Follow-up care for alcohol misuse among OEF/OIF veterans with and without alcohol use disorders and posttraumatic stress disorder

Alcohol consumption and dependence risk among male and female Veterans: Trajectories and predictors

BACKGROUND

With few exceptions, previously conducted research on hazardous drinking among Veterans has employed samples in which the majority of participants identify as male. In addition, past studies have solely focused on alcohol consumption, rather than associated risk for dependence. In this study, we expanded upon the extant literature by investigating sex differences in trajectories and predictors of change in alcohol consumption and dependence risk among post-9/11 Veterans.

METHODS

A national sample of 1649 Veterans (50.0% female) were recruited in a five-wave longitudinal study that followed Veterans for up to 16 years after deployment. We used growth curve modeling to investigate trajectories of change in alcohol consumption and dependence risk among men and women Veterans. We examined predictors of growth, including demographics, support and resources, psychiatric symptoms, and trauma exposure.

RESULTS

Among male Veterans, alcohol consumption and dependence risk remained stagnant, which is in contrast to past work using non-Veteran samples. For female Veterans, consumption exhibited initial reductions that decelerated, and dependence risk reduced at a continuous rate. PTSD diagnosis was a significant predictor of individual differences in growth for men. Psychiatric symptoms (i.e., PTSD diagnosis, probable depression diagnosis, suicidal ideation) and psychosocial functioning were significant predictors of decreasing alcohol use for women.

CONCLUSIONS

Results highlight important sex differences in patterns and predictors of change in alcohol consumption and dependence risk among post-9/11 Veterans. Findings are discussed in relation to screening for hazardous alcohol use and intervention strategies in this at-risk population.

Rates and predictors of brief intervention for women veterans returning from recent wars: Examining gaps in service delivery for unhealthy alcohol use

BACKGROUND

Approximately one in four women veterans accessing the Department of Veterans Affairs (VA) engage in unhealthy alcohol use. There is substantial evidence for gender-sensitive screening (AUDIT-C = 3) and brief intervention (BI) to reduce risks associated with unhealthy alcohol use in women veterans; however, VA policies and incentives remain gender-neutral (AUDIT-C = 5). Women veterans who screen positive at lower-risk-level alcohol use (AUDIT-C = 3 or 4) may screen out and therefore not receive BI. This study aimed to examine gaps in implementation of BI practice for women veterans through identifying rates of BI at different alcohol risk levels (AUDIT-C = 3-4; =5-7; =8-12), and the role of alcohol risk level and other factors in predicting receipt of BI.

METHODS

From administrative data (2010-2016), we drew a sample of women veterans returning from recent wars who accessed outpatient and/or inpatient care. Of 869 women veterans, 284 screened positive for unhealthy alcohol use at or above a gender-sensitive cut-point (AUDIT-C ≥ 3). We used chart review methods to abstract variables from the medical record and then employed logistic regression comparing women veterans who received BI at varying alcohol risk levels to those who did not.

RESULTS

While almost 60% of the alcohol positive-risk sample received BI, among the subset of women veterans who screened positive for lower-risk alcohol use (57%; AUDIT-C = 3 or 4) only 34% received BI. Nurses in primary care programs were less likely to deliver BI than other types of clinicians (e.g., physicians, psychologists, social workers) in mental health programs; further, nurses in women's health programs were less likely to deliver BI than other types of clinicians in mixed-gender programs; Those women veterans with more medical problems were no more likely to receive BI than those with fewer medical problems.

CONCLUSIONS

Given that women veterans are a rapidly growing veteran population and a VA priority, underuse of BI for women veterans screening positive at a lower-risk level and those with more medical comorbidities requires attention, as do potential gaps in service delivery of BI in primary care and women's health programs. Women veterans health and well-being may be improved by tailoring screening for a younger cohort of women veterans at high-risk for, or with co-occurring disorders and then training providers in best practices for BI implementation.

Use of Electronic Health Record Data to Estimate the Probability of Alcohol Withdrawal Syndrome in a National Cohort of Hospitalized Veterans

OBJECTIVES

Inpatient alcohol withdrawal syndrome (AWS) is common and early treatment improves outcomes, but no prior study has used electronic health record (EHR) data, available at admission, to predict the probability of inpatient AWS. This study estimated the probability of inpatient AWS using prior-year EHR data, hypothesizing that documented alcohol use disorder (AUD) and AWS would be strongly associated with inpatient AWS while exploring associations with other patient characteristics.

