Course of alcohol dependence among Vietnam combat veterans and nonveteran controls

Trajectories of alcohol consumption in U.S. military veterans: Results from a 10-year population-based longitudinal study

BACKGROUND

Alcohol use disorder is a public health problem, especially among US veterans. This study examined the nature and predictors of 10-year trajectories of alcohol consumption in US veterans.

METHODS

Data were analyzed from the 2011-2021 National Health and Resilience in Veterans Study, a nationally representative, longitudinal study of 2309 US veterans.

RESULTS

Latent growth mixture modeling analyses revealed four trajectories of alcohol consumption (Alcohol Use Disorders Identification Test-Consumption [AUDIT-C]) over a 10-year period: excessive (4.1%; mean [standard deviation] AUDIT-C baseline=8.6 [2.0], slope= -0.33 [0.07]); at-risk (22.1%; baseline=4.1 [1.6], slope=0.02 [0.07]); rare (71.7%; baseline=1.2 [1.3], slope= -0.01 [0.03]); and recovering alcohol consumption (2.1%; baseline=8.4 [1.9], slope= -0.70 [0.14]). The strongest predictors of excessive vs. rare alcohol consumption group were younger age (relative variance explained [RVE]=27.8%), and lower agreeableness (RVE=27.0%); at-risk vs. rare alcohol consumption group were fewer medical comorbidities (RVE=82.3%); recovering vs. rare alcohol consumption group were greater dysphoric arousal symptoms (RVE=46.1%) and current mental health treatment (RVE=26.5%); excessive vs. at-risk alcohol consumption group were younger age (RVE=25.9%), greater dysphoric arousal symptoms of posttraumatic stress disorder (RVE=22.0%), and lower conscientiousness (RVE=19.1%); and excessive vs. recovering alcohol consumption group were current mental health treatment (RVE=61.1%) and secure attachment style (RVE=12.4%).

CONCLUSIONS

Over the past decade, more than 1 in 4 US veterans consumed alcohol at the at-risk-to-excessive level. Veterans who are younger, score lower on agreeableness and conscientiousness, endorse greater dysphoric arousal symptoms, and currently not engaged in mental health treatment may require close monitoring and prevention efforts to mitigate the risk of a chronic course of at-risk-to-excessive alcohol consumption.

Parallel process modeling of posttraumatic stress disorder symptoms and alcohol use severity in returning veterans

Posttraumatic stress disorder (PTSD) is associated with higher levels of alcohol use among returning veterans. Persistent PTSD symptoms can predict alcohol use over the span of hours, days, weeks, and months; however, knowledge of the strength of these associations beyond 1 year remains limited. In this study, we examined the 6-year course of co-occurring PTSD and alcohol use to explicate the directional and possible enduring effects of PTSD on alcohol use severity over time. Our study included 1,649 returning veterans (M age = 37.49; SD = 9.88) who completed 4 waves of data collection between 2010 and 2016. We used parallel process modeling to evaluate temporal associations between PTSD symptoms and alcohol use severity across 4 (T1-T4) waves of data collection. PTSD and alcohol use both decreased significantly between T1 and T4 and in tandem with one another. That is, decreases in one were associated with decreases in the other. Further, individuals with higher levels of PTSD symptom severity at T1 reported accelerated rates of change regarding PTSD symptoms and alcohol use over time. Conversely, baseline alcohol use severity did not predict the rate of change in PTSD symptom severity. Our findings provide evidence of a prospective association between PTSD symptoms and alcohol use and highlight the potential for reciprocal associations between them over the span of years. Importantly, our demonstration of the natural course of co-occurring PTSD symptoms and alcohol use suggests further trauma-focused and combined intervention strategies are needed to disrupt this enduring and reciprocal pattern among returning veterans. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

Heterogeneity in the Co-occurrence of Substance Use and Posttraumatic Stress Disorder: A Latent Class Analysis Approach

