How should trauma-focused cognitive-behavioral therapy be adapted for a patient with a past substance use disorder (abstinent for 3 years) and moderate major depressive disorder?

Trauma-Focused CBT for Patient with Past Substance Use Disorder (3 Years Abstinent) and Moderate Depression

Proceed immediately with standard trauma-focused cognitive-behavioral therapy without modification or delay—the patient's 3-year abstinence and moderate depression are not contraindications and do not require a stabilization phase. 1

Primary Treatment Approach

Initiate trauma-focused psychotherapy as first-line treatment, choosing from:

• Prolonged Exposure (PE): 9-15 weekly sessions, with 40-87% of patients no longer meeting PTSD criteria after completion 2
• Cognitive Processing Therapy (CPT): 12-17 weekly sessions, produces large effect-size reductions in trauma symptoms and simultaneously improves depressive symptoms 2
• Eye Movement Desensitization and Reprocessing (EMDR): Comparable efficacy to PE and CPT 2

The evidence is clear that trauma-focused therapy should be offered routinely to individuals with past substance use disorders and comorbid depression, as these conditions do not diminish treatment response and typically improve alongside PTSD symptoms. 1, 3

Why No Stabilization Phase Is Needed

• Past substance use disorder (with sustained remission) is not an exclusion criterion for trauma-focused treatment—the patient's 3-year abstinence indicates sufficient stability 1
• Moderate depression does not reduce trauma-focused treatment efficacy; depressive symptoms generally improve following trauma-focused psychotherapy, and treatment response is unrelated to baseline depression severity 2, 3
• Delaying trauma-focused treatment is potentially iatrogenic, as it may communicate to the patient that they are "too fragile" to handle their traumatic memories, reducing self-confidence and motivation 1
• The evidence does not support the recommendation for a stabilization phase prior to providing trauma-focused treatment in persons with complex presentations, including those with multiple comorbidities 1

Concurrent Management of Depression

Add or optimize an SSRI (sertraline or paroxetine) as first-line pharmacotherapy if:

• Psychotherapy alone is insufficient after 8-12 weeks 2
• The patient prefers combined treatment 3
• Moderate depression symptoms interfere with daily functioning 3

Combination therapy (trauma-focused CBT + SSRI) is recommended for moderate to severe depression with trauma history, as it addresses both conditions simultaneously. 3

SSRI Dosing and Duration:

• Start sertraline 50 mg daily, titrate to 100-200 mg daily based on response 2
• Continue for a minimum of 6-12 months after symptom remission, as relapse rates are 26-52% with premature discontinuation versus only 5-16% when maintained on medication 2, 4
• Relapse rates are lower after completion of CBT compared to medication discontinuation, suggesting psychotherapy provides more durable benefits 2, 3

Substance Use Monitoring During Treatment

Trauma-focused exposure therapy does not promote relapse in patients with past substance use disorders:

• A pilot study of Concurrent Treatment of PTSD and Substance Use Disorders Using Prolonged Exposure (COPE) in women with alcohol dependence found no adverse events and concerns that trauma-focused, exposure-based therapy might promote relapse appear unwarranted 5
• Evidence shows trauma-focused therapy can improve PTSD for individuals with comorbid substance use, with modest benefits maintained at 6-13 months follow-up 6

Monitor substance use throughout treatment by:

• Asking directly about alcohol and drug use at each session
• Using validated screening tools (e.g., AUDIT-C for alcohol, DAST-10 for drugs) monthly
• Establishing a relapse prevention plan that includes identifying high-risk situations, coping strategies, and emergency contacts 6

Treatment Algorithm

Timeframe	Action
Week 1-2	Begin weekly trauma-focused psychotherapy (PE, CPT, or EMDR); assess depression severity; consider starting SSRI if moderate-severe depression [2,3]
Week 2-4	Continue weekly trauma-focused therapy; if SSRI started, titrate to therapeutic dose (sertraline 100-150 mg daily) [2]
Week 8-12	Evaluate PTSD and depression response; expect significant improvement in both PTSD and depressive symptoms if treatment adherence is good [2,3]
Week 12-17	Complete trauma-focused therapy protocol (typically 12-17 sessions for CPT, 9-15 for PE/EMDR) [2]
Month 6-12	Maintain SSRI (if used) for minimum 6-12 months after remission; monitor for relapse of PTSD, depression, or substance use [2,4]

Critical Pitfalls to Avoid

• Do not delay trauma-focused therapy to first "stabilize" mood or ensure prolonged abstinence—the evidence shows early initiation yields better outcomes 1, 3
• Do not label the patient as "complex" or "complicated" based on past substance use and depression, as this has iatrogenic effects by suggesting standard treatments will be ineffective 1, 3
• Avoid benzodiazepines entirely, as evidence shows 63% of patients receiving benzodiazepines developed PTSD at 6 months versus 23% on placebo 2, 4
• Do not use bupropion as monotherapy for PTSD, as it lacks demonstrated efficacy for core PTSD symptoms 2
• Do not assume the patient needs present-focused coping skills training first—there is no evidence that present-focused approaches provide benefits beyond standard SUD interventions for this population 6

Expected Outcomes

• PTSD remission: 40-87% of patients no longer meet PTSD criteria after completing trauma-focused psychotherapy 2
• Depression improvement: Depressive symptoms improve significantly following trauma-focused therapy, even without separate depression-specific interventions 2, 3
• Sustained abstinence: Trauma-focused therapy does not increase relapse risk and may improve substance use outcomes by addressing underlying trauma 6, 5
• Durable benefits: Effects of CBT are durable and may increase over time during follow-up, with lower relapse rates than medication alone 3, 7