Posttraumatic stress disorder (PTSD) and alcohol use disorder (AUD) often co-occur and present significant treatment challenges. Cognitive Processing Therapy (CPT) is a widely used, efficacious treatment for PTSD, but the application of CPT among individuals with co-occurring PTSD/AUD has been limited. To address this gap, we developed a novel, 12-session trauma-focused treatment that combines CPT with Relapse Prevention (RP) for AUD (CPT+RP). This paper describes CPT+RP and presents preliminary outcomes from the first six participants enrolled in a larger, ongoing multisite clinical trial of CPT+RP. PTSD symptoms were assessed using the Clinician-Administered PTSD Scale for DSM-5 (CAPS-5) and PTSD Checklist for DSM-5 (PCL-5). The Timeline Follow-Back (TLFB) assessed frequency (percent days drinking; PDD) and quantity (drinks per drinking day; DDD) of alcohol use, and craving was measured using the Penn Alcohol Craving Scale (PACS). The Client Satisfaction Questionnaire measured acceptability. Pre- to post-treatment reductions were observed in PTSD symptoms (ΔMCAPS-5 = 14.00; ΔMPCL-5 = 20.50), frequency and quantity of alcohol use (ΔMPDD = 38.65; ΔMDDD = 6.24), and craving (ΔPACS = 6.17). Most participants achieved clinically significant improvement in their PTSD symptoms and acceptability was high. Although preliminary, the findings suggest the new CPT+RP intervention is feasible, acceptable, and a promising treatment innovation for co-occurring PTSD and AUD.

OBJECTIVE:The prevalence and negative sequelae of co-occurring posttraumatic stress disorder and substance use disorder (PTSD + SUD) are well documented. Findings from evidence syntheses regarding which PTSD + SUD treatments work best overall have been mixed, potentially because these treatments are not equally effective for all PTSD + SUD patient subgroups. Epidemiological and qualitative research suggest that veteran status may be related to differential PTSD + SUD treatment response. This study, applying recent quantitative methodological advances in evidence synthesis, is the first to examine the potential moderating effect of veteran status on PTSD + SUD treatment outcome. METHOD:We report secondary analyses of psychotherapy arm data (k = 26 randomized controlled trials; n = 3,228) from Project Harmony, a meta-analysis of individual PTSD + SUD patient data from sociodemographically diverse samples incorporating propensity score weighting and integrative data analysis. Outcome models (examined separately for harmonized indicators of latent PTSD, alcohol use, and drug use severity) were fit under propensity score weighting multilevel modeling. RESULTS:Tests of causally moderated comparative effectiveness showed that trauma-focused psychotherapy targeting PTSD and integrated trauma-focused psychotherapy targeting PTSD and SUD were both superior to treatment as usual for alcohol use severity outcomes, and this effect was stronger for veterans than civilians. Analyses did not provide evidence for differential response to active PTSD + SUD psychotherapies, relative to treatment as usual, on PTSD or drug use severity outcomes as a function of veteran status. CONCLUSIONS:Findings lend support for delivering trauma-focused psychotherapies to patients with PTSD + SUD, especially veterans, and point to important future directions for inquiries into optimizing patient matching to PTSD + SUD treatment. (PsycInfo Database Record (c) 2026 APA, all rights reserved).