METHODS

The study investigated patients hospitalized ≥24 hours on medical services in the Veterans Health Administration during 2013 using EHR data extracted from the Veterans Health Administration Corporate Data Warehouse. ICD-9-CM diagnosis code, demographic, and healthcare utilization data documented in the year before admission defined prior-year AUD, AWS, and other factors associated with inpatient AWS. The primary outcome, inpatient AWS, was defined by inpatient ICD-9-CM codes.

RESULTS

The unadjusted probability of AWS was 5.0% (95% CI 4.5%-5.4%) among 209,151 medical inpatients overall, 26.4% (95% CI 24.4%-28.4%) among those with prior-year AUD, and 62.5% (95% CI 35.2%-39.7%) among those with prior-year AWS. Of those with AWS, 86% had documented prior-year AUD and/or AWS. Other patient characteristics associated with increased probability of inpatient AWS (P < 0.001) were: male sex, single relationship status, homelessness, seizure, and cirrhosis.

CONCLUSIONS

Although inpatient providers often use history to predict AWS, this is the first study in hospitalized patients to inform and validate this practice, showing that prior-year diagnosis of AUD and/or AWS in particular, can identify the majority of inpatients who should be monitored for AWS.

The Link between Posttraumatic Stress Disorder and Functionality among United States Military Service Members Psychiatrically Hospitalized Following a Suicide Crisis

Posttraumatic stress disorder (PTSD) is one of the most commonly diagnosed psychiatric disorders in the United States and has been linked to suicidal thoughts and behaviors, yet the role of a PTSD diagnosis on functional impairment among suicidal individuals remains unknown. This study examined the association between PTSD status and functional impairment among military psychiatric inpatients admitted for acute suicide risk (N = 166) with a lifetime history of at least one suicide attempt. Measures of functionality included: (1) alcohol use; (2) sleep quality; (3) social problem-solving; and (4) work and social adjustment. Thirty-eight percent of the sample met criteria for PTSD. Women were more likely than men to meet criteria for PTSD (p = 0.007), and participants who met PTSD criteria had significantly more psychiatric diagnoses (p < 0.001). Service members who met PTSD criteria reported more disturbed sleep (p = 0.003) and greater difficulties with work and social adjustment (p = 0.004) than those who did not meet PTSD criteria. However, functionality measures were not significantly associated with PTSD status after controlling for gender and psychiatric comorbidity. Gender and number of psychiatric comorbidities other than PTSD were significant predictors of PTSD in logistic regression models across four functionality measures. Future studies should assess the additive or mediating effect of psychiatric comorbidities in the association between impaired functioning and PTSD. Clinicians are encouraged to assess and address functionality during treatment with suicidal individuals, paying particular attention to individuals with multiple psychiatric diagnoses.

Post-deployment Mental Health Screening: A Systematic Review of Current Evidence and Future Directions

Population-based post-deployment screening programs within the Departments of Defense and Veterans Affairs have been implemented to assess for mental health conditions and traumatic brain injury. The purpose of this paper is to systematically review the literature on post-deployment screening within this context and evaluate evidence compared to commonly accepted screening implementation criteria. Findings reflected highly variable psychometric properties of the various screens, variable treatment referral rates following screening, low to moderate treatment initiation rates following screening, and no information on treatment completion or long-term outcomes following screening. In sum, the evidence supporting population based post-deployment screening is inconclusive. Implications are discussed.

Alcohol-related and mental health care for patients with unhealthy alcohol use and posttraumatic stress disorder in a National Veterans Affairs cohort

OBJECTIVE

Unhealthy alcohol use and posttraumatic stress disorder (PTSD) frequently co-occur. Patients with both conditions have poorer functioning and worse treatment adherence compared to those with either condition alone. Therefore, it is possible that PTSD, when co-occurring with unhealthy alcohol use, may influence receipt of evidence-based alcohol-related care and mental health care. We evaluated receipt of interventions for unhealthy alcohol use and receipt of mental health follow-up care among patients screening positive for unhealthy alcohol use with and without PTSD in a national sample from the Veterans Health Administration (VA).

