Mental Health Over Time in a Military Sample: The Impact of Alcohol Use Disorder on Trajectories of Psychopathology After Deployment

Long-term trajectories of depressive symptoms in deployed military personnel: A 10-year prospective study

BACKGROUND

Military missions, especially those involving combat exposure, are associated with an increased risk of depression. Understanding the long-term course of depressive symptoms post-deployment is important to improve decision-making regarding deployment and mental health policies in the military. This study investigates trajectories of depressive symptoms in the Dutch army, exploring the influence of factors such as demographics, early-life trauma, posttraumatic stress disorder (PTSD) symptoms, and deployment stressors.

METHODS

A cohort of 1032 military men and women deployed to Afghanistan (2005-2008) was studied from pre- to 10 years post-deployment. Depressive and PTSD symptoms were assessed using the Symptom CheckList-90 and the Self-Rating Inventory for PTSD. Demographics, early trauma, and deployment experiences were collected at baseline and after deployment, respectively. Latent Class Growth Analysis was used to explore heterogeneity in trajectories of depressive symptoms over time.

RESULTS

Four trajectories were found: resilient (65%), intermediate-stable (20%), symptomatic-chronic (9%), and late-onset-increasing (6%). The resilient group experienced fewer deployment stressors, while the symptomatic-chronic group reported more early life traumas. Trajectories with elevated depressive symptoms consistently demonstrated higher PTSD symptoms.

LIMITATIONS

Potential nonresponse bias and missing information due to the longitudinal design and extensive follow-up times.

CONCLUSIONS

This study identified multiple trajectories of depressive symptoms in military personnel up to 10 years post-deployment, associated with early trauma, deployment stressors, adverse life events and PTSD symptoms. The prevalence of the resilient trajectory suggests a substantial level of resilience among deployed military personnel. These findings provide valuable insights and a foundation for further research.

The evolution of PTSD symptoms in serving and ex-serving personnel of the UK armed forces from 2004 to 16: A longitudinal examination

Whilst most military personnel do not develop Post-Traumatic Stress Disorder (PTSD), ex-serving personnel exhibit higher levels compared to those in the military. The heterogeneity of symptom development for serving and ex-serving personnel has not yet been compared in the UK Armed Forces (UK AF). Latent class growth modelling was employed to estimate the trajectories of PTSD symptoms from three waves of data from the PTSD Checklist (PCL-C) from a UK AF sample (N = 7357). Regression mixture models were conducted to investigate covariates of class membership. Five trajectory classes were identified. Most of the sample reported no-low symptoms (71.3%). Of those reporting probable PTSD during the 12 year-period, 4.6% showed improvements, 4.9% worsened, and 1.8% displayed chronic symptoms. A class with subthreshold elevated symptoms (17.3%) was also identified. Trajectories of serving and ex-serving personnel were not substantially different, but more ex-serving personnel were symptomatic and those with chronic symptoms worsened over time. Chronic disorder was associated with lower rank, experiencing violent combat, and proximity to wounding/death on deployment. Worsening symptoms were associated with childhood stress/violence, lower rank, not being in a relationship, inconsistent post-deployment social support, proximity to wounding/death, and voluntary, or medical discharge. The present study found most UKAF personnel did not report PTSD symptoms between 2004 and 16 but, among those experiencing probable PTSD, more participants reported deteriorating/persistent symptoms than who improved. PTSD-onset was related to adversities across childhood and deployment, and lack of social support. Findings underscore the importance of addressing the through-life contributors of PTSD in order to prevent ingrained disorder.

Stressful life events and trajectories of depression symptoms in a U.S. military cohort

Depression is a common mental disorder that may comprise distinct, underlying symptom patterns over time. Associations between stressful life events throughout the civilian lifecourse-including during childhood-and adult depression have been documented in many populations, but are less commonly assessed in military samples. We identified different trajectories of depression symptoms across four years in a military cohort using latent class growth analysis, and investigated the relationship between these trajectories and two domains of civilian life experiences: childhood adversity (e.g., being mistreated during childhood) and more proximal stressful experiences (e.g., divorce). A four-group depression model was identified, including a symptom-free group (62%), an increasing symptom group (13%), a decreasing symptom group (16%), and a "chronic" symptom group (9%). Compared to the symptom-free group, soldiers with childhood adversity were more likely to be in the chronic depression, decreasing, and increasing symptom groups. Time-varying adult stressors had the largest effect on depression symptoms for the increasing symptom group compared to other groups, particularly in the last two years of follow-up. This study indicates the importance of considering events from throughout the lifecourse-not only those from deployment-when studying the mental health of servicemembers.