Objective: Posttraumatic stress disorder (PTSD) often co-occurs with substance use (SU). Although there has been independent research on subgroups of participants based on their PTSD or SU responses, rarely are PTSD-SU typologies examined consistent with a precision medicine approach (and corresponding person-centered statistical approaches). The current study examined the nature and construct validity (covariates of depression, physical aggression, verbal aggression, anger, hostility, reckless and self-destructive behaviors [RSDB]) of the best-fitting latent class solution in categorizing participants based on PTSD (PTSD Checklist for DSM-5) and alcohol/drug use responses (Alcohol Use and Disorders Identification Test Alcohol Consumption Questions, Drug Abuse Screening Test). Methods: The sample included 375 trauma-exposed participants recruited from Amazon's Mechanical Turk online labor market. Results: Latent class analyses indicated an optimal three-class solution (low PTSD/SU, moderate PTSD/drug and high alcohol, and high PTSD/SU). Multinomial logistic regressions indicated that depression (OR = 1.22) and frequency of RSDBs (OR = 1.20) were significant predictors of the moderate PTSD/drug and high alcohol class versus the low PTSD/SU class. Depression (OR = 1.55) and frequency of RSDBs (OR = 1.19) were significant predictors of the high PTSD/SU class versus the low PTSD/SU class. Only depression (OR = 1.27) was a significant predictor of the high PTSD/SU class versus the moderate PTSD/drug and high alcohol class. Conclusions: Results provide construct validity support for three meaningful latent classes with unique relations with depression and RSDBs. These findings improve our understanding of heterogeneous PTSD-SU comorbidity patterns and highlight acknowledgment of such subtyping (subgrouping) in considering differential treatment options, treatment effectiveness, and resource allocation.

Longitudinal Drinking Patterns and Their Clinical Correlates in Million Veteran Program Participants

BACKGROUND

A variety of measures have been developed to screen for hazardous or harmful drinking. The Alcohol Use Disorders Identification Test-Consumption (AUDIT-C) is one of the screening measures recommended by the U.S. Preventive Services Task Force. Annual administration of the AUDIT-C to all primary care patients is required by the U.S. Veterans Affairs Health System. The availability of data from the repeated administration of this instrument over time in a large patient population provides an opportunity to evaluate the utility of the AUDIT-C for identifying distinct drinking groups.

METHODS

Using data from the Million Veteran Program cohort, we modeled group-based drinking trajectories using 2,833,189 AUDIT-C scores from 495,178 Veterans across an average 6-year time period. We also calculated patients' age-adjusted mean AUDIT-C scores to compare to the drinking trajectories. Finally, we extracted data on selected clinical diagnoses from the electronic health record and assessed their associations with the drinking trajectories.

RESULTS

Of the trajectory models, the 4-group model demonstrated the best fit to the data. AUDIT-C trajectories were highly correlated with the age-adjusted mean AUDIT-C scores (rs = 0.94). Those with an alcohol use disorder diagnosis had 10 times the odds of being in the highest trajectory group (consistently hazardous/harmful) compared to the lowest drinking trajectory group (infrequent). Those with hepatitis C, posttraumatic stress disorder, liver cirrhosis, and delirium had 10, 7, 21, and 34%, respectively, higher odds of being classified in the highest drinking trajectory group versus the lowest drinking trajectory group.

CONCLUSIONS

Trajectories and age-adjusted mean scores are potentially useful approaches to optimize the information provided by the AUDIT-C. In contrast to trajectories, age-adjusted mean AUDIT-C scores also have clinical relevance for real-time identification of individuals for whom an intervention may be warranted.

Identification of Distinct Latent Classes Related to Sleep, PTSD, Depression, and Anxiety in Individuals Diagnosed With Severe Alcohol Use Disorder

