unintended effects were observed during the trial.
Frisman 2008	Not reported
Hien 2009	83 study related adverse events were identified (Killeen 2008). Of these 61 were rated as moderate to severe: 28 for the experimental condition; 33 for the control condition.
Najavits 2006a	Not reported
Norman unpublished	No adverse events occurred during the study.
Zlotnick 2009	Not reported

Analysis 3.12

Comparison 3 Non‐trauma‐focused psychological therapy for PTSD and SUD or PTSD only vs control therapy, Outcome 12 Adverse events.

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Analysis 3.13

Comparison 3 Non‐trauma‐focused psychological therapy for PTSD and SUD or PTSD only vs control therapy, Outcome 13 Study‐related adverse events.

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Study	Mean number treatment condition sessions attended by intervention group (& SD)	Number sessions available	Percentage active intervention sessions attended	Mean number sessions attended by control group (& SD)	Percentage attended
Group intervention
Boden 2012	Not reported			Not reported
Frisman 2008	3.41 (3.38) active intervention sessions + 30.67 (37.38) TAU sessions	9 active intervention sessions plus TAU sessions	37.9%	39.0 (69.62) TAU sessions
Hien 2009	6.2 (4.5)	12	51.7%	6.9 (4.3)	57.5%
Najavits 2006a	9.67(5.05) active intervention session (11.78 (6.25) active intervention +TAU sessions)	25 active intervention sessions plus TAU sessions	38.7%	Not reported
Norman unpublished	12.5 (8.77)	24	52.1%	7.78 (5.78)	32.4%
Zlotnick 2009	15.6 (6.2)	25	62.4%	Not reported

Analysis 3.14

Comparison 3 Non‐trauma‐focused psychological therapy for PTSD and SUD or PTSD only vs control therapy, Outcome 14 Mean number of sessions attended for intervention group.

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Analysis 3.15

Comparison 3 Non‐trauma‐focused psychological therapy for PTSD and SUD or PTSD only vs control therapy, Outcome 15 Mean number of sessions attended.

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Analysis 3.16

Comparison 3 Non‐trauma‐focused psychological therapy for PTSD and SUD or PTSD only vs control therapy, Outcome 16 Sensitivity analysis: PTSD severity 5‐7 months following treatment completion.

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Analysis 3.17

Comparison 3 Non‐trauma‐focused psychological therapy for PTSD and SUD or PTSD only vs control therapy, Outcome 17 Sensitivity analysis: PTSD severity 12 months following treatment completion.

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Analysis 3.18

Comparison 3 Non‐trauma‐focused psychological therapy for PTSD and SUD or PTSD only vs control therapy, Outcome 18 Sensitivity analysis: drug or alcohol use, or both 5‐7 months following treatment completion.

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Analysis 3.19

Comparison 3 Non‐trauma‐focused psychological therapy for PTSD and SUD or PTSD only vs control therapy, Outcome 19 Sensitivity analysis: drug or alcohol use, or both 12 months following treatment completion.

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Analysis 4.1

Comparison 4 Non‐trauma‐focused psychological therapy for PTSD and SUD or PTSD only vs active psychological therapy for SUD only, Outcome 1 PTSD severity following treatment completion.

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Analysis 4.2

Comparison 4 Non‐trauma‐focused psychological therapy for PTSD and SUD or PTSD only vs active psychological therapy for SUD only, Outcome 2 PTSD severity 3‐4 months following treatment completion.

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Analysis 4.3

Comparison 4 Non‐trauma‐focused psychological therapy for PTSD and SUD or PTSD only vs active psychological therapy for SUD only, Outcome 3 PTSD severity 5‐7 months following treatment completion.

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Analysis 4.4

Comparison 4 Non‐trauma‐focused psychological therapy for PTSD and SUD or PTSD only vs active psychological therapy for SUD only, Outcome 4 Drug or alcohol use, or both following treatment completion.

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Analysis 4.5

Comparison 4 Non‐trauma‐focused psychological therapy for PTSD and SUD or PTSD only vs active psychological therapy for SUD only, Outcome 5 Drug or alcohol use, or both 3‐4 months following treatment completion.