Opioid and Alcohol Misuse in Veterans with Chronic Pain: A Risk Screening Study

In United States military veterans, chronic pain represents a risk factor for opioid and alcohol misuse, yet few studies have examined interactions among chronic pain, opioid prescription, and opioid and alcohol misuse. Previous work found substantial risk of co-morbid alcohol and opioid misuse in a community sample of opioid-prescribed individuals with chronic pain, a finding expanded upon here. Specifically, 211 veterans assessed within a chronic pain treatment service for opioid-prescribed individuals completed self-report measures of opioid misuse, alcohol misuse, pain intensity, depression, pain catastrophizing, and post-traumatic stress symptoms (PTS). Based on the substance misuse measures, 32% (n = 68) were misusing neither opioids nor alcohol, 23% (n = 48) were misusing both opioids and alcohol, 40% (n = 84) were misusing opioids alone, and 5% (n = 11) were misusing alcohol alone. Group comparisons indicated that individuals not misusing either substance were less distressed in comparison to those who were misusing opioids alone or both substances. The latter groups differed in PTS. Overall, misuse frequencies mirrored previous work, with approximately 1 of 3 misusing opioids and approximately 1 of 5 misusing both substances. There is a need for increased focus on both polysubstance misuse and the development of integrated treatment.

Cohort profile: the Ohio Army National Guard Mental Health Initiative (OHARNG-MHI)

PURPOSE

Rates of mental disorders in the United States military have increased in recent years. National Guard members may be particularly at risk for mental disorders, given their dual role as citizen-soldiers and their increased involvement in combat deployments during recent conflicts. The Ohio Army National Guard Mental Health Initiative (OHARNG-MHI) was launched to assess the prevalence, incidence, and potential causes and consequences of mental disorders in this unique population.

METHODS

OHARNG-MHI is a decade-long dynamic cohort study that followed over 3,000 National Guard members yearly through structured telephone interviews.

RESULTS

Findings thus far have applied a pre-, peri-, post-deployment framework, identifying factors throughout the life course associated with mental disorders, including childhood events and more recent events, both during and outside of deployment. An estimated 61% of participants had at least one mental disorder in their lifetime, the majority of which initiated prior to military service. Psychiatric comorbidity was common, as were alcohol use and stressful events. Latent class growth analyses revealed four distinct trajectory paths of both posttraumatic stress and depression symptoms across four years. Only 37% of soldiers with probable past-year mental disorders accessed mental health services in the subsequent year, with substance use disorders least likely to be treated.

CONCLUSION

Strengths of this study include a large number of follow-up interviews, detailed data on both military and non-military experiences, and a clinical assessment subsample that assessed the validity of the telephone screening instruments. Findings, methods, and procedures of the study are discussed, and collaborations are welcome.

Mental Health Correlates of Probable Posttraumatic Stress Disorder, Probable Alcohol Use Disorder, and Their Co-Occurrence among Firefighters

Firefighters demonstrate high rates of posttraumatic stress disorder (PTSD) and alcohol use disorder (AUD). Research has yet to compare how these diagnoses and their co-occurrence relate to firefighter mental health. This study evaluated trauma load, PTSD, alcohol use, depression, sleep, suicide risk, anger, and occupational stress across four discrete groups of firefighters (N = 660): (1) trauma-exposed only (n = 471), (2) probable PTSD-only (n = 36), (3) probable AUD-only (n = 125), and (4) probable PTSD-AUD (n = 28). Firefighters completed an online survey. Firefighters with probable PTSD-AUD demonstrated higher scores on all criterion variables, except trauma load, compared to firefighters with probable AUD-only or trauma-only. Firefighters with probable PTSD-AUD and probable PTSD-only reported similar levels of all indices, except alcohol use severity and suicide risk, which were higher among the probable PTSD-AUD group. Results provide preliminary empirical evidence of the deleterious impact of PTSD-AUD comorbidity among firefighters.

Trajectories of depression in aging veterans and former prisoners-of-war: The role of social support and hardiness

OBJECTIVES

Depression is a prevalent outcome of traumatic experiences, such as combat and war captivity. This study explores the heterogeneity of changes over time and assesses the contribution of trauma exposure (combat vs. war captivity), hardiness, and social support for depression trajectories.

METHODS

Two groups of Israeli veterans were assessed in 1991, 2003, 2008, and 2015: 149 former prisoners-of-war (ex-POWs) and 107 combat veterans. Protective factors were evaluated in 1991. Group-based trajectory modeling was conducted to identify latent trajectories of change.

RESULTS

Four trajectories of "resiliency" (62.8%), "delayed onset" (25.1%), "exacerbation" (6.2%), and "chronicity" (5.9%) were found. The majority of the resilient group were combat veterans whereas the clinical groups consisted primarily of ex-POWs. Lower hardiness and social support were related to more deleterious trajectories.