Objective/Background: Alcohol use disorders (AUDs) are often accompanied by comorbid physiologic and psychosocial conditions, including sleep disturbances. Sleep disturbances in these individuals may be associated with increased risk of relapse to drinking following detoxification and rehabilitation. Participants: The sample of inpatient treatment-seeking individuals with AUDs (N = 164) was 70.1% male and 47.6% African American with a mean age of 45.6 years (±9.5 years). Methods: Latent class analysis (LCA) was used to identify unmeasured class membership based on seven indicators: maximum Clinical Institute Withdrawal Assessment (CIWA) scores; sleep efficiency (actigraphy); sleep disturbances (Pittsburgh Sleep Quality Index-PSQI); anxiety or depression (Comprehensive Psychopathological Rating Scale [CPRS]); and current and lifetime posttraumatic stress disorder (PTSD). Results: The average number of drinking days in the 90 days preceding admission was 72.0 (±22.0 days), with an average of 13.16 drinks per day (±5.70 drinks). Nearly one quarter (24.4%) of respondents reported lifetime PTSD. Three latent classes were identified: Sleep Disturbance (SD); Sleep Disturbance, Anxiety and Depression (SD/AD); and Sleep Disturbance, Anxiety and Depression, and PTSD (SD/AD/PTSD). Members of the SD/AD/PTSD group were more likely to be female and had the highest withdrawal and sleep disturbance scores of all three groups. Conclusion: Findings support the use of LCA to identify subgroups of individuals with AUDs and accompanying sleep disturbances. Class identification may provide clinicians with insight into the integrative tailoring of interventions that meet the varied needs of individuals with AUDs, accompanying comorbidities, and sleep disturbances.

Heterogeneity in the Development of Drug Use Versatility: Risk Factors for Polydrug Use throughout the Life-Course

BACKGROUND

Polydrug use is a major public health issue associated with numerous undesirable physical and mental health outcomes. While past research has identified risk factors for polydrug use and elevated drug use variety, there has yet to be any research which seeks to examine this phenomenon from a developmental perspective. There also has yet to be any research which examines the impact of risk factors for predicting differential development.

OBJECTIVES

Identify developmental subgroups of polydrug use. Identify risk factors predicting heterogeneity in development.

METHODS

The Pathways to Desistance data were used in this research. The present study used group-based trajectory modeling to elucidate general developmental patterns of drug use variety and sought to identify risk factors predicting the heterogeneity in the development of this outcome using multinomial logistic regression among a sample of juvenile offenders.

RESULTS

A six group model best fit the drug use variety count data. Several risk factors were identified which predicted assignment to the most problematic developmental subgroup, including: low self-control, low religiosity, and history of victimization at baseline. White participants were more likely to engage in any level of drug use. Conclusions/Importance: These results indicate that juvenile offenders are at-risk for chronic issues with polydrug use and more general engagement in polydrug use. Public health and criminal justice professionals should work together to develop and implement psychosocial interventions for targeting risk factors associated with accelerating and chronic polydrug use.

Illicit Stimulant Use Development in Adolescence and Early Adulthood Among Juvenile Offenders: Risk Factors Predicting Heterogeneity

The objectives of this article are to identify groups of trajectories of stimulant use across adolescence and early adulthood among juvenile offenders and to identify risk factors predicting development. Group-based trajectory modeling was used to identify developmental subgroups of stimulant users during the study period. Multinomial logistic regression was used to examine baseline covariates’ relevance for predicting assignment to identified trajectory groups. A six-group model of stimulant use was found to best fit the data. Race, history of direct victimization at baseline, gender, low school commitment at baseline, low religiosity at baseline, and other substance use at baseline were all identified as predictors of trajectory group assignment. Juvenile offenders, particularly White and female offenders, are at elevated risk of illicit stimulant use during adolescence and early adulthood. Despite this, the vast majority of juvenile offenders in the sample had desisted by age 23, differing from research on other substances using this same sample.

Trajectories of alcohol consumption in U.S. military veterans: Results from the National Health and Resilience in Veterans Study

BACKGROUND AND OBJECTIVES

While alcohol use disorder is prevalent in U.S. veterans, little is known about the nature and determinants of predominant trajectories of alcohol consumption in this population. The objective of the current study was to identify predominant trajectories of alcohol consumption over a 4-year period, and baseline determinants of these trajectories in veterans.

METHODS

Data were analyzed from the National Health and Resilience in Veteran Study, which surveyed a nationally representative sample of 3,157 veterans (Wave 1). Assessments (Waves 2 and 3) were conducted every 2 years thereafter. Alcohol consumption was assessed using the Alcohol Use Disorders Identification Test-Consumption, a brief alcohol screen for identifying problematic drinking based on alcohol consumption. Wave 1 sociodemographic, military, health, and psychosocial variables were examined as possible determinants of trajectories of alcohol consumption.