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Analysis 4.6

Comparison 4 Non‐trauma‐focused psychological therapy for PTSD and SUD or PTSD only vs active psychological therapy for SUD only, Outcome 6 Drug or alcohol use, or both 5‐7 months following treatment completion.

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Analysis 4.7

Comparison 4 Non‐trauma‐focused psychological therapy for PTSD and SUD or PTSD only vs active psychological therapy for SUD only, Outcome 7 Treatment completers.

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Analysis 4.8

Comparison 4 Non‐trauma‐focused psychological therapy for PTSD and SUD or PTSD only vs active psychological therapy for SUD only, Outcome 8 PTSD diagnosis following treatment completion.

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Analysis 4.9

Comparison 4 Non‐trauma‐focused psychological therapy for PTSD and SUD or PTSD only vs active psychological therapy for SUD only, Outcome 9 Mean number of sessions attended.

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Trauma‐focused psychological therapy compared to control intervention
Patient or population: Individuals with post‐traumatic stress disorder and comorbid substance use disorder Settings: Community addiction and mental health services Intervention: Individual‐based psychological therapy including a trauma‐focused component Comparison: Treatment as usual/minimal intervention/placebo intervention
Outcomes	*Illustrative comparative risks (95% CI)**		Relative effect (95% CI)	No of Participants (studies)	Quality of the evidence (GRADE)	Comments
	Assumed risk	Corresponding risk
	TAU/ minimal intervention	Individual‐based psychological therapyincluding a trauma‐focused component
PTSD severity following treatment completion As assessed by the CAPS, PSS‐I, or IES‐R. High scores indicate greater symptom severity	‐	The mean PTSD severity following treatment completion in the intervention groups was 0.41 standard deviations lower (0.72 to 0.1 lower)	‐	405 (4 studies)	⊕⊝⊝⊝ very low^1,2,3	SMD ‐0.41 (‐0.72 to ‐0.1) Effect sizes of the range 0.2 to 0.5 indicate a small treatment effect
Drug or alcohol use, or both following treatment completion As assessed by the TLFB or CIDI. High scores indicate greater symptom severity	‐	The mean drug/alcohol use following treatment completion in the intervention groups was 0.13 standard deviations lower (0.41 lower to 0.15 higher)	‐	388 (3 studies)	⊕⊝⊝⊝ very low^1,2,3	SMD ‐0.13 (‐0.41 to 0.15) Not significant
Treatment completers	Study population		RR 0.80 (0.69 to 0.93)	316 (3 studies)	⊕⊕⊝⊝ low^1,3	Indicates higher drop‐out in the intervention group
	761 per 1000	609 per 1000 (525 to 708)
	Moderate
	718 per 1000	574 per 1000 (495 to 668)
The basis for the assumed risk* (e.g. the median control group risk across studies) is provided in footnotes. The corresponding risk (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI). CAPS: Clinician Administered PTSD Scale; CI: confidence interval; CIDI: Composite International Diagnostic Interview; IES‐R: Impact of Events Scale‐Revised; PSS‐I: PTSD Symptom Scale‐Interview; PTSD: post‐traumatic stress disorder; RR: risk ratio; SMD: standardised mean difference; TAU: treatment as usual; TLFB: Timeline Followback Interview
GRADE Working Group grades of evidence High quality: Further research is very unlikely to change our confidence in the estimate of effect. Moderate quality: Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate. Low quality: Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate. Very low quality: We are very uncertain about the estimate.
¹Quality of evidence downgraded by one point because the risk of bias in most trials was high or unclear in several domains. ²Quality of evidence downgraded by one point because of a high level of unexplained statistical heterogeneity. ³Quality of evidence downgraded by one point as a result of significant clinical heterogeneity. SUD based adjunctive therapy was not a formal part of either the experimental or control condition in one study (Coffey 2006). However, participants were recruited through an SUD based service and it is likely that they would have had access to adjunctive SUD‐ based therapy on an informal basis. All other studies in this comparison included formal access SUD‐based adjunctive therapy.