CONCLUSIONS

Spirals of loss involving hardiness and social support, normative experiences, and contextual factors may present explanations for the various depression trajectories.

Psychological distress across the deployment cycle: exploratory growth mixture model

BACKGROUND

Prior research has identified behavioural health outcomes as key sequelae to combat deployment. However, relatively little is known about differential patterns of change in depression or generalised anxiety linked to deployment to a combat zone. In this paper, we add to the existing trajectory literature and examine key predictive factors of behavioural health risk.

AIMS

The primary aim is to leverage growth mixture modelling to ascertain trajectories of psychological distress, operationalised as a coherent construct combining depression and generalised anxiety, and to identify factors that differentiate adaptive and maladaptive patterns of change.

METHOD

Data were collected from a brigade combat team prior to a combat deployment to Afghanistan, during deployment, at immediate re-integration and approximately 2-3 months thereafter. The main outcome was measured using the Patient Health Questionnaire Anxiety and Depression Scale (PHQ-ADS).

RESULTS

Three latent trajectories were identified: a low-stable trajectory, a declining trajectory and a rising trajectory. Most individuals aligned with the low-stable trajectory. A conditional model using covariates measured during deployment showed that the low-stable trajectory differed consistently from the remaining trajectories on self-reported loneliness and non-combat deployment stressors.

CONCLUSIONS

The examination of differential patterns of adaptation, to identify individuals at higher risk, is critical for the efficient targeting of resources. Our findings further indicate that loneliness may be a useful leverage point for clinical and organisational intervention.

Trajectories of depression symptoms from pre- to post- deployment: Does previous trauma predict symptom increase?

BACKGROUND

A significant minority of individuals experience depression following military deployment. The course of depression symptoms varies over time and across individuals; several factors including combat exposure influence depressions incidence and course. Importantly, previous trauma, especially in childhood, have been found increase the risk of post-deployment depression.

METHODS

In a prospective sample of 530 soldiers deployed to Afghanistan in 2009, we used latent growth mixture modeling (LGMM) to estimate trajectories of depression symptoms from before through 6.5 years after deployment. In a multinomial logistic regression model, we tested if childhood and adult life trauma predicted trajectory membership in combination with combat exposure and neuroticism.

RESULTS

We identified a large trajectory of few depression symptoms from before through 6.5 years after deployment (Low-stable, 86.5%), a trajectory with somewhat elevated symptoms (Medium-fluctuating, 4.0%), and a trajectory with few symptoms before deployment and a steep increase to a severe symptom level 6.5 years after deployment (Low-increasing, 9.4%). The Low-increasing trajectory was predicted by lower rank and childhood trauma, while the Medium-fluctuating trajectory was predicted by neuroticism, adult life trauma, and post-deployment PTSD symptoms.

LIMITATIONS

Attrition and use of self-report measures for depression and trauma.

CONCLUSIONS

Depression symptoms follow a heterogeneous course from before through 6.5 years after deployment with 9.4% experiencing symptom increase, resulting in severe symptoms 6.5 years after deployment. Trajectories are differentially predicted by rank, childhood and adult life trauma as well as neuroticism and PTSD symptoms, illustrating the clinical importance of taking individual differences of symptom course into account.

Chronic repeated predatory stress induces resistance to quinine adulteration of ethanol in male mice

BACKGROUND

Trauma related psychiatric disorders, such as posttraumatic stress disorder (PTSD), and alcohol use disorder (AUD) are highly comorbid illnesses that separately present an opposing, sex-specific pattern, with increased prevalence of PTSD in females and increased prevalence of AUD diagnoses in males. Likewise, PTSD is a risk factor in the development of AUD, with conflicting data on the impact of sex in the comorbid development of both disorders. Because the likelihood of experiencing more than one traumatic event is high, we aim to utilize chronic repeated predatory stress (CRPS) to query the extent to which sex interacts with CRPS to influence alcohol consumption, or cessation of consumption.

METHODS

Male (n = 16) and female (n = 15) C57BL/6 J mice underwent CRPS or daily handling for two weeks during adolescence (P35-P49) and two weeks during adulthood (P65-P79). Following the conclusion of two rounds of repeated stress, behavior was assessed in the open field. Mice subsequently underwent a two-bottle choice intermittent ethanol access (IEA) assessment (P90-131) with the options of 20 % ethanol or water. After establishing drinking behavior, increasing concentrations of quinine were added to the ethanol to assess the drinking response to adulteration of the alcohol.

