For the majority of urban women with alcohol dependence, the consequences of chronic victimization are ongoing obstacles to achieving abstinence. One psychiatric effect of chronic trauma is developing posttraumatic stress disorder (PTSD). Studies have demonstrated that comorbid PTSD in female alcohol and other drug (AOD) abusers is associated with poorer outcomes, such as: (1) poor treatment compliance manifested by ongoing substance abuse and high treatment drop-out rates;and (2) chronic psychiatric symptoms (e.g. intrusive memories, hyperarousal, affective numbing, depression). Preliminary findings demonstrate the strong potential of cognitive-behavioral psychotherapy (CBT) and of antidepressant medication, particularly selective serotonin reuptake inhibitors (SSRIs), in treating this population. However, these studies have shown Further Stage II treatment trials are needed to support their respective efficacies and the impact of combining these components, especially for this subgroup of women with alcohol dependence. To date there are no known published controlled studies examining the efficacy of combining these two most promising active ingredients. Therefore we have assembled a team of experts in the psychological and medication treatment of these disorders to collaborate on the present study. The proposed study aims to (a) examine if adding a medication component will have an additive effect significantly improving efficacy above and beyond the impact of two different platform treatments alone (either Seeking Safety(SS) a manualized cognitive-behavioral treatment specifically designed for women with comorbid AOD disorders and PTSD or Twelve Step Facilitation (TSF) a widely used and known efficacious manualized behavioral treatment for individuals with AOD disorders, (b).provide further support for the effectiveness of SS, and c) examine if TSF is efficacious in alcoholic women with PTSD. Our randomized, 4 armed clinical trial will assess the relative efficacy of four active treatments: Seeking Safety plus sertraline (SS-Med), Seeking Safety plus placebo (SS-P), Twelve-Step Facilitation treatment plus sertraline (TSF-Med), and Twelve Step Facilitation plus placebo (TSF-P) in treating urban women with alcohol dependence and comorbid PTSD over a three month period with repeated measures at baseline, completion of treatment, 6-month and 12-month post-treatment follow-ups. The main outcomes to be examined in the present study are efficacy in: (1a) reducing alcohol drinks/drinking days and increasing abstinence;(1b) reducing PTSD symptom severity;(1c) reducing global psychiatric symptom severity;(1d) improving retention rates in alcohol treatment. Secondary aims include exploring (2a) the applicability of a two-dimensional alcoholism subtype model using cluster procedures and examining potential differences between subtypes on treatment outcomes, and (2b) the trajectory and trends of AOD use and PTSD symptom changes in each condition to detect potential differences in the time course and order of changes.
