Cognitive Remediation for Alcohol Use Disorder and Posttraumatic Stress Disorder
Condition: Alcohol Use Disorder; PTSD; Cognitive Dysfunction
MeSH terms: Alcoholism; Alcohol Drinking; Stress Disorders, Post-Traumatic; Cognitive Dysfunction
Study type: Interventional

Summary: 
      The project will examine whether a computerized neuroscience-based cognitive training program
      can improve cognitive functioning and recovery outcomes among Veterans with Alcohol Use
      Disorder and co-occurring PTSD. Information from this study will help determine the
      malleability of cognitive dysfunction, an established risk factor for poor recovery outcomes
      in this population. Improved functional outcomes can decrease risk of chronic impairment and
      ultimately help affected individuals live richer, more productive lives. Web-based treatment
      technologies may increase the reach and impact of treatment, and foster patient recovery in
      cases where staffing, space, acceptability of counseling, and transportation are barriers.
      Findings may also support expanding use of existing, highly-accessible cognitive remediation
      technologies to other vulnerable clinical populations.
    

Detailed description: 
      The prevalence of Alcohol Use Disorder (AUD), Posttraumatic Stress Disorder (PTSD) and
      co-occurring AUD and PTSD is elevated among Veterans compared to civilians (Carter et al.,
      2011). Despite available empirically supported treatments, relapse and non-response rates
      remain high and individuals with co-occurring AUD and PTSD evidence particularly poor
      clinical and functional outcomes (McCarthy & Petrakis, 2010). Given recent estimates that
      63-76% of Operation Enduring Freedom/Operation Iraqi Freedom (OEF/OIF) Veterans with an AUD
      also have a diagnosis of PTSD (Seal et al., 2011), there is urgent need to reduce chronic
      impairment among this growing and highly vulnerable population.

      AUD and PTSD are characterized by separate and overlapping deficits in attention, memory and
      higher-order skills known as executive functions (e.g., planning, inhibition,
      self-regulation), which are in turn, associated with poor clinical and functional outcomes
      (Bates et al., 2013; Polak et al., 2012, Aupperle, 2012). Indeed, cognitive dysfunction can
      interfere with many aspects of recovery (e.g. gaining control of maladaptive, over-trained
      behaviors) and its targeting as a trans-disease process for direct intervention represents a
      potentially high-yield and innovative approach for optimizing recovery outcomes.
      Neuroscience-based computerized cognitive training programs for psychiatric illness have
      achieved growing support in the literature and demonstrate strong potential to remediate
      disrupted cognitive processes observed in AUD and co-occurring PTSD (Bates et. 2013;
      Vinogradov et al., 2012). These programs offer a highly accessible, individualized,
      patient-driven, non-medication treatment approach for improving cognitive functioning. Such
      improvements may increase emotional and behavioral control and enhance patients' capacity to
      effectively employ more adaptive self-management strategies. To date however, no studies have
      capitalized on available evidence-based cognitive remediation technologies to comprehensively
      target patterns of neurocognitive dysfunction that underlie both AUD and PTSD.

      The proposed Rehabilitation Research and Development (RR&D) Career Development Award-2
      (CDA-2) seeks to fill this gap by conducting a randomized prospective study, designed to
      evaluate the feasibility and efficacy of an existing web-based cognitive training program
      (BrainHQ; Posit Science/Brain Plasticity Institute) versus a placebo, for improving cognitive
      functioning and recovery outcomes. The research will be conducted iteratively, in two stages,
      based on the Stage Model of Behavioral Therapy Development per the National Institute on Drug
      Abuse, and has two overarching aims: Aim 1: Examine the acceptability, usability and
      feasibility of an existing web-based cognitive training program tailored for AUD and
      co-occurring PTSD. Aim 2: Test the efficacy of the web-based cognitive training program to
      improve cognitive functioning as well as clinical and functional outcomes. To test these
      aims, 148 Veterans with AUD and PTSD will be recruited from an outpatient Substance Use
      Disorder (SUD) treatment program. Participants will be randomized into either cognitive
      training or a computer game control. Individuals will then complete a baseline assessment,
      followed by 30 hours of home-based cognitive training or computer games over 6 weeks.
      Assessments will be completed each week of the training, as well as post-training and at
      post-training follow-up. The primary outcome will be performance on an (untrained)
      neuropsychological assessment battery 6 months post-training. Secondary outcomes include
      alcohol use, PTSD symptoms and quality of life.

      Findings from the proposed study will inform clinical practice and policy by investigating
      whether a cognitive training program (shown to improve cognitive functioning in other
      clinical populations) can improve cognitive functioning and promote gains in functional
      recovery from AUD and PTSD. This study will lay the groundwork to investigate the potential
      for cognitive training to remediate neurocognitive disruptions in other dually diagnosed SUD
      patient populations across different VA treatment programs. This translational program of
      research will help vulnerable Veteran populations achieve more optimal and enduring recovery
      outcomes.
    

Intervention name(s): Cognitive Training; Cognitive training placebo control
Intervention type(s): Behavioral; Behavioral
Intervention description(s): Participants will complete 22.5 hours of cognitive training exercises over 6-weeks (training 5 times a week) using an app-based program, BrainHQ (BPI/Posit Science, San Francisco). BrainHQ is based on a previous neuroscience-based cognitive training program shown to improve cognition in several different randomized controlled studies with other clinical populations. The investigators will use a suite of BrainHQ exercises designed to target and ameliorate cognitive disruptions in 4 cognitive domains (see main outcome). The investigators will employ basic exercises that focus on increasing processing efficiency in the auditory and visual perceptual and working memory domains, as well as exercises that target impulsivity and cognitive biases. Exercises will be packaged into 4 modules (attention skills, memory skills, executive functioning skills, cognitive control skills) comprised of 4 exercises each. All participants will progress through the same fixed schedule of modules.; Participants will play a rotating set of commercial computer games at the same dose and frequency as the cognitive training. The investigators selected this control activity because it mirrors the game-like properties of the cognitive training and it will be used to control for contact with research personnel and for the non-specific effects of participant motivation and engagement with daily computerized activities. It also allows for a double blind study design. Games from the website Sporcle will be used and an online account can be created for each participant.
Allocation: Randomized
Intervention model: Factorial Assignment
Masking: Triple (Participant, Investigator, Outcomes Assessor)
Primary purpose: Treatment
Keywords: PTSD; Alcohol Use Disorder; Cognitive Training; Veterans