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Summary of findings 2. Trauma‐focused psychological intervention compared to active psychological intervention for SUD only

Trauma‐focused psychological therapy compared to active psychological therapy for SUD only
Patient or population: Individuals with post‐traumatic stress disorder and comorbid substance use disorder Settings: Community addiction and mental health services Intervention: Individual‐based psychological therapy including a trauma‐focused component Comparison: Active psychological therapy for SUD only
Outcomes	*Illustrative comparative risks (95% CI)**		Relative effect (95% CI)	No of Participants (studies)	Quality of the evidence (GRADE)	Comments
	Assumed risk	Corresponding risk
	Active psychological therapyfor SUD only	Individual‐based psychological therapyincluding a trauma‐focused component
PTSD severity following treatment completion As assessed by the CAPS. High scores indicate greater symptom severity	‐	The mean PTSD severity following treatment completion in the intervention groups was 3.91 lower (19.16 lower to 11.34 higher)	‐	46 (1 study)	⊕⊕⊝⊝ low¹	Not significant
Drug or alcohol use, or both following treatment completion As assessed by the TLFB. High scores indicate greater symptom severity	‐	The mean drug/alcohol use following treatment completion in the intervention groups was 1.27 lower (5.76 lower to 3.22 higher)	‐	46 (1 study)	⊕⊕⊝⊝ low¹	Not significant
Treatment completers	Study population		RR 1 (0.74 to 1.36)	62 (1 study)	⊕⊕⊝⊝ low¹	Not significant
	724 per 1000	724 per 1000 (536 to 985)
	Moderate
	724 per 1000	724 per 1000 (536 to 985)
The basis for the assumed risk* (e.g. the median control group risk across studies) is provided in footnotes. The corresponding risk (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI). CAPS: Clinician Administered PTSD Scale; CI: confidence interval; PTSD: post‐traumatic stress disorder; RR: risk ratio; SUD: substance use disorder; TLFB: Timeline Followback Interview
GRADE Working Group grades of evidence High quality: Further research is very unlikely to change our confidence in the estimate of effect. Moderate quality: Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate. Low quality: Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate. Very low quality: We are very uncertain about the estimate.
¹Quality of evidence downgraded by two points because findings were based on outcomes from one study with a small sample size. SUD based adjunctive therapy was not a formal part of either the experimental or control condition in the study contributing to this comparison.

Summary of findings 2. Trauma‐focused psychological intervention compared to active psychological intervention for SUD only

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Summary of findings 3. Non‐trauma‐focused psychological intervention for PTSD and SUD or PTSD only compared to control intervention

