Trauma exposure predicts alcohol, nicotine, and drug problems beyond the contribution of PTSD and depression in patients with cardiovascular disease: data from the Heart and Soul Study

Tobacco use, trauma exposure and PTSD: a systematic review

Tobacco use remains one of the most significant preventable public health problems globally and is increasingly concentrated among vulnerable groups, including those with trauma exposure or diagnosed with PTSD. The goal of this systematic review was to update and extend previous reviews. Of the 7224 publications that met the initial criteria, 267 were included in the review. Summary topic areas include conceptual frameworks for the relation between trauma or PTSD and tobacco use; associations between trauma exposure or PTSD and tobacco use; number and type of trauma exposures and tobacco use; PTSD symptoms and tobacco use; Treatment-related studies; and the examination of causal relations. Evidence continues to indicate that individuals exposed to trauma or diagnosed with PTSD are more likely to use tobacco products, more nicotine dependent and less likely to abstain from tobacco even when provided evidence-based treatments than individuals without trauma. The most commonly cited causal association proposed was use of tobacco for self-regulation of negative affect associated with trauma. A small proportion of the studies addressed causality and mechanisms of action. Future work should incorporate methodological approaches and measures from which we can draw causal conclusions and mechanisms to support the development of viable therapeutic targets.

Posttraumatic stress disorder symptoms, work-related trauma exposure, and substance use in first responders

BACKGROUND

Posttraumatic stress disorder (PTSD) symptoms have been shown to increase the likelihood of substance use in the general population. First responders (e.g., EMTs, paramedics, and firefighters) are routinely exposed to potentially traumatic events (PTEs) as part of their regular duties, increasing their risk for a range of adverse mental health outcomes including PTSD symptoms. However, no study to our knowledge has explored the relationship between PTEs, PTSD symptoms, and substance use in this population. In the current study, we examined whether PTSD symptoms were associated with alcohol and drug use in first responders above and beyond demographic variables, job-related characteristics, social support, and cumulative work-related PTE exposure, and whether work-related PTE exposure had an indirect effect on substance use via PTSD symptoms.

METHODS

Participants (N = 885; mean age = 37.13; 59.0% male; 91.5% White) were recruited from all 50 U.S. states, the Virgin Islands, and Puerto Rico to complete an online survey.

RESULTS

In hierarchical regression analyses, PTSD symptoms were significantly associated with alcohol and drug use above and beyond all the other variables. Work-related PTE exposure was not a significant predictor of either outcome once PTSD symptoms were included, suggesting that PTEs confer risk for substance use via their association with PTSD symptoms. This finding was confirmed by an analysis showing that PTE exposure had a significant indirect effect on both alcohol and drug use via PTSD symptoms.

CONCLUSION

Results support the need for periodic assessment of both PTSD symptoms and substance use in first responders.

Causes of death following discharge after trauma in North Carolina

BACKGROUND

While a "fourth peak" of delayed trauma mortality has been described, limited data describe the causes of death (CODs) for patients in the years following an injury. This study investigates the difference in COD statewide for patients with and without a recent trauma admission.

METHODS

This retrospective cohort study compared COD for trauma and nontrauma patients in North Carolina. Death certificates in NC's death registry were matched with the NC trauma registry between January 2013 and December 2018 using matching on name and date of birth. Patients who died during the index trauma admission were excluded. Underlying COD recorded on the death certificate were used for the primary analysis.

RESULTS

Of 481,415 death records, 19,083 (4.0%) were linked to an alive discharge within the trauma registry during the study period. Prior trauma patients (PTPs) had a higher incidence of mental illness (9.2 vs. 6.1%), Alzheimer's (6.1% vs. 4.2%), and opioid-related (1.8% vs. 1.6%) COD compared to nontrauma patients, p < 0.05. Overall, suicide was higher in the nontrauma cohort (1.5% vs. 1.1%); however, PTP had higher incidences of death by motor vehicle collision and other injury (6.0% vs. 3.8%) and homicide (0.9% vs. 0.6%), p < 0.001. Prior trauma patients had 1.16 increased odds of an opioid-related death (p = 0.009; 95% confidence interval, 1.04-1.29) compared with those without prior trauma. Younger PTP had a much higher rate of death from suicide (12.0%) compared with those 41 to 65 years (2.8%) and older than 65 years (0.2%; p < 0.001). Discharge to skilled nursing facility (odds ratio, 1.87; p < 0.05) and severe injury (odds ratio, 1.93; p < 0.05) were associated with early death after discharge (≤90 days).

CONCLUSION

After hospital discharge, PTPs remain at risk of dying from future trauma and opioid-related conditions. Prevention strategies for PTP should address the increased risk of death from a subsequent traumatic injury and the at-risk populations for early death after discharge.