RESULTS

CRPS increased fecal corticosterone concentrations and anxiety-like behaviors in the open field in both male and female mice as compared to control mice that had not been exposed to CRPS. Consistent with previous reports, we observed a sex difference in alcohol consumption such that females consumed more ethanol per gram of body mass than males. In addition, CRPS reduced alcohol aversion in male mice such that higher concentrations of quinine were necessary to reduce alcohol intake as compared to control mice. CRPS did not alter alcohol-related behaviors in female mice.

CONCLUSION

Collectively, we demonstrate that repeated CRPS can induce anxiety-like behavior in both sexes but selectively influences the response to ethanol adulteration in males.

Dissemination of cognitive behavioral therapy for substance use disorders in the Department of Veterans Affairs Health Care System: Description and evaluation of Veteran outcomes

BACKGROUND

As part of the nation's largest dissemination and implementation of evidence-based psychotherapies (EBPs) and the promotion of EBPs for substance use disorders (SUDs), the Veterans Health Administration (VHA) is working to nationally implement Cognitive Behavioral Therapy for SUD (CBT-SUD). The current manuscript describes the approach to system-wide training and reports Veteran outcomes associated with CBT-SUD implementation. Methods: Four-hundred fifty-eight Veterans with a range of treatment goals received treatment through the Department of Veterans Affairs (VA) CBT-SUD Training Program. Veteran outcomes related to substance use, substance use-related problems, and quality of life were assessed with the Brief Addiction Monitor, the Short Inventory of Problems, and the World Health Organization Quality of Life-BREF. Results: Statistically significant reductions in alcohol use, heavy alcohol use, other drug use, and substance use-related problems, as well as significant improvements in quality of life, were observed over the course of treatment. Conclusions: Program evaluation findings suggest that large-scale training in and implementation of EBPs for SUDs is associated with improvements in substance use and other functional outcomes. Limitations from this real-world implementation project, including the lack of a control group and missing post-treatment data, are discussed.

PCSK9 is Increased in Cerebrospinal Fluid of Individuals With Alcohol Use Disorder

BACKGROUND

Recent studies have shown that alcohol use affects the regulation and expression of proprotein convertase subtilisin/kexin 9 (PCSK9). While a major role of PCSK9 in hepatic function and lipid regulation has been clearly established, other pleiotropic effects remain poorly understood. Existing research suggests a positive association between PCSK9 expression in the brain and psychopathology, with increased levels of PCSK9 in the cerebrospinal fluid (CSF) of individuals with dementia and epigenetic modifications of PCSK9 associated with alcohol use disorder (AUD). In this study, we hypothesized that chronic alcohol use would increase PCSK9 expression in CSF.

METHODS

PCSK9 levels in CSF were measured in individuals with AUD (n = 42) admitted to an inpatient rehabilitation program and controls (n = 25). CSF samples in AUD were assessed at 2 time points, at day 5 and day 21 after admission. Furthermore, plasma samples were collected and measured from the individuals with AUD.

RESULTS

PCSK9 in CSF was significantly increased in the AUD group at day 5 and day 21 compared to the controls (p < 0.0001). Plasma PCSK9 levels were correlated positively with CSF PCSK9 levels in AUD (p = 0.0493).

CONCLUSIONS

Our data suggest that PCSK9 is elevated in the CSF of individuals with AUD, which may indicate a potential role of PCSK9 in AUD. Additional studies are necessary to further elucidate the functions of PCSK9 in the brain.

The Association Between Posttraumatic Negative Self-Conscious Cognitions and Emotions and Maladaptive Behaviors: Does Time Since Trauma Exposure Matter?

Negative beliefs about the self, self-blame, guilt, and shame have been consistently linked to emotional problems, such as posttraumatic stress disorder and depression, following trauma exposure. To expand understanding of the potential role of negative self-conscious cognitions and emotions in other forms of posttrauma maladjustments, such as maladaptive behaviors, the current study examined the associations between these cognitions and emotions with dissociation, alcohol use, and avoidant problem-solving. As a secondary goal, the influence of time since trauma exposure was considered given recent data suggesting that some posttraumatic responses require lengthier time following trauma to become salient. Multiple-group analysis was conducted in two groups of female survivors of intimate partner violence (IPV): women whose IPV experiences occurred within 3 months prior to assessment (early posttrauma phase [EPP]; n = 67) and those whose experiences occurred 12 months or more prior to assessment (chronic posttrauma phase [CPP]; n = 145). The results suggested model invariance. Posttraumatic negative self-conscious cognitions and emotions were significantly correlated with dissociation (EPP group: β = .61, p < .001 and CPP group: β = .48, p < .001), alcohol use (EPP group: β = .31, p = .014 and CPP group: β = .30, p < .001), and avoidant problem-solving (EPP group: β = .58, p < .001 and CPP group: β = .56, p < .001). The findings highlight the importance of negative self-conscious cognitions and emotions in posttrauma maladjustment and support intervening in these domains shortly after trauma exposure.