Non‐trauma‐focused psychological therapy for PTSD and SUD or PTSD only compared to control intervention
Patient or population: Individuals with post‐traumatic stress disorder and comorbid substance use disorder Settings: Community addiction services and prison service Intervention: Group‐ and individual‐based non‐trauma‐focused psychological therapy
Outcomes	*Illustrative comparative risks (95% CI)**		Relative effect (95% CI)	No of Participants (studies)	Quality of the evidence (GRADE)	Comments
	Assumed risk	Corresponding risk
	TAU/minimal intervention	Group or Indvidual based non‐trauma‐focused psychological therapy
PTSD severity following treatment completion ‐ Individual‐based intervention As assessed by the CAPS. High scores indicate greater symptom severity	‐	The mean PTSD severity following treatment completion in the intervention groups was 0.22 standard deviations lower (0.83 lower to 0.39 higher)	‐	44 (1 study)	⊕⊕⊝⊝ low¹	SMD ‐0.22 (‐0.83 to 0.39)
PTSD severity following treatment completion ‐ Group‐based intervention As assessed by the CAPS or IES‐R. High scores indicate greater symptom severity	‐	The mean PTSD severity following treatment completion in the intervention groups was 0.02 standard deviations lower (0.19 lower to 0.16 higher)	‐	513 (4 studies)	⊕⊕⊝⊝ low^2,3	SMD ‐0.02 (‐0.19 to 0.16)
Drug or alcohol use, or both following treatment completion ‐ Individual‐based intervention	‐	No data	‐	‐	‐	Not estimable
Drug or alcohol use, or both following treatment completion ‐ Group‐based intervention As assessed by the ASI, TLFB or CIDI. High scores indicate greater symptom severity	‐	The mean drug/alcohol use following treatment completion in the intervention groups was 0.41 standard deviations lower (0.97 lower to 0.14 higher)	‐	464 (3 studies)	⊕⊝⊝⊝ very low^2,3,4	SMD ‐0.41 (‐0.97 to 0.14) Not significant
Treatment completers ‐ Individual‐based intervention	‐	No data	‐	‐	‐	Not estimable
Treatment completers ‐ Group‐based intervention	Study population		RR 1.13 (0.88 to 1.45)	381 (2 studies)	⊕⊕⊝⊝ low^2,3	‐
	538 per 1000	608 per 1000 (473 to 780)
	Moderate
	493 per 1000	557 per 1000 (434 to 715)
The basis for the assumed risk* (e.g. the median control group risk across studies) is provided in footnotes. The corresponding risk (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI). ASI: Addiction Severity Index; CAPS: Clinician Administered PTSD Scale; CI: confidence interval; CIDI: Composite International Diagnostic Interview; IES‐R: Impact of Events Scale‐Revised; PTSD: post‐traumatic stress disorder; RR: risk ratio; SMD: standardised mean difference; SUD: substance use disorder; TAU: treatment as usual; TLFB: Timeline Followback Interview
GRADE Working Group grades of evidence High quality: Further research is very unlikely to change our confidence in the estimate of effect. Moderate quality: Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate. Low quality: Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate. Very low quality: We are very uncertain about the estimate.
¹Quality of evidence downgraded by two points because findings were based on outcomes from one study with a small sample size. ²Quality of evidence downgraded by one point because the risk of bias in most trials was high or unclear in several domains. ³Quality of evidence downgraded by one point because of significant clinical heterogeneity. ⁴Quality of evidence downgraded by one point because of a high level of unexplained statistical heterogeneity. The individual‐based study (Mueser 2008) in this comparison did not include access to SUD based adjunctive therapy. Participants in all other studies were able to access SUD‐based adjunctive therapy.

Summary of findings 3. Non‐trauma‐focused psychological intervention for PTSD and SUD or PTSD only compared to control intervention

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Summary of findings 4. Non‐trauma‐focused psychological intervention for PTSD and SUD or PTSD only compared to active psychological intervention for SUD only

Non‐trauma‐focused psychological therapy for PTSD and SUD or PTSD only compared to active psychological therapy for SUD only
Patient or population: Individuals with post‐traumatic stress disorder and comorbid substance use disorder Settings: Community substance abuse treatment programs Intervention: Individual‐based combined non‐trauma‐focused psychological therapy Comparison: Active psychological therapy for SUD only
Outcomes	*Illustrative comparative risks (95% CI)**		Relative effect (95% CI)	No of Participants (studies)	Quality of the evidence (GRADE)	Comments
	Assumed risk	Corresponding risk
	Active psychological therapyfor SUD only	Individual‐based combined non‐trauma‐focused psychological therapy
PTSD severity following treatment completion As assessed by the CAPS. High scores indicate greater symptom severity	‐	The mean PTSD severity following treatment completion in the intervention groups was 0.26 standard deviations lower (1.29 lower to 0.77 higher)	‐	128 (2 studies)	⊕⊝⊝⊝ very low^1,2,3	SMD ‐0.26 (‐1.29 to 0.77) Not significant
Drug or alcohol use, or both following treatment completion As assessed by the SUI or ASI. High scores indicate greater symptom severity	‐	The mean drug/alcohol use following treatment completion in the intervention groups was 0.22 standard deviations higher (0.13 lower to 0.57 higher)	‐	128 (2 studies)	⊕⊕⊝⊝ low^1,3	SMD 0.22 (‐0.13 to 0.57) Not significant
Treatment completers	Study population		RR 0.91 (0.68 to 1.20)	128 (2 studies)	⊕⊝⊝⊝ very low^1,3	Not significant
	618 per 1000	563 per 1000 (420 to 742)
	Moderate
	591 per 1000	538 per 1000 (402 to 709)
The basis for the assumed risk* (e.g. the median control group risk across studies) is provided in footnotes. The corresponding risk (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI). ASI: Addiction Severity Index; CAPS: Clinician Administered PTSD Scale; CI: confidence interval; PTSD: post‐traumatic stress disorder; RR: risk ratio; SMD: standardised mean difference; SUD: substance use disorder; SUI: Substance Use Inventory
GRADE Working Group grades of evidence High quality: Further research is very unlikely to change our confidence in the estimate of effect. Moderate quality: Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate. Low quality: Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate. Very low quality: We are very uncertain about the estimate.
¹Quality of evidence downgraded by one point because the risk of bias in most trials was high or unclear in several domains. ²Quality of evidence downgraded by two points because of a high level of unexplained statistical heterogeneity. ³Quality of evidence downgraded by one point because findings were based on outcomes from two studies with small sample sizes. Both studies in this comparison involved access to adjunctive SUD‐based therapy.