RESULTS

Latent growth mixture modeling revealed that a four-class model best fit the data: rare drinkers (65.3%), moderate drinkers (30.2%), excessive drinkers (2.6%), and recovering drinkers (1.9%). Lifetime major depressive disorder (MDD) was linked to an excessive drinking trajectory, while fewer medical conditions and lower social support were linked to a moderate drinking trajectory. Having a secure attachment style and greater social support, and absence of lifetime MDD was linked to recovery from excessive drinking.

CONCLUSIONS AND SCIENTIFIC SIGNIFICANCE

Four predominant trajectories of alcohol consumption were identified. Targeting MDD and related interpersonal factors such as attachment style and social support in population-based prevention and treatment initiatives may help prevent, mitigate, and promote recovery from excessive alcohol consumption in veterans. (Am J Addict 2018;XX:1-8).

Natural Course of Co-Occurring PTSD and Alcohol Use Disorder Among Recent Combat Veterans

Posttraumatic stress disorder (PTSD) and alcohol use disorder (AUD) commonly co-occur in veterans, yet little is known about the longitudinal course of PTSD and drinking in comorbid populations. This study assessed the natural course of daily alcohol consumption and weekly changes in PTSD symptoms in 112 recent combat veterans over the course of 11 months. Latent class growth mixture modeling was used to classify individuals into distinct classes with similar PTSD symptom and alcohol use growth trajectories. We then investigated theorized predictors of class membership including sociodemographics; pre-, peri-, and postdeployment factors; coping; symptom severity; and number of mental health/substance use appointments attended. Results revealed that most participants had severe and nonremitting PTSD. Trajectories for alcohol use included gradual and drastic declines, and chronic low-level drinking. The use of behavioral health services (odds ratio = 2.47) and fewer current stressors (odds ratio = 0.42) predicted AUD remission. Because little variation was observed in the PTSD course, our study did not observe coordinated fluctuations of PTSD symptoms and heavy drinking. Our findings suggest that treatment impacts the course of AUD and that recent combat veterans who do not seek PTSD treatment may have chronic and severe PTSD symptoms.

Longitudinal phenotypes for alcoholism: Heterogeneity of course, early identifiers, and life course correlates

Alcoholism is a heterogeneous disorder; however, characterization of life-course variations in symptomatology is almost nonexistent, and developmentally early predictors of variations are very poorly characterized. In this study, the course of alcoholic symptomatology over 32 years is differentiated, and predictors and covariates of trajectory class membership are identified. A community sample of alcoholic and neighborhood matched control families, 332 men and 336 women, was recruited based on alcoholism in the men. Symptoms were assessed retrospectively at baseline (mean age = 32) back to age 15 and prospectively from baseline every 3 years for 15 years. Trajectory classes were established using growth mixture modeling. Men and women had very similarly shaped trajectory classes: developmentally limited (men: 29%, women: 42%), developmentally cumulative (men: 26%, women: 38%), young adult onset (men: 31%, women: 21%), and early onset severe (men: 13%). Three factors at age 15 predicted class membership: family history of alcoholism, age 15 symptoms, and level of childhood antisocial behavior. Numerous measures of drinking and other psychopathology were also associated with class membership. The findings suggest that clinical assessments can be crafted where the profile of current and historical information can predict not only severity of prognosis but also future moderation of symptoms and/or remission over intervals as long as decades.