Examination of Treatment Effects on Hazardous Drinking Among Service Members With Posttraumatic Stress Disorder

Posttraumatic stress disorder (PTSD) and alcohol use disorder are frequently comorbid and present significant treatment challenges. Unfortunately, since the September 11, 2001, terrorist attacks in the United States, the rates of PTSD and hazardous drinking among active duty service members have increased significantly. Previous research on PTSD has typically excluded participants with current substance abuse. However, there is some research examining independent treatments for PTSD and substance abuse provided consecutively, concurrently, or as enhancements to other treatment. The current study examined the association between current hazardous drinking and PTSD treatment among 108 active duty service members with PTSD in a randomized controlled trial of group cognitive processing therapy and group present-centered therapy. Total scores above 8 on the Alcohol Use Disorders Identification Test defined hazardous alcohol use. At baseline, 25.0% of the sample was categorized as hazardous drinkers, and the hazardous and nonhazardous drinking groups did not differ in PTSD symptom severity, F(1, 106) = 0.08, p = .777, d = 0.06. Over the course of treatment, the two groups also did not differ significantly in PTSD symptom severity change on the PTSD Checklist, F(1, 106) = 1.20, p = .280, d = 0.33. Treatment for PTSD did not exacerbate hazardous drinking, and the hazardous drinking group showed significant reductions in drinking following PTSD treatment. Limitations and implications for treatment considerations are discussed.

Association of suicidal ideation with trajectories of deployment-related PTSD symptoms

This study examined the association between suicidal ideation and posttraumatic stress disorder (PTSD) symptom trajectories in a nationally representative sample of United States Reserve Component soldiers. PTSD symptoms related to a traumatic event during the most recent deployment were assessed in four annual waves in 2010-2013 among 682 Reserve Component soldiers. Latent Growth Mixture Modeling (LGMM) was used to examine the longitudinal trajectories of PTSD symptoms. The association between the PTSD trajectories and suicidal ideation at waves 2 to 4 was examined in logistic regression analyses. Four trajectories were identified: resilience (73.0%), recovery (11.7%), late onset (11.6%) and chronic (3.6%). Pairwise comparisons demonstrated significant differences between trajectories in risk of suicidal ideation. Among the chronic trajectory group, 50.9% reported suicidal ideation (25.8% late onset group; 11.3% recovery group; 4.0% resilience group). After controlling for baseline characteristics, the late onset and chronic trajectory groups were more likely to have suicidal ideation than the resilience and recovery trajectories, respectively. Findings suggest the late onset and chronic trajectories of PTSD symptoms are associated with higher risk of suicidal ideation. They support the importance of follow-up assessment of suicide risk even among individuals with low PTSD symptoms at homecoming.

Prospective risk factors for post-deployment heavy drinking and alcohol or substance use disorder among US Army soldiers

BACKGROUND

Investigations of drinking behavior across military deployment cycles are scarce, and few prospective studies have examined risk factors for post-deployment alcohol misuse.

METHODS

Prevalence of alcohol misuse was estimated among 4645 US Army soldiers who participated in a longitudinal survey. Assessment occurred 1-2 months before soldiers deployed to Afghanistan in 2012 (T0), upon their return to the USA (T1), 3 months later (T2), and 9 months later (T3). Weights-adjusted logistic regression was used to evaluate associations of hypothesized risk factors with post-deployment incidence and persistence of heavy drinking (HD) (consuming 5 + alcoholic drinks at least 1-2×/week) and alcohol or substance use disorder (AUD/SUD).

RESULTS

Prevalence of past-month HD at T0, T2, and T3 was 23.3% (s.e. = 0.7%), 26.1% (s.e. = 0.8%), and 22.3% (s.e. = 0.7%); corresponding estimates for any binge drinking (BD) were 52.5% (s.e. = 1.0%), 52.5% (s.e. = 1.0%), and 41.3% (s.e. = 0.9%). Greater personal life stress during deployment (e.g., relationship, family, or financial problems) - but not combat stress - was associated with new onset of HD at T2 [per standard score increase: adjusted odds ratio (AOR) = 1.20, 95% CI 1.06-1.35, p = 0.003]; incidence of AUD/SUD at T2 (AOR = 1.54, 95% CI 1.25-1.89, p < 0.0005); and persistence of AUD/SUD at T2 and T3 (AOR = 1.30, 95% CI 1.08-1.56, p = 0.005). Any BD pre-deployment was associated with post-deployment onset of HD (AOR = 3.21, 95% CI 2.57-4.02, p < 0.0005) and AUD/SUD (AOR = 1.85, 95% CI 1.27-2.70, p = 0.001).