Summary of findings 4. Non‐trauma‐focused psychological intervention for PTSD and SUD or PTSD only compared to active psychological intervention for SUD only

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Comparison 1. Trauma‐focused psychological therapy vs control therapy

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 PTSD severity following treatment completion Show forest plot	4	405	Std. Mean Difference (IV, Random, 95% CI)	‐0.41 [‐0.72, ‐0.10]

1.1 Individual intervention	4	405	Std. Mean Difference (IV, Random, 95% CI)	‐0.41 [‐0.72, ‐0.10]
2 PTSD severity 3‐4 months following treatment completion Show forest plot	1		Mean Difference (IV, Fixed, 95% CI)	Totals not selected

2.1 Individual intervention	1		Mean Difference (IV, Fixed, 95% CI)	0.0 [0.0, 0.0]
3 PTSD severity 5‐7 months following treatment completion Show forest plot	3	388	Std. Mean Difference (IV, Random, 95% CI)	‐0.34 [‐0.58, ‐0.10]

3.1 Individual intervention	3	388	Std. Mean Difference (IV, Random, 95% CI)	‐0.34 [‐0.58, ‐0.10]
4 Drug or alcohol use, or both following treatment completion Show forest plot	3	388	Std. Mean Difference (IV, Random, 95% CI)	‐0.13 [‐0.41, 0.15]

4.1 Individual intervention	3	388	Std. Mean Difference (IV, Random, 95% CI)	‐0.13 [‐0.41, 0.15]
5 Drug or alcohol use, or both 3‐4 months following treatment completion Show forest plot	1		Mean Difference (IV, Fixed, 95% CI)	Totals not selected

5.1 Individual intervention	1		Mean Difference (IV, Fixed, 95% CI)	0.0 [0.0, 0.0]
6 Drug or alcohol use, or both 5‐7 months following treatment completion Show forest plot	3	388	Std. Mean Difference (IV, Random, 95% CI)	‐0.28 [‐0.48, ‐0.07]

6.1 Individual intervention	3	388	Std. Mean Difference (IV, Random, 95% CI)	‐0.28 [‐0.48, ‐0.07]
7 Treatment completers Show forest plot	3	316	Risk Ratio (M‐H, Random, 95% CI)	0.78 [0.64, 0.96]

7.1 Individual intervention	3	316	Risk Ratio (M‐H, Random, 95% CI)	0.78 [0.64, 0.96]
8 PTSD diagnosis following treatment completion Show forest plot	1		Risk Ratio (M‐H, Fixed, 95% CI)	Totals not selected

8.1 Individual intervention	1		Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
9 Adverse events Show forest plot			Other data	No numeric data