OBJECTIVE:This individual participant data meta-analysis aimed to investigate the effectiveness of cognitive behavioral therapy with a trauma focus (CBT-TF) for posttraumatic stress disorder (PTSD). Furthermore, we examined the effect of moderators on PTSD symptom severity. METHOD:This study included randomized controlled trials comparing CBT-TF to an inactive or active comparison group for adults with PTSD. The primary and secondary outcomes were PTSD symptom severity and remission, respectively. Moderators included sociodemographic and clinical variables. RESULTS:Twelve studies compared CBT-TF with inactive (n = 625) and 11 with active comparison conditions (n = 706). The one-stage individual participant data meta-analysis found that CBT-TF was more effective than inactive comparison conditions (β = -0.78; OR = 2.34) and not significantly different from active comparison conditions (β = 0.02; OR = 0.53) in reducing PTSD symptom severity and achieving PTSD remission, respectively. When comparing CBT-TF with inactive treatments, moderator analysis found that divorced participants had greater PTSD symptoms postintervention following CBT-TF than participants who were single, cohabitating, or married receiving CBT-TF, both in the completer (β = 0.93) and full-sample (β = 0.59) analyses. For the active treatment comparison, moderator analysis found that participants taking psychotropic medication had lower PTSD symptoms following CBT-TF than those not taking psychotropic medication in the completer analysis (β = -0.39). CONCLUSION:Based on our moderator analyses, further research is needed to understand the effect of psychotropic medication on the CBT-TF intervention process. Moreover, divorced participants with PTSD receiving CBT-TF might benefit from enhanced support. (PsycInfo Database Record (c) 2025 APA, all rights reserved).

Sexual assault is common and often leads to co-occurring symptoms of posttraumatic stress disorder (PTSD) and alcohol misuse. Early intervention may help prevent development of severe, chronic comorbidities, but evidence-based interventions tailored for this population do not currently exist. This study evaluated a novel, integrated, early intervention called Skills Training and Exposure for PTSD and Substance Misuse (STEPS) following recent sexual assault. STEPS includes five sessions integrating Written Exposure Therapy for PTSD with cognitive behavioral skills for alcohol misuse. STEPS was administered to 11 individuals (63.6% White, average of 28.8 years old) who experienced sexual assault in the past three months and demonstrated current symptoms of PTSD and alcohol misuse. Outcomes included satisfaction and retention, PTSD symptom severity as measured by the PTSD Checklist (PCL-5) for the Diagnostic and Statistical Manual of Mental Disorders Fifth Edition (DSM-5), the Clinician-Administered PTSD Scale for DSM-5 (CAPS-5), and change in frequency and amount of alcohol use, as measured by the Timeline Follow Back. Assessments were completed at baseline, post-treatment, and one-month follow-up. Ten of 11 participants (90.9%) completed the STEPS intervention. Large within-in person effects were observed for self-report and interview PTSD symptoms from baseline to follow-up (Cohen’s d = 3.22-3.50; average decrease in PCL-5 = 40.44 and CAPS-5 severity scores = 27). Medium to large effect sizes were observed for decreases in percent days drinking, percent days heavy drinking, and number of drinks per drinking day from baseline to follow-up (Cohen’s d = .55-1.39). Participants reported high satisfaction and acceptability with the STEPS intervention. Although preliminary, the findings demonstrate that STEPS is safe, feasible and may help reduce severity of PTSD symptoms and alcohol misuse following recent sexual assault.

Objective: Posttraumatic stress disorder (PTSD) and alcohol use disorder (AUD) are common co-occurring conditions associated with a more severe clinical profile and poorer treatment outcomes than either disorder alone. To date, no medications have proven efficacious in the treatment of co-occurring PTSD/AUD. Methods: This randomized, double-blind, placebo-controlled trial examined the efficacy of N-acetylcysteine (NAC; 2,400 mg/day) among individuals (N=182, aged 21-65 years) who met DSM-5 criteria for current PTSD/AUD. Participants were randomized 1:1 to receive 12 weeks of NAC (n=93) or placebo (n=89). All participants received weekly, individual, cognitive behavioral therapy (CBT) for AUD. Follow-up visits occurred at 3-, 6-, and 12-months posttreatment. Primary outcomes included the Clinician Administered PTSD Scale for DSM-5 (CAPS-5), PTSD Checklist for DSM-5 (PCL-5), Timeline Follow-Back (TLFB), and the Obsessive Compulsive Drinking Scale at 12 weeks. The TLFB evaluated the frequency and amount of alcohol consumption. A secondary measure evaluated depression symptoms. Results: Intent-to-treat analyses showed that participants in both the NAC and placebo groups evidenced significant reductions in the CAPS-5 (B=-0.19, P<.001) and PCL-5 (B=-0.20, P<.001) during treatment, with no significant group differences. Both groups also showed significant reductions in alcohol use (drinks per drinking day [B=-0.02, P<.001], percent heavy drinking days [B=-0.14, P<.001], percent days abstinent [B=0.29, P=.022]) and craving (B=-0.12, P<.001) during treatment, but with no significant group differences. There were no group differences in retention or adverse events. Conclusions: Although NAC was well tolerated, it was not more effective than placebo in improving symptoms of PTSD or AUD when added to individual CBT for AUD. Trial Registration: ClinicalTrials.gov identifier: NCT02966873.