CONCLUSIONS

Alcohol misuse is common during the months preceding and following deployment. Timely intervention aimed at alleviating/managing personal stressors or curbing risky drinking might reduce risk of alcohol-related problems post-deployment.

Posttraumatic stress disorder symptoms improve after an integrated brief alcohol intervention for OEF/OIF/OND veterans

OBJECTIVE

Although brief alcohol interventions (BAIs) that incorporate personalized feedback demonstrate efficacy for reducing the frequency and quantity of alcohol consumption in veteran samples, little research has explored the influence of BAIs in reducing symptoms of posttraumatic stress disorder (PTSD). The goal of this investigation was to understand whether PTSD symptom severity and diagnostic status changed after exposure to an intervention that targeted alcohol misuse and integrated feedback on PTSD.

METHOD

Sixty-eight combat veterans (8.8% female; 27.9% African American) who screened positive for hazardous drinking were recruited from a Veterans Affairs Medical Center. Participants received a 1-session brief intervention that primarily targeted alcohol misuse but also included personalized feedback and psychoeducation on PTSD symptoms and coping. Participants were randomized to receive personalized written feedback either with or without a motivational interview.

RESULTS

A mixed-model repeated measures analysis revealed that PTSD symptom severity was significantly lower at the 6-week (M = 41.47, SD = 28.94) and 6-month (M = 35.56 SD = 26.99) follow-up appointments relative to baseline (M = 51.22, SD = 26.67), F(2, 127.24) = 38.32, p < .001. Regression analyses demonstrate that the percent change in alcohol use was related to the change in PTSD severity. Further, results indicated that a motivational-interviewing-style counseling session accompanying the feedback was not significantly more efficacious than receiving feedback only.

CONCLUSION

A brief alcohol intervention that integrates information on PTSD has the potential to reduce PTSD severity. Personalized alcohol and PTSD feedback may be useful as an opportunistic intervention for OEF/OIF veterans. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Alcohol and Opioid Use in Chronic Pain: A Cross-Sectional Examination of Differences in Functioning Based on Misuse Status

Opioid misuse is regularly associated with disrupted functioning in those with chronic pain. Less work has examined whether alcohol misuse may also interfere with functioning. This study examined frequency of opioid and alcohol misuse in 131 individuals (61.1% female) prescribed opioids for the treatment of chronic pain. Participants completed an anonymous survey online, consisting of measures of pain, functioning, and opioid and alcohol misuse. Cut scores were used to categorize individuals according to substance misuse status. Individuals were categorized as follows: 35.9% (n = 47) were not misusing either opioids or alcohol, 22.9% (n = 30) were misusing both opioids and alcohol, 38.2% (n = 50) were misusing opioids alone, and only 3.0% (n = 4) were misusing alcohol alone. A multivariate analysis of variance was performed to examine differences in pain and functioning between groups (after excluding individuals in the alcohol misuse group due to the small sample size). Group comparisons indicated that individuals who were not misusing either substance were less disabled and distressed in comparison to those who were misusing opioids alone or both opioids and alcohol. No differences were indicated between the latter 2 groups. Overall, the observed frequency of opioid misuse was somewhat higher in comparison to previous work (approximately 1 out of every 3 participants), and misuse of both alcohol and opioids was common (approximately 1 out of every 5 participants). While these data are preliminary, they do suggest that issues of substance misuse in those with chronic pain extends beyond opioids alone.

PERSPECTIVE

Opioid and alcohol misuse was examined in 131 individuals prescribed opioids for chronic pain. In total, 35.9% were not misusing either, 22.9% were misusing both, 38.2% were misusing opioids, and 3.1% were misusing alcohol. Individuals not misusing either were generally less disabled and distressed compared to those misusing opioids or both.

Bayesian PTSD-Trajectory Analysis with Informed Priors Based on a Systematic Literature Search and Expert Elicitation

There is a recent increase in interest of Bayesian analysis. However, little effort has been made thus far to directly incorporate background knowledge via the prior distribution into the analyses. This process might be especially useful in the context of latent growth mixture modeling when one or more of the latent groups are expected to be relatively small due to what we refer to as limited data. We argue that the use of Bayesian statistics has great advantages in limited data situations, but only if background knowledge can be incorporated into the analysis via prior distributions. We highlight these advantages through a data set including patients with burn injuries and analyze trajectories of posttraumatic stress symptoms using the Bayesian framework following the steps of the WAMBS-checklist. In the included example, we illustrate how to obtain background information using previous literature based on a systematic literature search and by using expert knowledge. Finally, we show how to translate this knowledge into prior distributions and we illustrate the importance of conducting a prior sensitivity analysis. Although our example is from the trauma field, the techniques we illustrate can be applied to any field.