9.1 Individual intervention			Other data	No numeric data
10 Adverse events Show forest plot	2	268	Risk Ratio (M‐H, Random, 95% CI)	0.81 [0.34, 1.90]

10.1 Individual intervention	2	268	Risk Ratio (M‐H, Random, 95% CI)	0.81 [0.34, 1.90]
11 Mean number of sessions attended for intervention group Show forest plot			Other data	No numeric data

11.1 Studies including intervention for SUD			Other data	No numeric data
12 Sensitivity analysis: PTSD severity following treatment completion Show forest plot	3	388	Std. Mean Difference (IV, Random, 95% CI)	‐0.33 [‐0.56, ‐0.10]

12.1 Individual intervention	3	388	Std. Mean Difference (IV, Random, 95% CI)	‐0.33 [‐0.56, ‐0.10]

Comparison 1. Trauma‐focused psychological therapy vs control therapy

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Comparison 2. Trauma‐focused psychological therapy vs active psychological therapy for SUD only

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 PTSD severity following treatment completion Show forest plot	1		Mean Difference (IV, Fixed, 95% CI)	Totals not selected

1.1 Individual intervention	1		Mean Difference (IV, Fixed, 95% CI)	0.0 [0.0, 0.0]
2 PTSD severity 5‐7 months following treatment completion Show forest plot	1		Mean Difference (IV, Fixed, 95% CI)	Totals not selected

2.1 Individual intervention	1		Mean Difference (IV, Fixed, 95% CI)	0.0 [0.0, 0.0]
3 PTSD severity 8‐10 months following treatment completion Show forest plot	1		Mean Difference (IV, Fixed, 95% CI)	Totals not selected

3.1 Individual intervention	1		Mean Difference (IV, Fixed, 95% CI)	0.0 [0.0, 0.0]
4 Drug or alcohol use, or both following treatment completion Show forest plot	1		Mean Difference (IV, Fixed, 95% CI)	Totals not selected

4.1 Individual intervention	1		Mean Difference (IV, Fixed, 95% CI)	0.0 [0.0, 0.0]
5 Drug or alcohol use, or both 5‐7 months following treatment completion Show forest plot	1		Mean Difference (IV, Fixed, 95% CI)	Totals not selected

5.1 Individual intervention	1		Mean Difference (IV, Fixed, 95% CI)	0.0 [0.0, 0.0]
6 Drug or alcohol use, or both 8‐10 months following treatment completion Show forest plot	1		Mean Difference (IV, Fixed, 95% CI)	Totals not selected

6.1 Individual intervention	1		Mean Difference (IV, Fixed, 95% CI)	0.0 [0.0, 0.0]
7 Treatment completers Show forest plot	1		Risk Ratio (M‐H, Fixed, 95% CI)	Totals not selected

7.1 Individual intervention	1		Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
8 PTSD diagnosis following treatment completion Show forest plot	1		Risk Ratio (M‐H, Fixed, 95% CI)	Totals not selected

8.1 Individual intervention	1		Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
9 SUD diagnosis following treatment completion Show forest plot	1		Risk Ratio (M‐H, Fixed, 95% CI)	Totals not selected

9.1 Individual intervention	1		Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]

Comparison 2. Trauma‐focused psychological therapy vs active psychological therapy for SUD only

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Comparison 3. Non‐trauma‐focused psychological therapy for PTSD and SUD or PTSD only vs control therapy

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 PTSD severity following treatment completion Show forest plot	5		Std. Mean Difference (IV, Random, 95% CI)	Subtotals only

1.1 Individual intervention	1	44	Std. Mean Difference (IV, Random, 95% CI)	‐0.22 [‐0.83, 0.39]
1.2 Group intervention	4	513	Std. Mean Difference (IV, Random, 95% CI)	‐0.02 [‐0.19, 0.16]
2 PTSD severity 3‐4 months following treatment completion Show forest plot	5		Std. Mean Difference (IV, Random, 95% CI)	Subtotals only