Trajectories of alcohol use over time among adults with alcohol dependence

This study sought to identify trajectories of drinking behavior change over time in a sample of adults with current alcohol use disorder (AUD). We conducted secondary analyses of seven waves of data from a prospective longitudinal study of 364 adults (mean age=44.0 years, SD=12.8 years) who met criteria for DSM-IV alcohol dependence (AD), 74.4% of whom were entering alcohol treatment. Participants were followed for 2 1/2 to 3 years with in-person interviews every 6 months. Results from latent class growth analyses of drinks per drinking day over 3 years indicated five trajectory classes: 1) Moderate Baseline→Slow Decline; 2) Heavy Baseline→Stable Abstinent; 3) Heavy Baseline→Slow Decline; 4) Heaviest Baseline→Steep Decline, and 5) Heaviest Baseline→Stable Heavy. Findings are consistent with previous research and suggest that these trajectory classes might represent longitudinal phenotypes of alcohol involvement across diverse samples. Treatment modality, Alcoholics Anonymous involvement, and purpose in life were associated with diverse trajectories of drinking behavior among adults with AD. AA involvement was associated with higher odds of membership in trajectory classes that showed declines in drinking from baseline, and having higher purpose in life predicted lower odds of membership in the Heaviest Baseline→Stable Heavy class. AA involvement predicts different pathways of recovery characterized by stable abstinence, steep declines, and/or slower declines in drinking over time. Higher purpose in life may protect against chronic heavy drinking by strengthening motivations to pursue goals that are unrelated to substance use.

Drug use disorders and post-traumatic stress disorder over 25 adult years: role of psychopathology in relational networks

BACKGROUND

In traumatized populations, drug use disorders and post-traumatic stress disorder (PTSD) persist for many years. Relational factors that mediate this persistence have rarely been systematically examined. Our aim is to examine the relative effects of psychopathology in familial and non-familial networks on the persistence of both disorders over adulthood.

METHODS

We utilized longitudinal data from an epidemiologically ascertained sample of male Vietnam veterans (n=642). Measures included DSM-IV drug use disorders, other psychiatric disorders, network problem history and time-varying marital and employment characteristics. Longitudinal measures of veterans' psychopathology and social functioning were retrospectively obtained for each year over a 25 year period. We used generalized estimating equations (GEE) to estimate the relative effects of network problems on veteran's drug use disorders and PTSD after adjusting for covariates.

RESULTS

Veterans' mean age was 47 years in 1996. Prevalence of illicit drug disorders declined from 29.8% in 1972 to 8.3% in 1996, but PTSD remained at 11.7% from 13.2% in 1972. While 17.0% of veterans reported a familial drug use problem, 24.9% reported a non-familial drug use problem. In full GEE models, a non-familial drug problem was a significant predictor of illicit drug use disorders over 25 years (OR=2.21, CI=1.59-3.09), while both familial depression (OR=1.69, CI=1.07-2.68) and non-familial drinking problem (OR=1.66, CI=1.08-2.54) were significant predictors of PTSD over 25 years.

CONCLUSIONS

Familial and non-familial problems in networks differentially affect the persistence of drug use disorders and PTSD in traumatized male adults.

Lifetime drinking trajectories among veterans in treatment for HIV

BACKGROUND

Previous work on the course of drinking across the life course identified 4 distinct patterns of problem drinking: severe chronic (SC), severe nonchronic (SNC), late onset (LO), and young adult (YA). The purpose of the current study was to determine the generalizability of these findings to a sample of midlife veterans with quite different characteristics from those previously assessed; specifically, veterans in treatment for HIV and veterans in treatment for non-HIV medical issues.

METHODS

Participants were drawn from the Veterans Aging Cohort Study that included HIV-positive and matched non-HIV participants. As in our earlier studies, the lifetime drinking history was used to assess drinking phases, and latent growth mixture models were used for analyses.

RESULTS

Similar to previous findings, both the HIV+ and non-HIV groups exhibited 4 patterns of drinking (SC, SNC, LO, and YA). SC drinkers had younger ages of onset for drinking and longer duration of smoking. SC drinkers also had the highest rates of cocaine use. Within the HIV+ subsample, SC and LO drinkers increased their drinking after their HIV diagnosis.

CONCLUSIONS

This study is the first to examine lifetime drinking patterns among those treated for HIV and provides an excellent starting point for examining finer-grained relationships involving drinking, onset of HIV, and treatment outcomes. Absent from the current study and of particular importance to future work in this area is the need for precise information regarding the temporal relationship between date of HIV diagnosis, onset of treatment, and changes in drinking behavior over the life course.