Objective Alcohol use disorder (AUD) clinical trials have traditionally prioritized abstinence, and more recently, heavy drinking cessation as primary treatment endpoints. Reductions in World Health Organization (WHO) risk drinking levels may offer a viable harm reduction-aligned alternative. Despite evidence supporting WHO risk level reductions as meaningful indicators of AUD treatment response, their utility in individuals with co-occurring posttraumatic stress disorder (PTSD) remains unknown. The present study compared 1- and 2-level WHO risk drinking reductions with abstinence and heavy drinking (HD) outcomes, and assessed their sensitivity across PTSD and substance use disorder (SUD) interventions, including behavioral and pharmacological treatments. Methods We conducted an integrative data analysis of 10 trials for adults with comorbid PTSD and SUD (PTSD+SUD). The proportion of participants achieving each of the four alcohol outcomes was calculated. Logistic regression models assessed treatment effects relative to treatment as usual (TAU). Results Across the 10 trials (N = 433; mean [SD] age, 39.7 [11.6] years; 359 [73.0 %] men), the most frequently achieved drinking outcome at end-of-treatment was a 1 +  level WHO risk reduction (82.8 %), followed by a 2 +  level reduction (72.2 %), HD cessation (65.6 %) and, least frequently, abstinence (53.0 %). Pharmacological interventions significantly outperformed TAU across all drinking outcomes. Conclusions Findings provide initial support for WHO risk drinking levels as viable endpoints in PTSD+SUD trials. Given their attainability, WHO risk levels may provide clinically relevant outcome metrics for these interventions. Future research should assess whether such reductions correspond to improvements in alcohol-related harms and broader functional outcomes.

Opioid use disorder (OUD) and posttraumatic stress disorder (PTSD) frequently co-occur. However, there are no psychotherapy treatments intentionally designed for this comorbidity, nor designed to be augmented with medications for OUD. In this open-label pilot trial, we tested Helping Opioid Use Disorder and PTSD with Exposure (HOPE), a novel integrated, trauma-focused treatment for individuals (N = 6) with OUD/PTSD who were stabilized on medications for OUD. HOPE was delivered weekly for 10–12 sessions, and one follow-up visit was conducted ~1-month post-treatment. Primary outcomes included urine drug screens, the Timeline Followback, Desire for Drugs Questionnaire, Clinician-Administered PTSD Scale-5 (CAPS-5), and PTSD Checklist-5 (PCL-5). Boot-strapped linear mixed effect models and generalized estimating equations showed that PTSD symptoms (CAPS-5: B = −7.16, SE = 1.24, p < 0.01; PCL-5: B = −2.04, SE = 0.26, p < 0.01), desire for opioids (B = −0.56, SE = 0.15, p < 0.01), depression symptoms (B = −0.43, SE = 0.09, p < 0.01), and anxiety symptoms (B = −0.50, SE = 0.08, p < 0.01) decreased significantly over time. Client satisfaction increased throughout the study (B = 0.18, SE = 0.08, p = 0.02), and 83.3% of participants completed the therapy and follow-up visit. There were no significant changes in opioid or other substance use from baseline to follow-up. Although preliminary, results show high acceptability and feasibility of the HOPE therapy and demonstrate significant improvements in PTSD and associated symptoms with an integrated, trauma-focused treatment.