2.1 Individual intervention	1	44	Std. Mean Difference (IV, Random, 95% CI)	‐0.25 [‐0.86, 0.36]
2.2 Group intervention	4	499	Std. Mean Difference (IV, Random, 95% CI)	0.00 [‐0.17, 0.18]
3 PTSD severity 5‐7 months following treatment completion Show forest plot	5		Std. Mean Difference (IV, Random, 95% CI)	Subtotals only

3.1 Individual intervention	1	44	Std. Mean Difference (IV, Random, 95% CI)	‐0.20 [‐0.81, 0.41]
3.2 Group intervention	4	566	Std. Mean Difference (IV, Random, 95% CI)	‐0.14 [‐0.31, 0.03]
4 PTSD severity 12 months following treatment completion Show forest plot	2	518	Std. Mean Difference (IV, Random, 95% CI)	‐0.07 [‐0.25, 0.10]

4.1 Group intervention	2	518	Std. Mean Difference (IV, Random, 95% CI)	‐0.07 [‐0.25, 0.10]
5 Drug or alcohol use, or both following treatment completion Show forest plot	3	464	Std. Mean Difference (IV, Random, 95% CI)	‐0.41 [‐0.97, 0.14]

5.1 Group intervention	3	464	Std. Mean Difference (IV, Random, 95% CI)	‐0.41 [‐0.97, 0.14]
6 Drug or alcohol use, or both 3‐4 months following treatment completion Show forest plot	4	499	Std. Mean Difference (IV, Random, 95% CI)	‐0.08 [‐0.40, 0.23]

6.1 Group intervention	4	499	Std. Mean Difference (IV, Random, 95% CI)	‐0.08 [‐0.40, 0.23]
7 Drug or alcohol use, or both 5‐7 months following treatment completion Show forest plot	4	572	Std. Mean Difference (IV, Random, 95% CI)	‐0.06 [‐0.23, 0.11]

7.1 Group intervention	4	572	Std. Mean Difference (IV, Random, 95% CI)	‐0.06 [‐0.23, 0.11]
8 Drug or alcohol use, or both 12 months following treatment completion Show forest plot	2	528	Std. Mean Difference (IV, Random, 95% CI)	0.02 [‐0.15, 0.20]

8.1 Group intervention	2	528	Std. Mean Difference (IV, Random, 95% CI)	0.02 [‐0.15, 0.20]
9 Treatment completers Show forest plot			Other data	No numeric data

9.1 Individual intervention			Other data	No numeric data
9.2 Group intervention			Other data	No numeric data
10 Treatment completers Show forest plot	2	381	Risk Ratio (M‐H, Random, 95% CI)	1.13 [0.88, 1.45]

10.1 Group intervention	2	381	Risk Ratio (M‐H, Random, 95% CI)	1.13 [0.88, 1.45]
11 PTSD diagnosis following treatment completion Show forest plot	2	77	Risk Ratio (M‐H, Random, 95% CI)	1.01 [0.66, 1.54]

11.1 Group intervention	2	77	Risk Ratio (M‐H, Random, 95% CI)	1.01 [0.66, 1.54]
12 Adverse events Show forest plot			Other data	No numeric data

12.1 Group intervention			Other data	No numeric data
13 Study‐related adverse events Show forest plot	1		Risk Ratio (M‐H, Fixed, 95% CI)	Totals not selected

13.1 Group intervention	1		Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
14 Mean number of sessions attended for intervention group Show forest plot			Other data	No numeric data

14.1 Group intervention			Other data	No numeric data
15 Mean number of sessions attended Show forest plot	2	381	Std. Mean Difference (IV, Random, 95% CI)	0.10 [‐0.59, 0.79]

15.1 Group intervention	2	381	Std. Mean Difference (IV, Random, 95% CI)	0.10 [‐0.59, 0.79]
16 Sensitivity analysis: PTSD severity 5‐7 months following treatment completion Show forest plot	3		Std. Mean Difference (IV, Random, 95% CI)	Subtotals only