Deployment and Alcohol Use in a Military Cohort: Use of Combined Methods to Account for Exposure-Related Covariates and Heterogeneous Response to Exposure

Studies have shown that combat-area deployment is associated with increases in alcohol use; however, studying the influence of deployment on alcohol use faces 2 complications. First, the military considers a confluence of factors before determining whether to deploy a service member, creating a nonignorable exposure and unbalanced comparison groups that inevitably complicate inference about the role of deployment itself. Second, regression analysis assumes that a single effect estimate can approximate the population's change in postdeployment alcohol use, which ignores previous studies that have documented that respondents tend to exhibit heterogeneous postdeployment drinking behaviors. Therefore, we used propensity score matching to balance baseline covariates for the 2 comparison groups (deployed and nondeployed), followed by a variable-oriented difference-in-differences approach to account for the confounding and a person-oriented approach using a latent growth mixture model to account for the heterogeneous response to deployment in this prospective cohort study of the US Army National Guard (2009-2014). We observed a nonsignificant increase in estimated monthly drinks in the first year after deployment that regressed to predeployment drinking levels 2 years after deployment. We found a 4-class model that fit these data best, suggesting that common regression analyses likely conceal substantial interindividual heterogeneity in postdeployment alcohol-use behaviors.

Coincident alcohol dependence and depression increases risk of suicidal ideation among Army National Guard soldiers

PURPOSE

Suicide rates among military service members have risen dramatically, while drivers remain poorly understood. We examined the relationship between coincident alcohol dependence and depression in shaping risk of suicidal ideation among National Guard forces.

METHODS

We performed a longitudinal analysis using a randomly selected, population-based sample of Ohio Army National Guard soldiers. Telephone-based surveys of 1582 soldiers who participated in both wave 1 (2008-2009) and wave 2 (2009-2010) were analyzed.

RESULTS

Odds ratios (ORs) for suicidal ideation among those with versus without alcohol dependence were similar among nondepressed (OR = 3.85 [95% confidence intervals (CIs) = 1.18-12.52]) and depressed individuals (OR = 3.13 [95% CI = 0.88-11.14]); multiplicative interaction was not observed. In contrast, the risk differences (RDs) among those with versus without alcohol dependence diverged for those without depression (RD = 0.04 [95% CI = 0.02-0.07]) compared with those with depression (RD = 0.11 [95% CI = 0.06-0.18]); strong evidence of additive interaction was observed.

CONCLUSIONS

We found that alcohol dependence and depression interact statistically in shaping risk for incident suicidal ideation among Army National Guard service members. A high-risk prevention approach including population-based screening for suicidality among patients with alcohol dependence, depression, and particularly those with both conditions is warranted in military populations.

Alcohol Misuse and Co-Occurring Mental Disorders Among New Soldiers in the U.S. Army

BACKGROUND

Problem drinking that predates enlistment into military service may contribute to the overall burden of alcohol misuse in the Armed Forces; however, evidence bearing on this issue is limited. This study examines prevalence and correlates of alcohol misuse among new U.S. Army soldiers.

METHODS

Cross-sectional survey data were collected from soldiers reporting for basic combat training. The survey retrospectively assessed lifetime alcohol consumption and substance abuse/dependence, enabling estimation of the prevalence of lifetime binge drinking and heavy drinking in a sample of 30,583 soldiers and of probable alcohol use disorder (AUD) among 26,754 soldiers with no/minimal lifetime use of other drugs. Co-occurrence of mental disorders and other adverse outcomes with binge drinking, heavy drinking, and AUD was examined. Discrete-time survival analysis, with person-year the unit of analysis and a logistic link function, was used to estimate associations of AUD with subsequent onset of mental disorders and vice versa.

RESULTS

Weighted prevalence of lifetime binge drinking was 27.2% (SE = 0.4) among males and 18.9% (SE = 0.7) among females; respective estimates for heavy drinking were 13.9% (SE = 0.3) and 9.4% (SE = 0.4). Among soldiers with no/minimal drug use, 9.5% (SE = 0.2) of males and 7.2% (SE = 0.5) of females had lifetime AUD. Relative to no alcohol misuse, binge drinking, heavy drinking, and AUD were associated with increased odds of all mental disorders and other adverse outcomes under consideration (adjusted odds ratios [AORs] = 1.5 to 4.6; ps < 0.001). Prior mental disorders and suicidal ideation were associated with onset of AUD (AORs = 2.3 to 2.8; ps < 0.001), and prior AUD was associated with onset of mental disorders and suicidal ideation (AORs = 2.0 to 3.2, ps < 0.005).

CONCLUSIONS

Strong bidirectional associations between alcohol misuse and mental disorders were observed in a cohort of soldiers beginning Army service. Conjoint recognition of alcohol misuse and mental disorders upon enlistment may provide opportunities for risk mitigation early in a soldier's career.