Relationships and social support have direct effects on opioid misuse, which is highly prevalent and associated with morbidity and mortality. However, there is a dearth of research focusing on the characteristics and quality of intimate relationships in the context of opioid misuse, which is important for informing interventions with the dual target of improving intimate relationships and reducing opioid use. The current study surveyed individuals with opioid misuse who are in intimate relationships to characterize how they perceive (1) their relationship functioning and (2) how their intimate partners impact their opioid use. Individual participants (N=93) were recruited from Amazon's Mechanical Turk (mTurk) and answered quantitative survey questions related to their opioid and other substance use, intimate relationship quality and functioning, and intimate partners' behaviors in relation to their opioid use. Opioid misuse severity significantly differed by sexuality and rates of polysubstance use were high in this sample. Many participants reported low relationship quality and intimate partner violence in their relationship. Some participants reported using opioids with their intimate partners (33.3%) and having an intimate partner who had overdosed on opioids (15.1%). Many participants also reported that arguments with intimate partners impacted their opioid cravings (52.7%) and that they have an interest in couples treatment for opioid use (80.7%). Findings highlight links between intimate relationships and opioid misuse and identify areas in which behavioral treatments may be adapted to address the needs of couples with OUD. Future research should replicate the current findings in larger and more diverse samples.

BACKGROUND AND AIMS:Post-traumatic stress disorder (PTSD) commonly co-occurs with substance use disorders (SUD). Comorbid PTSD and SUD (PTSD+SUD) is associated with greater severity and impairment and poorer treatment outcomes. Several interventions exist to treat PTSD, SUD and PTSD+SUD; however, research has yet to elucidate the indirect pathways underlying treatment for PTSD+SUD. The present study examined how changes in PTSD severity relate to changes in SUD severity across treatment types during and post-treatment. METHODS:Observational study using data collected as part of Project Harmony, a virtual clinical trial employing integrative data analysis to compare treatment effectiveness of PTSD+SUD interventions from 36 randomized controlled trials for PTSD+SUD (n = 4046). Multilevel mediated linear growth modeling was used to examine potential outcomes mediation. Each of the eight active treatments was compared to treatment as usual (TAU) for both alcohol and drug use outcomes. RESULTS:Alcohol use severity outcomes were fully or partially mediated by changes in PTSD severity for trauma-focused psychotherapy + AUD medication [ab = -0.16 (95% confidence interval = -0.30 to -0.04)]; other treatments with mediation effects included trauma-focused integrated psychotherapy, AUD medications and PTSD medications. Drug use severity outcomes were fully or partially mediated by changes in PTSD severity for trauma-focused psychotherapy + AUD medication [ab = -0.08 (-0.18 to -0.001)]; other treatments with mediation effects on drug use severity included trauma-focused integrated psychotherapy, AUD medications, PTSD medications and placebo medications. CONCLUSIONS:Among people with co-occurring post-traumatic stress disorder (PTSD) and substance use disorders (SUD), reductions in alcohol and drug use severity appear to be mediated by reductions in PTSD during treatment. For those with drug use disorders, PTSD reductions appear to mediate further SUD reductions after treatment.

Background/Objectives: The co-occurrence of posttraumatic stress disorder (PTSD) and cannabis use disorder (CUD) symptoms is common following sexual assault, particularly among emerging adult women. CUD is associated with more severe PTSD symptoms and other mental health comorbidities including depression, suicidality, and emotion dysregulation. Addressing these issues concurrently soon after sexual assault could help decrease the risk for downstream negative health outcomes. Integrated trauma-focused interventions for PTSD and co-occurring substance use disorders have been shown to decrease PTSD severity and substance use. Yet, existing protocols are lengthy and have rarely been applied following recent trauma exposure or specifically to address CUD symptoms. Methods: This case series describes the application of Written Exposure Therapy (WET) for PTSD adapted to integrate cognitive-behavioral skills training for substance use among women following recent sexual assault. The adapted integrated intervention, Skills Training and Exposure for PTSD and Substance Misuse (STEPS), was delivered to three emerging adult women (age range = 19–25) who experienced recent sexual assault (weeks since assault range = 1–12 weeks). Results: This case series describes the novel intervention and examines clinical outcomes post-treatment and at the 1-month follow-up. Past-week PTSD symptoms (based on a clinical interview) and past-month cannabis use decreased among all participations after receiving STEPS. Conclusions: Preliminary findings from the case series provide new knowledge and insights regarding the application of STEPS following recent sexual assault among individuals with co-occurring PTSD and CUD. Therapeutic strategies for addressing PTSD and CUD concurrently and implications for future clinical research are discussed.