METHODS

National clinical and administrative data from VA's electronic medical record were used to identify all patients who screened positive for unhealthy alcohol use (AUDIT-C score≥5) between 10/1/09-5/30/13. Unadjusted and adjusted Poisson regression models were fit to estimate the relative rate and prevalence of receipt of: brief interventions (advice to reduce or abstain from drinking≤14days after positive screening), specialty addictions treatment for alcohol use disorder (AUD; documented visit≤365days after positive screening), pharmacotherapy for AUD (filled prescription≤365days after positive screening), and mental health care ≤14days after positive screening for patients with and without PTSD (documented with ICD-9 CM codes). In secondary analyses, we tested effect modification by both severity of unhealthy alcohol use and age.

RESULTS

Among 830,825 patients who screened positive for unhealthy alcohol use, 140,388 (16.9%) had documented PTSD. Of the full sample, 71.6% received brief interventions, 10.3% received specialty AUD treatment, 3.1% received pharmacotherapy for AUD, and 24.0% received mental health care. PTSD was associated with increased likelihood of receiving all types of care. Adjusted relative rates were 1.04 (95% CI 1.03-1.05) for brief interventions, 1.06 (1.05-1.08) for specialty AUD treatment, 1.35 (1.31-1.39) for AUD pharmacotherapy, and 1.82 (1.80-1.84) for mental health care. Alcohol use severity modified effects of PTSD for specialty AUD treatment, AUD pharmacotherapy, and mental health care such that effects were maintained at lower severity but attenuated among patients with severe unhealthy alcohol use. Age modified all effects with the strength of the association between PTSD and care outcomes being strongest for younger (18-29years) and older veterans (65+ years) and weaker or non-significant for middle-aged veterans (30-44 and 45-64years).

CONCLUSIONS

In this large national sample of patients with unhealthy alcohol use, PTSD was associated with increased likelihood of receiving alcohol-related and mental health care. PTSD does not appear to be a barrier to care among VA patients with unhealthy alcohol use.

Alcohol Use Disorder Moderates the Effect of Age on Heart Rate Variability in Veterans With Posttraumatic Stress Disorder

Research on heart rate variability (HRV) in posttraumatic stress disorder (PTSD) and comorbid alcohol use disorder (AUD) is limited despite its use as a biomarker of both disorders. This study examined whether AUD comorbidity contributes an additive effect on HRV for veterans with PTSD. HRV was assessed in 70 male Operation Enduring Freedom/Operation Iraqi Freedom veterans with PTSD, including 32 with co-occurring AUD. Mean HRV values for both groups were below the mean for healthy adults, but additive effects of PTSD and AUD on HRV were not observed. Consistent with prior studies, hierarchical regressions showed that HRV decreased with age in the PTSD-only group. However, HRV increased slightly with age among veterans with both PTSD and AUD. This interaction remained significant after controlling for common HRV covariates. These findings support HRV as a biomarker of PTSD and extend research by demonstrating the complex relationship between PTSD and HRV in the context of co-occurring AUD.

Web-based alcohol intervention for veterans: PTSD, combat exposure, and alcohol outcomes

OBJECTIVE

The purpose of the current study was to evaluate the relationship between baseline levels of posttraumatic stress disorder (PTSD), combat exposure, and alcohol outcomes in a sample of Operation Enduring Freedom (OEF) and Operation Iraqi Freedom (OIF) veterans using a web-based self-management intervention (VetChange) for problem drinking.

METHOD

The current study focuses on 523 veterans who participated in a larger randomized clinical trial. Analyses in the current study include (a) multivariable linear regression models to assess the relationship between PTSD, combat exposure, and alcohol variables at baseline, and (b) general linear models accounting for correlated data within subjects to analyze change over time for alcohol outcomes as a function of baseline PTSD symptoms, combat exposure, and covariates.

RESULTS

There was a positive association between PTSD symptom severity and alcohol use and alcohol problem severity at baseline. However, participants with higher baseline PTSD symptoms demonstrated a significantly greater reduction in alcohol use during the intervention and a greater reduction in alcohol problems from baseline to 3-month follow-up. Combat exposure severity was positively associated with alcohol problems at baseline. However, veterans with higher exposure demonstrated a greater reduction in average weekly drinking between end of intervention and follow-up, and otherwise showed changes similar to participants with lower exposure.