LEVEL OF EVIDENCE

Prognostic and Epidemiologic, Level IV.

Military Combat, Posttraumatic Stress Disorder, and the Course of Alcohol Use Disorders in a Cohort of Australian Vietnam War Veterans

The present study examined the course of diagnosed alcohol use disorders (AUDs) in a cohort of Australian veterans of the Vietnam War (N = 388) who were assessed 22 and 36 years after returning home. Standardized interviews provided data on AUDs, posttraumatic stress disorder (PTSD), other psychiatric diagnoses, and combat exposure. Overall, 148 veterans (38.1%) had no history of alcohol-related diagnoses, 151 veterans (38.9%) had a past AUD diagnosis that was not current at the second assessment point, and 89 veterans (22.9%) had a current AUD diagnosis at the second assessment. Less education, lower intelligence test scores, and misconduct were individual risk factors for AUDs, as were first-interview diagnoses of PTSD, antisocial personality disorder, generalized anxiety, and dysthymia, but not depression; these variables were all nonsignificant after controlling for combat exposure and PTSD. Multinomial regression was used to assess the relative contributions of combat exposure and PTSD to the course of AUDs. Combat exposure and PTSD had different patterns of association with AUDs whereby combat exposure, but not PTSD, was associated with a history of AUDs, odds ratio (OR) = 1.02, but not with current AUDs, whereas PTSD, but not combat exposure, was associated with current AUDs, OR = 3.37. Current numbing and avoidance symptoms were associated with current AUDs, OR = 4.48. The results do not support a mutual maintenance model of PTSD and AUDs but are consistent with a self-medication model, which suggests treatment for PTSD may have beneficial effects on AUDs.

The association between post-traumatic stress disorder and coronary artery disease: a meta-analysis

OBJECTIVES

There are some psychosocial factors that have similar importance to biological factors in the genesis of coronary diseases. However, reasons for high rates of coronary heart disease in individuals with post-traumatic stress disorder (PTSD) are yet to be fully elucidated. Using a meta-analysis, we investigated the longitudinal relationship between PTSD and coronary heart disease (CHD) as an independent factor in the aetiology of CHD.

METHODS

The databases of Medline, EBSCOhost and Psychoinfo were electronically searched for relevant articles.

RESULTS

The pooled hazard ratio (HR) for the magnitude of the relationship between PTSD and CHD was an HR of 1.61, and p-value of p < 0.0005, 95% confidence interval (CI) [1.46-1.77] before adjustment for depression in nine studies ( N = 151,144) that met inclusion criteria. The HR estimates for the seven depression-adjusted estimates was 1.46, and a p-value of p < 0.0005, 95% CI[0.26-1.69].

CONCLUSIONS

This study demonstrates an association between CHD and PTSD.

Does trauma exposure predict prescription drug problems beyond the contribution of post-traumatic stress disorder and depression? An analysis of the Mind Your Heart cohort study

It is not clear from prior studies whether trauma exposure predicts substance use problems independent of psychiatric comorbidities. Most prior studies were cross-sectional in nature, and none focused on prescription drug problems. To address this gap in the literature, the current article is a secondary analysis of veterans from the Mind Your Heart prospective cohort study. The primary research question is whether trauma exposure predicts prescription drug problems even after controlling for major psychiatric symptoms, such as post-traumatic stress disorder and depression. Multinomial logistic regression was used to assess whether the 10-item lifetime Brief Trauma Questionnaire (e.g., serious car accidents, war traumas, life-threatening illness, natural disasters, physical, or sexual abuse) predicts prescription drug problems as determined by a self-report categorical question (three answer choices) over a 4-year follow-up time period (n = 661 [100%] at year 1; 83.4% at year 2; 85.9% at year 3; and 78.2% at year 4). Trauma exposure was positively associated with prescription drug problems in unadjusted and age-, sex-, and race-adjusted analyses at follow-up. After accounting for post-traumatic stress disorder (PTSD Checklist-17 Civilian Version) and depression (Patient Health Questionnaire-9) symptoms, trauma exposure was no longer associated with prescription drug problems at all time points (relative risk ratios range 0.91-1.47). These results were robust to different missing data strategies. Trauma exposure was not associated with prescription drug problems over a 4-year follow-up in a prospective cohort study of veterans. Future directions include detailed measures of prescription drug problems and recruitment from community sites.

Posttraumatic Symptom Reporting and Reported Cigarette Smoking During Pregnancy

INTRODUCTION

Increased prevalence of nicotine dependence among individuals suffering from posttraumatic stress disorder (PTSD) is well established. However, there are limited studies on the prevalence of smoking during pregnancy in relation to prepregnancy history of trauma exposures and active PTSD symptoms during pregnancy. Prenatal smoking has been implicated in a host of negative outcomes for mother and baby. Given maternal and fetal risk, it is critical to define predictors of continued cigarette smoking during pregnancy.

