N-Acetylcysteine for the Treatment of Co-Occurring Posttraumatic Stress Disorder and Alcohol Use Disorder: A Double-Blind, Randomized Controlled Trial

Sudie E. Back, PhD; Kevin Gray, MD; Amber M. Jarnecke, PhD; Tanya C. Saraiya, PhD; Elizabeth J. Santa Ana, PhD; Therese Killeen, PhD; Jane E. Joseph, PhD; James J. Prisciandaro, PhD; Delisa G. Brown, PhD; Paul J. Nietert, PhD; Tracy Stecker, PhD; Alex Rothbaum, PhD; Jennifer L. Jones, MD; Julianne C. Flanagan, PhD; Kathleen T. Brady, MD, PhD

J Clin Psychiatry 2025;86(4):25m15803

Abstract

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.

J Clin Psychiatry 2025;86(4):25m15803

Author affiliations are listed at the end of this article.

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