Overview of the Genetics of Alcohol Use Disorder

AIMS

Alcohol Use Disorder (AUD) is a chronic psychiatric illness characterized by harmful drinking patterns leading to negative emotional, physical, and social ramifications. While the underlying pathophysiology of AUD is poorly understood, there is substantial evidence for a genetic component; however, identification of universal genetic risk variants for AUD has been difficult. Recent efforts in the search for AUD susceptibility genes will be reviewed in this article.

METHODS

In this review, we provide an overview of genetic studies on AUD, including twin studies, linkage studies, candidate gene studies, and genome-wide association studies (GWAS).

RESULTS

Several potential genetic susceptibility factors for AUD have been identified, but the genes of alcohol metabolism, alcohol dehydrogenase (ADH) and aldehyde dehydrogenase (ALDH), have been found to be protective against the development of AUD. GWAS have also identified a heterogeneous list of SNPs associated with AUD and alcohol-related phenotypes, emphasizing the complexity and heterogeneity of the disorder. In addition, many of these findings have small effect sizes when compared to alcohol metabolism genes, and biological relevance is often unknown.

CONCLUSIONS

Although studies spanning multiple approaches have suggested a genetic basis for AUD, identification of the genetic risk variants has been challenging. Some promising results are emerging from GWAS studies; however, larger sample sizes are needed to improve GWAS results and resolution. As the field of genetics is rapidly developing, whole genome sequencing could soon become the new standard of interrogation of the genes and neurobiological pathways which contribute to the complex phenotype of AUD.

SHORT SUMMARY

This review examines the genetic underpinnings of Alcohol Use Disorder (AUD), with an emphasis on GWAS approaches for identifying genetic risk variants. The most promising results associated with AUD and alcohol-related phenotypes have included SNPs of the alcohol metabolism genes ADH and ALDH.

Trajectories of posttraumatic stress symptoms after civilian or deployment traumatic event experiences

OBJECTIVE

Growth mixture model studies have observed substantial differences in the longitudinal patterns of posttraumatic stress symptom (PTSS) trajectories. This variability could represent chance iterations of some prototypical trajectories or measurable variability induced by some aspect of the source population or traumatic event experience. Testing the latter, the authors analyzed a nationally representative sample of U.S. Reserve and National Guard members to identify the influence of civilian versus deployment trauma on the number of PTSS trajectories, the nature of these trajectories, and the proportion of respondents in each trajectory.

METHOD

Data were collected from 2010 to 2013 and latent class growth analysis was used to identify different patterns of PTSS in persons exposed to both a civilian and a deployment trauma and to test whether respondents' exposure to civilian trauma developed similar or distinct patterns of response compared to respondents exposed to deployment trauma.

RESULTS

PTSS were found to follow 3 trajectories, with respondents predominantly clustered in the lowest symptom trajectory for both trauma types. Covariates associated with each trajectory were similar between the 2 traumas, except number of civilian-related traumatic events; specifically, a higher number of civilian traumatic events was associated with membership in the borderline-stable, compared to low-consistent, trajectory, for civilian traumas and associated with the preexisting chronic trajectory for military traumas.

CONCLUSIONS

Holding the source population constant, PTSS trajectory models were similar for civilian and deployment-related trauma, suggesting that irrespective of traumatic event experienced there might be some universal trajectory patterns. Thus, the differences in source populations may have induced the heterogeneity observed among prior PTSS trajectory studies. (PsycINFO Database Record

Long-Term Trajectories of PTSD in Vietnam-Era Veterans: The Course and Consequences of PTSD in Twins

We estimated the temporal course of posttraumatic stress disorder (PTSD) in Vietnam-era veterans using a national sample of male twins with a 20-year follow-up. The complete sample included those twins with a PTSD diagnostic assessment in 1992 and who completed a DSM-IV PTSD diagnostic assessment and a self-report PTSD checklist in 2012 (n = 4,138). Using PTSD diagnostic data, we classified veterans into 5 mutually exclusive groups, including those who never had PTSD, and 4 PTSD trajectory groups: (a) early recovery, (b) late recovery, (c) late onset, and (d) chronic. The majority of veterans remained unaffected by PTSD throughout their lives (79.05% of those with theater service, 90.85% of those with nontheater service); however, an important minority (10.50% of theater veterans, 4.45% of nontheater veterans) in 2012 had current PTSD that was either late onset (6.55% theater, 3.29% nontheater) or chronic (3.95% theater, 1.16% nontheater). The distribution of trajectories was significantly different by theater service (p < .001). PTSD remains a prominent issue for many Vietnam-era veterans, especially for those who served in Vietnam.