Trauma-related correlates of alcohol use in recently deployed OEF/OIF veterans

The co-occurrence of posttraumatic stress disorder (PTSD) and alcohol use disorders (AUDs) is well documented. Little is known about the factors that contribute to alcohol use and the development of AUDs among military personnel following deployment. The primary aim of this study was to examine trauma-related correlates of alcohol use in recently deployed Operation Enduring Freedom/Operation Iraqi Freedom veterans. Members of the Rhode Island National Guard and Army Reserves (N = 238) completed an in-person, initial assessment an average of 6 months postdeployment. Multiple regression analyses examined predictors of drinking outcomes (combat exposure, total PTSD symptoms, and PTSD symptom clusters) after accounting for gender, age, and history of AUD. Results indicated that total PTSD symptoms, but not combat exposure, significantly predicted alcohol use at the initial assessment. When PTSD symptom clusters were considered separately, reexperiencing symptoms (Cluster B) were the strongest predictor of total alcohol use (B = 3.58, p = .002) and heavy drinking episodes (B = 0.31, p = .005). Implications for these findings include early identification of risk factors that could lead to the development of AUDs, and the importance of integrated treatment approaches for co-occurring PTSD and AUD among veterans postdeployment.

Psychiatric morbidity is linked to problem drinking in midlife among alcohol-dependent men: a co-twin control study

OBJECTIVE

Prior research on predictors of problem drinking has been limited because of an inability to attribute an unambiguous environmental explanation to observed findings. Using a prospective co-twin control design, we examined the extent to which a history of psychiatric symptoms exerts an environmental influence on problem drinking in midlife that is unconfounded by genetic underpinnings.

METHOD

Participants were 367 complete male twin pairs (208 monozygotic, 159 dizygotic) from the Vietnam Era Twin Registry who were assessed in midlife as part of the Family Twin Study (Mage = 51.4 years, SD = 2.8). Twin pairs who were concordant for a lifetime diagnosis of an alcohol use disorder (AUD) in 1992 were selected for participation and were reinterviewed in 2001 to measure symptoms of AUD (i.e., problem drinking) since the prior assessment (past 10 years).

RESULTS

Within-pair differences in lifetime symptom counts of several psychiatric disorders measured in 1992 (i.e., major depression, dysthymia, generalized anxiety disorder, panic disorder, antisocial personality, mania, and posttraumatic stress disorder) were significantly associated with within-pair differences in AUD symptoms in the subsequent 10 years.

CONCLUSIONS

A history of psychiatric problems, particularly one marked by internalizing symptoms, appears to be linked to problem drinking in midlife above and beyond the confounding influence of genetic effects and underscores the potential value of integrated interventions for comorbidity to address problem drinking among individuals during this period of the life course.

Drinking course through midlife based on diagnostic versus quantity-frequency indices

BACKGROUND

Prior efforts to examine the course of drinking from onset to midlife have been limited to analyses of year-to-year changes in alcohol dependence (AD). The current investigation sought to examine the course of drinking over this time frame using consumption-based measures of drinking and evaluate the degree of comparability in trajectories estimated from diagnostic and quantity-frequency data.

METHODS

Participants included 420 men with a lifetime history of AD who were drawn from the Vietnam Era Twin Registry and administered the Lifetime Drinking History, which provided person-year (retrospective) data on patterns of consumption and diagnostic symptoms from drinking onset to participants' current age. Consumption-based data were aggregated into age categories that ranged from "up to age 20" to "ages 54 to 56" and analyzed separately as a dichotomous measure of "heavy drinking (HD)" and continuous quantity-frequency index (QFI) scores.

RESULTS

Using latent growth mixture modeling, trajectories based on the HD measure were moderately concordant with those based on changes in AD that were previously identified in this sample, whereas trajectories based on QFI scores were only weakly related to those based on AD diagnoses. Moreover, examination of the degree of concordance between AD- and QFI-derived trajectories revealed that measures of consumption (and potentially other continuous indices of drinking) may qualify past interpretations of various developmental trajectories that have been discussed in the alcoholism typology literature (particularly "Late Onset" alcoholism).

CONCLUSIONS

Collectively, the findings highlight the importance of integrating repeated measures of alcohol consumption in future efforts to describe the course of drinking across the life span.