Making causal statements regarding dose-response in treatments for posttraumatic stress disorder (PTSD) and alcohol/other drug use disorders (AODs; PTSD+AOD) is difficult because (a) dosage is rarely randomized and (b) self-selected dosage can be affected by treatment assignment. In the present study, we sought to clarify causal inferences regarding treatment-by-dosage interactions in PTSD+AOD treatment using Project Harmony, an individual-patient meta-analytic data set of behavioral, pharmacological, and combination PTSD+AOD treatments ( k = 36; N = 4,046). Using propensity score weighting and moderated multilevel “net treatment difference” modeling, trauma-focused (TF) treatments, whether integrated or nonintegrated with AOD treatment, outperformed treatment as usual by greater margins on reductions in PTSD and alcohol use as dosage increased. Furthermore, appropriately treating dosage as a posttreatment covariate and moderator revealed effects for TF treatments on drug use that had not been detected in previous studies. Implications for approaches to increasing TF-treatment attendance and greater use of causal-inference methodologies with dose-response analyses are discussed.

Though half of people with posttraumatic stress disorder (PTSD) develop alcohol use disorder (AUD), co-occurring PTSD and AUD (PTSD + AUD) is associated with more severe clinical outcomes relative to either alone and little remains known about the pathophysiology of PTSD + AUD. PTSD and AUD have each been associated with marked dysfunction in brain glutamate and GABA systems, making these systems promising targets for pharmacological intervention, including N-acetylcysteine (NAC), which restores extracellular glutamate concentrations via GLT-1 and System Xc-. Based on promising results from our pilot study of NAC, we recently completed a 12-week, randomized, double-blind, placebo-controlled clinical trial of NAC for PTSD + AUD. As part of this trial, we acquired proton MR spectroscopy (1H-MRS) data at pretreatment and 8-weeks posttreatment in a subsample of (n = 44) participants to evaluate whether NAC significantly affects frontal glutamate levels (i.e., represented by Glx, glutamate + glutamine), with exploratory evaluation of GABA and glutathione levels, and whether NAC-related changes in neurometabolite levels correspond to decreased drinking and/or PTSD symptoms, in people with PTSD + AUD. We found that NAC was associated with significantly higher frontal Glx (t = 2.45, p = 0.017), and significantly lower GABA (t = -2.82, p = 0.007) but equivalent glutathione (t = -1.00, p = 0.321), levels relative to placebo. Finally, lower NAC-related GABA, but not Glx or glutathione, levels were significantly associated with decreased drinks per drinking day (t = 2.57, p = 0.014), but not percent drinking days or PTSD symptoms (ps > 0.10). Though preliminary, these findings are consistent with the mechanistic hypothesis that NAC reduces drinking quantity through its effects on excitatory and inhibitory neurotransmission in people with PTSD + AUD.

Research on the links between intimate relationships and PTSD and the treatments for PTSD tend to be limited to couples in which only one partner within the dyad has PTSD. No investigations, to our knowledge, have empirically examined the simultaneous provision of evidence-based PTSD treatment to both partners in an intimate relationship diagnosed with PTSD. The current case study describes two partners in a different-sex relationship, both diagnosed with current PTSD, who received individual Prolonged Exposure (PE) therapy at the same time as part of a larger randomized clinical trial. Each partner received ten, 90-minute individual sessions of PE therapy by two separate clinicians trained in PE followed by a 1-month follow-up. The findings demonstrated significant pre- to posttreatment reductions in PTSD symptoms as measured by the Clinician Administered PTSD Scale-5 (CAPS-5) for the male partner (Δ = 18) and the female partner (Δ = 24). Both partners achieved diagnostic remission of PTSD by end of treatment. In addition, both partners expressed enhancements in relationship functioning that they experienced while receiving PE therapy concurrently. Clinical considerations for the provision of concurrent PE to partners in an intimate relationship are discussed. The positive findings from this case study may inform future research in this much-needed area of treatment for couples where both partners are suffering from PTSD.