CONCLUSIONS

Higher levels of baseline PTSD symptoms and combat exposure severity did not prevent OEF/OIF veterans from achieving positive alcohol outcomes through participation in a self-management web intervention for problem drinking. (PsycINFO Database Record

Prevalence of Alcohol Misuse and Follow-Up Care in a National Sample of OEF/OIF VA Patients With and Without TBI

OBJECTIVE

Information on prevalence and management of alcohol misuse among Afghanistan and Iraq veterans with traumatic brain injury (TBI) is limited. This study compared rates of alcohol misuse and follow-up care-brief intervention (BI) and addiction treatment-among Afghanistan and Iraq veterans with and without TBI receiving care from the Department of Veterans Affairs (VA).

METHODS

The sample included veterans ages 18 and older screened with the Alcohol Use Disorders Identification Test alcohol consumption questions (AUDIT-C) in 2012 who received VA health care in the prior year (N=358,417). Overall and age-specific estimates of alcohol misuse (AUDIT-C score ≥5) were compared for men and women with and without TBI by logistic regression. BI and addiction treatment after screening were compared between groups by using multivariable logistic regression.

RESULTS

Alcohol misuse was higher among men with TBI than among men without TBI (20.3%, 95% confidence interval [CI]=19.9-20.8, versus 16.4%, CI=16.3-16.6) and among women with TBI than among women without TBI (6.8%, CI=5.8-8.1, versus 5.6%, CI=5.4-5.8); younger (age <30) patients with TBI had the highest rates. BI rates did not differ by TBI status (76.4%-80.2%). Addiction treatment rates for those with severe misuse were higher among those with TBI (men, 20.0%, CI=18.4-21.6, versus 15.4%, CI=14.9-15.9; women, 36.6%, CI=21.8-51.3, versus 21.1%, CI=18.2-24.0).

CONCLUSIONS

Alcohol misuse is common among Iraq and Afghanistan veterans with TBI, particularly young men. BI rates were high and did not vary by TBI status, although addiction treatment rates were higher among patients with TBI than among those without TBI.

The many wounds of war: The association of service-related and clinical characteristics with problems with the law in Iraq and Afghanistan veterans

Previous research has demonstrated that veterans with posttraumatic stress disorder (PTSD) are at higher risk for aggression, hostility, and anger, potentially leading to problems with the law or disciplinary action while in the military. There have been calls for increased consideration of the unique aspects of the judicial system in legal matters with veterans involved. The bulk of the research so far has considered the link between PTSD, traumatic brain injury (TBI), and combat exposure, but little is known about the potential role of chronic pain and Military Sexual Trauma (MST) in a veteran's experience of anger, aggression, and discipline while in the military and legal concerns. The present study used retrospective cross-sectional health screening data in a sample of 1250 Iraq and Afghanistan veterans to examine the associations of demographic, service-related, and clinical characteristics with self-reported legal problems. A total of 440 veterans (34.6%) endorsed having experienced some type of problems with the law. Independent logistic regression analyses demonstrated that those who screened positive for PTSD, MST, TBI, and clinical levels of pain were more likely to report legal problems; only the associations with positive PTSD (p=0.001) and MST (p=0.007) screens remained significant in multivariate regression analyses. The findings underscore the need for a thorough psychological evaluation when veterans are involved in the legal system with a special emphasis on factors prevalent to Iraq and Afghanistan veterans.

The prevalence of binge drinking and receipt of provider drinking advice among US veterans with military service in Iraq or Afghanistan

BACKGROUND

Binge drinking is a significant public health concern linked to a number of health and psychosocial problems. Military service in Afghanistan (OEF) and Iraq (OIF) has been associated with posttraumatic stress disorder (PTSD) and increased hazardous drinking. Brief alcohol interventions may reduce hazardous drinking but are infrequently provided to at-risk drinkers.

OBJECTIVES

This study examined the association of combat exposure, PTSD symptoms, binge drinking, use of VA and non-VA healthcare services, and the incidence of provider drinking advice.

METHODS

OEF/OIF veterans (n = 1087) completed measures of demographics, military history, combat exposure, PTSD symptoms, and binge drinking as part of a confidential mail survey study conducted in 2009 and 2010 (response rate = 29%). Patient report of receiving advice in the past year from a provider about their drinking was queried for frequent binge drinkers. The association of demographic variables, combat exposure, PTSD, and use of healthcare services with binge drinking and receipt of provider drinking advice was estimated using logistic regression.

