Cognitive Remediation for Alcohol Use Disorder and Posttraumatic Stress Disorder

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.

Inclusion Criteria:

- Be a Veteran

- Meet DSM-5 diagnostic criteria for current AUD

- Meet DSM-5 criteria for current PTSD

- Be willing to perform daily home-based computer exercises for 6 weeks

Exclusion Criteria:

Individuals will be excluded based on evidence of the following:

- History of, or current, psychotic disorder or Schizophrenia

- Current scheduled (i.e., daily) prescribed use of cognitive enhancers (e.g.,
Memantine) or stimulants (e.g., Methylphenidate) that may enhance cognitive
performance

- Current severe traumatic brain injury (DoD TBI Screen 2)

- Any type of dementia (Mini Mental Status Exam (MMSE) < 24), delirium or medical
illnesses associated with potential cognitive issues (HIV, Hypothyroidism, B-12
deficiency)

- Any level of mental retardation (Wechsler Test of Adult Reading WTAR)

- Limited ability to speak/read/write/understand English (WTAR)

- Inadequate vision or hearing

- Active suicidal/homicidal intent

- Self-report and collateral history from medical record/primary care
physician/outpatient addiction treatment team will be used as necessary to determine
inclusion and exclusion.

- Suicidal and homicidal intent will be assessed in the context of a structured
clinical interview.

- In the unlikely event that respondents endorse active intent they will be
referred immediately for treatment and will be excluded from the current study.