Posttraumatic stress disorder and alcohol use disorder in women

<p dir="ltr">Background: Most people experience traumatic events, for instance a natural disaster or the unexpected death of a loved one.</p><p dir="ltr">Some people then develop posttraumatic stress disorder (PTSD), a debilitating disorder characterized by intrusion symptoms, e.g. intense distress and nightmares, avoidance, negative changes in cognitions and mood as well as changes in arousal and reactivity, e.g. startling easily and finding it difficult to concentrate. PTSD is approximately twice as common among women as among men.</p><p dir="ltr">Some people find that alcohol provides short-term relief from their PTSD symptoms, for example by reducing intense distress or being able to sleep and wake without remembering one's nightmares. Over time alcohol use can lead to alcohol use disorder (AUD), which is characterized by problematic alcohol use. There are other trajectories to comorbid PTSD and AUD, but this is the most supported by research to date. PTSD and AUD often occur together.</p><p dir="ltr">PTSD and AUD are associated with negative outcomes, e.g. other mental disorders, suicidality and ill physical health. Similarly, PTSD and alcohol use during pregnancy are associated with adverse outcomes for those pregnant as well as their expected children, including antepartum complications and fetal alcohol spectrum disorders (FASD).</p><p dir="ltr">Comorbid PTSD and AUD tend to be more severe and more impairing than either disorder on its own. For instance, higher rates of comorbid mental disorders, suicidality and homelessness have been found among people with comorbid PTSD and AUD than among individuals with either PTSD or AUD.</p><p dir="ltr">Comorbid PTSD and AUD are regarded as difficult to treat. Traditionally, sequential treatment, where AUD was treated first, then PTSD, was suggested. Patients were typically required to achieve and maintain abstinence before PTSD treatment was initiated, something which potentially is a great barrier to PTSD treatment for those with comorbid PTSD and AUD.</p><p dir="ltr">Great strides have been made in developing treatment of comorbid PTSD and AUD, but the evidence on how to treat comorbid PTSD and AUD is not yet robust. Women are overrepresented among those with comorbid PTSD and AUD, yet, underrepresented in the extant treatment research. Trials of treatment of comorbid PTSD and AUD have included mainly men. Women and men may have different treatment needs and may also respond differently to treatment. So, we need to know more about treatment of comorbid PTSD and AUD in women.</p><p dir="ltr">Objectives: The present thesis sought to estimate the current prevalence of PTSD and alcohol use during pregnancy in Stockholm, Sweden, and to investigate the safety, feasibility, and efficacy of concurrent treatment of comorbid PTSD and AUD, which does not require abstinence, in treatment- seeking women with comorbid PTSD and AUD in Swedish healthcare.</p><p dir="ltr">Methods: Cross-sectional studies were conducted to estimate the current prevalence of PTSD and alcohol use during pregnancy. A pilot study was undertaken to investigate the safety and feasibility of concurrent treatment of PTSD and AUD in treatment-seeking women in Swedish healthcare. A randomized clinical trial was conducted to investigate whether concurrent treatment of PTSD and AUD reduces PTSD symptom severity and alcohol use more than AUD treatment in treatment-seeking women with comorbid PTSD and AUD in Swedish healthcare.</p><p dir="ltr">Results: Approximately 4.1 percent of pregnant people are estimated to have current PTSD and approximately 4.2 percent estimated to use alcohol during pregnancy in Stockholm, Sweden. Concurrent treatment of PTSD and AUD in women was safe and feasible. In the randomized clinical trial, PTSD symptom severity and alcohol use decreased from baseline to 9-month follow-up for both treatments. There was a significantly greater reduction in PTSD symptom severity in the concurrent treatment arm than in the AUD treatment arm. There was no detectable difference in alcohol use between treatments.</p><p dir="ltr">Conclusions: Further efforts to spread information about alcohol use during pregnancy may be needed, continued screening for alcohol use during pregnancy is warranted as well as treatment of risky alcohol use and AUD, when necessary, to reduce the risk of adverse outcomes for those pregnant as well as their expected children. It may be useful to investigate screening for PTSD in antenatal care further, to evaluate whether systematic screening for PTSD should be introduced in antenatal care. The present findings indicate that concurrent treatment of PTSD and AUD is feasible, safe, and efficacious for treatment-seeking women with comorbid PTSD and AUD in Swedish healthcare, and that abstinence is not required before or during treatment.</p><h3>List of scientific papers</h3><p dir="ltr">I. <b>Persson, A;</b> Lindmark, S; Petersson, K; Gabriel, E; Thorsell, M; Lindström, K; Göransson, M; Cardell, G; Magnusson, Å. Fear of childbirth, potentially traumatic events and posttraumatic stress disorder during pregnancy in Stockholm, Sweden: A cross-sectional study. Sexual & Reproductive Healthcare, 2020, Vol. 25, p. 100516. <a href="https://doi.org/10.1016/j.srhc.2020.100516" rel="noreferrer" target="_blank">https://doi.org/10.1016/j.srhc.2020.100516</a></p><p dir="ltr">II. <b>Persson, A;</b> Lindmark, S; Petersson, K; Gabriel, E; Thorsell, M; Lindström, K; Göransson, M; Cardell, G; Magnusson, Å. Alcohol and illicit and non-medical prescription drug use before and during pregnancy in Stockholm, Sweden: A cross-sectional study. Sexual & Reproductive Healthcare, 2021, Vol. 29, p. 100622. <a href="https://doi.org/10.1016/j.srhc.2021.100622" rel="noreferrer" target="_blank">https://doi.org/10.1016/j.srhc.2021.100622</a></p><p dir="ltr">III. <b>Persson, A;</b> Back, S E; Killeen, T K; Brady, K T; Schwandt, M L; Heilig, M; Magnusson, A. Concurrent Treatment of PTSD and Substance Use Disorders Using Prolonged Exposure (COPE): A pilot study in alcohol-dependent women. Journal of Addiction Medicine, 2017, Vol. 11(2), p. 119-125. <a href="https://doi.org/10.1097/ADM.0000000000000286" rel="noreferrer" target="_blank">https://doi.org/10.1097/ADM.0000000000000286</a></p><p dir="ltr">IV. <b>Persson, A;</b> Axén, Å; Capusan, A J; Magnusson, Å; Heilig, M. Concurrent Treatment of Posttraumatic Stress Disorder and Alcohol Use Disorder in Women: A Randomized Clinical Trial. JAMA Network Open, 2025, Vol. 8(7), p. e2521087. <a href="https://doi.org/10.1001/jamanetworkopen.2025.21087" rel="noreferrer" target="_blank">https://doi.org/10.1001/jamanetworkopen.2025.21087</a></p>