16.1 Group intervention	3	425	Std. Mean Difference (IV, Random, 95% CI)	‐0.12 [‐0.34, 0.10]
17 Sensitivity analysis: PTSD severity 12 months following treatment completion Show forest plot	1	353	Std. Mean Difference (IV, Random, 95% CI)	‐0.04 [‐0.25, 0.17]

17.1 Group intervention	1	353	Std. Mean Difference (IV, Random, 95% CI)	‐0.04 [‐0.25, 0.17]
18 Sensitivity analysis: drug or alcohol use, or both 5‐7 months following treatment completion Show forest plot	3	425	Std. Mean Difference (IV, Random, 95% CI)	‐0.11 [‐0.30, 0.08]

18.1 Group intervention	3	425	Std. Mean Difference (IV, Random, 95% CI)	‐0.11 [‐0.30, 0.08]
19 Sensitivity analysis: drug or alcohol use, or both 12 months following treatment completion Show forest plot	1	353	Std. Mean Difference (IV, Random, 95% CI)	0.0 [‐0.21, 0.21]

19.1 Group intervention	1	353	Std. Mean Difference (IV, Random, 95% CI)	0.0 [‐0.21, 0.21]

Comparison 3. Non‐trauma‐focused psychological therapy for PTSD and SUD or PTSD only vs control therapy

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Comparison 4. Non‐trauma‐focused psychological therapy for PTSD and SUD or PTSD only vs active psychological therapy for SUD only

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 PTSD severity following treatment completion Show forest plot	2	128	Std. Mean Difference (IV, Random, 95% CI)	‐0.26 [‐1.29, 0.77]

1.1 Individual intervention	2	128	Std. Mean Difference (IV, Random, 95% CI)	‐0.26 [‐1.29, 0.77]
2 PTSD severity 3‐4 months following treatment completion Show forest plot	2	128	Std. Mean Difference (IV, Random, 95% CI)	0.12 [‐0.31, 0.55]

2.1 Individual intervention	2	128	Std. Mean Difference (IV, Random, 95% CI)	0.12 [‐0.31, 0.55]
3 PTSD severity 5‐7 months following treatment completion Show forest plot	1		Mean Difference (IV, Fixed, 95% CI)	Totals not selected

3.1 Individual intervention	1		Mean Difference (IV, Fixed, 95% CI)	0.0 [0.0, 0.0]
4 Drug or alcohol use, or both following treatment completion Show forest plot	2	128	Std. Mean Difference (IV, Random, 95% CI)	0.22 [‐0.13, 0.57]

4.1 Individual intervention	2	128	Std. Mean Difference (IV, Random, 95% CI)	0.22 [‐0.13, 0.57]
5 Drug or alcohol use, or both 3‐4 months following treatment completion Show forest plot	2	128	Std. Mean Difference (IV, Random, 95% CI)	0.18 [‐0.18, 0.53]

5.1 Individual intervention	2	128	Std. Mean Difference (IV, Random, 95% CI)	0.18 [‐0.18, 0.53]
6 Drug or alcohol use, or both 5‐7 months following treatment completion Show forest plot	1		Mean Difference (IV, Random, 95% CI)	Totals not selected

6.1 Individual intervention	1		Mean Difference (IV, Random, 95% CI)	0.0 [0.0, 0.0]
7 Treatment completers Show forest plot	2	128	Risk Ratio (M‐H, Random, 95% CI)	0.91 [0.68, 1.20]

7.1 Individual intervention	2	128	Risk Ratio (M‐H, Random, 95% CI)	0.91 [0.68, 1.20]
8 PTSD diagnosis following treatment completion Show forest plot	1		Risk Ratio (M‐H, Fixed, 95% CI)	Totals not selected

8.1 Individual intervention	1		Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
9 Mean number of sessions attended Show forest plot	1		Mean Difference (IV, Fixed, 95% CI)	Totals not selected

9.1 Individual intervention	1		Mean Difference (IV, Fixed, 95% CI)	0.0 [0.0, 0.0]

Comparison 4. Non‐trauma‐focused psychological therapy for PTSD and SUD or PTSD only vs active psychological therapy for SUD only

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