Posttraumatic stress disorder (PTSD) and substance use disorders (SUDs) co-occur at high rates, with research showing that up to nearly 60% of individuals with PTSD also suffer from an alcohol and/or drug use disorder. PTSD/SUD is complex; associated with adverse health, social, and economic outcomes; and can be challenging to treat. Over the past decade, the landscape of treatment research addressing PTSD/SUD has significantly expanded. Ongoing efforts aimed at developing and evaluating novel treatments for PTSD/SUD, encompassing both psychotherapy and pharmacotherapy approaches, are steadily advancing. As such, this State of the Science paper reviews the literature on the latest scientific advances in treating PTSD/SUD. Clinical practice guidelines for the treatment of PTSD/SUD are discussed, along with evidence-based psychotherapies and emerging interventions. Rigorously conducted clinical trials demonstrate that individual, manualized, trauma-focused treatments are the most efficacious psychotherapies to use among individuals with PTSD/SUD. Moreover, patients do not need to be abstinent to initiate or benefit from evidence-based PTSD treatment. To date, no medications have been established for this comorbidity. We highlight ongoing research on novel treatments for PTSD/SUD, such as new forms of integrated trauma-focused psychotherapies, pharmacological augmentation strategies, and technology-based enhancements. Finally, promising future directions for the field are discussed.

High rates of cannabis use among people with posttraumatic stress disorder (PTSD) have raised questions about the efficacy of evidence-based PTSD treatments for individuals reporting cannabis use, particularly those with cooccurring alcohol or other substance use disorders (SUDs). Using a subset of four randomized clinical trials (RCTs) included in Project Harmony, an individual patient meta-analysis of 36 RCTs (total N = 4046) of treatments for co-occurring PTSD+SUD, we examined differences in trauma-focused (TF) and non-trauma-focused (non-TF) treatment outcomes for individuals who did and did not endorse baseline cannabis use (N = 410; 70% male; 33.2% endorsed cannabis use). Propensity score-weighted mixed effects modeling evaluated main and interactive effects of treatment assignment (TF versus non-TF) and baseline cannabis use (yes/no) on attendance rates and within-treatment changes in PTSD, alcohol, and non-cannabis drug use severity. Results revealed significant improvements across outcomes among participants in all conditions, with larger PTSD symptom reductions but lower attendance among individuals receiving TF versus non-TF treatment in both cannabis groups. Participants achieved similar reductions in alcohol and drug use across all conditions. TF outperformed non-TF treatments regardless of recent cannabis use, underscoring the importance of reducing barriers to accessing TF treatments for individuals reporting cannabis use.

We conducted a systematic review and network meta-analyses (NMA) of psychotherapy and pharmacologic treatments for individuals with co-occurring posttraumatic stress disorder (PTSD) and alcohol or other drug use disorder (AOD). A comprehensive search spanning 1995-2019 yielded a pool of 39 studies for systematic review, including 24 randomized controlled trials for the NMA. Study interventions were grouped by target of treatment (PTSD + AOD, PTSD-only, and AOD-only) and approach (psychotherapy or medication). Standardized mean differences (SMD) from the NMA yielded evidence that at the end of treatment, integrated, trauma-focused therapy for PTSD + AOD was more effective at reducing PTSD symptoms than integrated, non-trauma-focused therapy (SMD = -0.30), AOD-focused psychotherapy (SMD = -0.29), and other control psychotherapies (SMD = -0.43). End-of-treatment alcohol use severity was less for AOD medication compared to placebo medication (SMD = -0.36) and trauma-focused therapy for PTSD + placebo medication (SMD = -0.67), and less for trauma-focused psychotherapy + AOD medication compared to PTSD medication (SMD = -0.53), placebo medication (SMD = -0.50), and trauma-focused psychotherapy + placebo medication (SMD = -0.81). Key limitations include the small number of studies in the NMA for pharmacologic treatments and the lack of demographic diversity apparent in the existing literature. Findings suggest room for new studies that can address limitations in study sample composition, sample sizes, retention, and apply new techniques for conducting comparative effectiveness in PTSD + AOD treatment. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