METHODS

Pregnant women from an urban perinatal clinic completed an anonymous survey of trauma history using a modified Traumatic Life Events Questionnaire (TLEQ), PTSD symptoms using the PTSD Symptom Checklist-Civilian Version (PCL-C) and current and past smoking behavior. Those who smoked any number of cigarettes per day after pregnancy confirmation were considered to be "pregnant smokers."

RESULTS

Of 218 women who completed the survey, 34 (15.6%) reported smoking cigarettes after confirmation of pregnancy. In unadjusted models, trauma exposure that resulted in fear, helplessness, or horror (FHH), as well as current PTSD symptom severity and probable PTSD diagnosis showed statistical significance as predictors of smoking during pregnancy. After adjusting for age only, PTSD symptoms retained their significant association with smoking during pregnancy. When history of smoking at least five cigarettes per day was added to our models, none of the associations remained significant.

CONCLUSIONS

These findings emphasize the importance of the behavioral response to past traumatic exposures in influencing cigarette smoking behavior before pregnancy. Given such behaviors enhance risk for continued tobacco use during pregnancy, a trauma-informed approach to smoking cessation in preconception care may ultimately reduce the likelihood of smoking during pregnancy and requires further study.

Causes of excessive late death after trauma compared with a matched control cohort

BACKGROUND

Studies on mortality following trauma have been restricted mainly to in-hospital or 30-day death. Mortality risk may be sustained several years after trauma, but the causes of late death have not been elucidated. The aim was to investigate mortality and analyse causes of late death after trauma.

METHODS

All injured patients from a regional trauma registry with long-term follow-up were matched in a 1 : 5 ratio with uninjured controls by age, sex and municipality. By linkage to national registries, long-term mortality, causes of death and co-morbidity status were identified. Excess mortality was examined by calculating the all-cause mortality rate ratio (MRR).

RESULTS

Among the trauma cohort of 7382 patients, 662 (9·0 per cent) died within 3 years after the index trauma; the 30-day mortality rate was 5·0 per cent. Compared with the control group (36 759 individuals), there was a sustained increase in mortality up to 3 years after trauma; the MRR was 2·88 (95 per cent c.i. 2·37 to 3·50) for days 31-365, 1·59 (1·24 to 2·04) for years 1-2 and 1·43 (1·06 to 1·92) for years 2-3. External causes, including new trauma, were far more common causes of late death in injured patients than in matched controls.

CONCLUSION

Postinjury mortality is increased for several years after trauma. Excess mortality is largely attributed to recurrent trauma and other external causes of death.

Post-Traumatic Stress Disorder among Cardiac Patients: Prevalence, Risk Factors, and Considerations for Assessment and Treatment

There is increasing awareness of the impact of post-traumatic stress disorder (PTSD) on physical health, particularly cardiovascular disease. We review the literature on the role of trauma in the development of cardiovascular risk factors and disease, aftermath of a cardiac event, and risk for recurrence in cardiac patients. We explore possible mechanisms to explain these relationships, as well as appropriate assessment and treatment strategies for this population. Our main conclusion is that screening and referral for appropriate treatments are important given the high prevalence rates of PTSD in cardiac populations and the associated impact on morbidity and mortality.

The association of interpersonal trauma with somatic symptom severity in a primary care population with chronic pain: exploring the role of gender and the mental health sequelae of trauma

OBJECTIVE

Female trauma survivors develop somatic symptoms more frequently than males. We propose a model for somatic symptom development among trauma survivors, focusing on gender.

METHODS

Among 597 urban primary care patients with chronic pain, we examined the association between somatic symptom severity and three interpersonal trauma types: 1) sexual trauma (ST), 2) intimate partner violence (IPV), and 3) childhood trauma history (≥3 adverse childhood experiences (3+ACE)). We developed a structural equation model in which PTSD, depression, and substance abuse were evaluated as potential mediators of the path between trauma exposure and somatic symptom severity, and explored the role of gender in this model.

RESULTS

350 (59%) respondents were female; the mean age was 47. Women reported significantly more somatic symptoms than men, although somatic symptoms were increased among all interpersonal trauma survivors. In models in which the potential intervening variables are considered in aggregate, we did not find a signficant interaction between gender and trauma on somatic symptom severity, with the exception of 3+ACEs. A structural equation model showed depression and substance abuse, for men, and depression, for women, were associated with somatic symptom severity. PTSD was not associated with somatic symptom severity. Paths from trauma exposures to mental health sequelae were stronger for men.

CONCLUSIONS

Women have more severe somatic symptoms. With the exception of 3+ACEs, the association between trauma and somatic symptoms is amplified in both genders. Structural equation models showed the pathways differed by gender in function and strength of association.