RESULTS

Overall, 51% of the sample reported at least one episode of binge drinking in the past year and 19% were identified as frequent binge drinkers. PTSD was related to frequent binge drinking. At-risk veterans using VA healthcare services were significantly more likely to receive provider drinking advice (50%) than veterans not using VA (13.4%).

CONCLUSIONS

There is a need for increased vigilance and action to identify and counsel at-risk veterans about alcohol misuse in this population.

Risk factors for relapse to problem drinking among current and former US military personnel: a prospective study of the Millennium Cohort

BACKGROUND

Military service members may be prone to relapse to problem drinking after remission, given a culture of alcohol use as a coping mechanism for stressful or traumatic events associated with military duties or exposures. However, the prevalence and correlates of relapse are unknown. We sought to identify socio-demographic, military, behavioral, and health characteristics associated with relapse among current and former military members with remittent problem drinking.

METHODS

Participants in the longitudinal Millennium Cohort Study who reported problem drinking at baseline (2001-2003) and were remittent at first follow-up (2004-2006) were included (n=6909). Logistic regression models identified demographic, military service, behavioral, and health characteristics that predicted relapse (report of ≥1 past-year alcohol-related problem on the validated Patient Health Questionnaire) at the second follow-up (2007-2008).

RESULTS

Sixteen percent of those with remittent problem drinking relapsed. Reserve/National Guard members compared with active-duty members (odds ratio [OR]=1.71, 95% confidence interval [CI]: 1.45-2.01), members separated from the military during follow-up (OR=1.46, 95% CI: 1.16-1.83), and deployers who reported combat exposure (OR=1.32, 95% CI: 1.07-1.62, relative to non-deployers) were significantly more likely to relapse. Those with multiple deployments were significantly less likely to relapse (OR=0.73, 95% CI: 0.58-0.92). Behavioral factors and mental health conditions also predicted relapse.

CONCLUSION

Relapse was common and associated with military and non-military factors. Targeted intervention to prevent relapse may be indicated for military personnel in particular subgroups, such as Reservists, veterans, and those who deploy with combat exposure.

Alcohol and drug misuse, abuse, and dependence in women veterans

We conducted a systematic literature review on substance misuse, abuse, and dependence in women veterans, including National Guard/reserve members. We identified 837 articles published between 1980 and 2013. Of 56 included studies, 32 reported rates of alcohol misuse, binge drinking, or other unhealthy alcohol use not meeting diagnostic criteria for abuse or dependence, and 33 reported rates of drug misuse or diagnosed alcohol or drug use disorders. Rates ranged from 4% to 37% for alcohol misuse and from 7% to 25% for binge drinking; among Veterans Health Administration (VA) health-care system outpatients, rates ranged from 3% to 16% for substance use disorder. Studies comparing women veterans and civilians reported no clear differences in binge or heavy drinking. Substance misuse rates were generally lower among women veterans than men veterans. Substance misuse was associated with higher rates of trauma, psychiatric and medical conditions, and increased mortality and suicide rates. Most studies included only VA patients, and many used only VA medical record data; therefore, the reported substance misuse rates likely do not reflect true prevalence. Rates also varied by assessment method, source of data, and the subgroups studied. Further efforts to develop epidemiologically valid prevalence estimates are needed to capture the true health burden of substance misuse in women veterans, particularly those not using VA care.

National prevalence and correlates of alcohol misuse in women veterans

Our goal was to estimate the prevalence and correlates of alcohol misuse in women veterans and to assess the associations between alcohol misuse and mental health (MH) care utilization in a group comprising both Veterans Health Administration (VA) healthcare system users and non-users. We assessed alcohol misuse using survey-based AUDIT-C scores. The prevalence of alcohol misuse was 27% in VA users and 32% in non-users. Prevalence rates were higher for VA users who were younger, served in OEF/OIF, or had combat exposure and for VA non-users who screened positive for posttraumatic stress disorder or sexual assault in the military. In contrast to VA users, VA non-users with alcohol misuse had a low prevalence of past-year MH care despite having indications of MH care need. Our results on alcohol misuse prevalence, its correlates, and its association with MH care may aid program planning and resource allocation in VA and non-VA settings.