Introduction: Women show a gender-specific risk for co-occurring opioid use disorder (OUD) and posttraumatic stress disorder (PTSD). Expert groups have called for the development of integrated treatments for women with OUD/PTSD, but there remains limited information on such interventions. Methods: This mixed-methods study interviewed and surveyed 10 women with current or past OUD and cooccurring posttraumatic stress symptoms (PTSS) and 16 providers who work with these women. Interviews and surveys queried patient participants' and providers' experiences of OUD/PTSS and how to best design an integrated, trauma-focused treatment for OUD/PTSD. Results: Patient participants (90 % white, 90 % mothers, Mage = 45.70) met criteria for severe, lifetime OUD and 40 % met a provisional diagnosis for PTSD. Four themes emerged for participants' experiences of OUD/PTSS: 1) numerous stressors; 2) shame; 3) multiple motivations to use opioids; and 4) a cycle of trauma and opioid use. Four themes emerged regarding patient participants' perceptions on the development of an OUD/PTSD treatment: 1) mixed attitudes towards medications for OUD; 2) barriers to treatment (e.g., insufficient treatments and contextual factors); 3) treatment facilitators (e.g., social support); and 4) preferences in treatment (e.g., traumafocused, gender-focused, family content, ambivalence around group therapy). Providers (Mage = 38.94) were primarily white women (76.5 %). Two themes emerged from their experiences working with women with OUD/ PTSS: 1) perceiving women to use opioids to regulate emotions and 2) gender differences in trauma types. Three themes emerged for providers' perceptions on the development of an OUD/PTSD treatment: 1) barriers to treatment (e.g., chaotic lives, contextual factors, family); 2) treatment facilitators (e.g., trust and external motivations); and 3) desired treatment modifications (e.g., stabilization, early skills in therapy, flexibility in therapy, social supports, safety guidelines, and assistance in identifying an index trauma). Most participants (90.0 %) and providers (93.5 %) preferred working on OUD/PTSD symptoms simultaneously rather than separately. Conclusions: Findings demonstrate the need to modify integrated treatments to meet the preferences of providers and women with OUD/PTSS and OUD/PTSD. Treatments should consider therapeutic content, structure, contextual factors, social support, and PTSD severity to enhance uptake and reach.

Background Available empirical evidence on participant-level factors associated with dropout from psychotherapies for post-traumatic stress disorder (PTSD) is both limited and inconclusive. More comprehensive understanding of the various factors that contribute to study dropout from cognitive-behavioural therapy with a trauma focus (CBT-TF) is crucial for enhancing treatment outcomes.Objective Using an individual participant data meta-analysis (IPD-MA) design, we examined participant-level predictors of study dropout from CBT-TF interventions for PTSD.Methods A comprehensive systematic literature search was undertaken to identify randomised controlled trials comparing CBT-TF with waitlist control, treatment-as-usual or another therapy. Academic databases were screened from conception until 11 January 2021. Eligible interventions were required to be individual and in-person delivered. Participants were considered dropouts if they did not complete the post-treatment assessment.Findings The systematic literature search identified 81 eligible studies (n=3330). Data were pooled from 25 available CBT-TF studies comprising 823 participants. Overall, 221 (27%) of the 823 dropped out. Of 581 civilians, 133 (23%) dropped out, as did 75 (42%) of 178 military personnel/veterans. Bivariate and multivariate analyses indicated that military personnel/veterans (RR 2.37) had a significantly greater risk of dropout than civilians. Furthermore, the chance of dropping out significantly decreased with advancing age (continuous; RR 0.98).Conclusions These findings underscore the risk of premature termination from CBT-TF among younger adults and military veterans/personnel.Clinical implication Understanding predictors can inform the development of retention strategies tailored to at-risk subgroups, enhance engagement, improve adherence and yield better treatment outcomes.