Co-occurring medical, psychiatric, and alcohol-related disorders among veterans returning from Iraq and Afghanistan

Drinking Patterns of Post-Deployment Veterans: The Role of Personality, Negative Urgency, and Posttraumatic Stress

Rates of posttraumatic stress disorder (PTSD) and alcohol misuse are known to be high among post-deployment Veterans. Previous research has found that personality factors may be relevant predictors of post-deployment drinking, yet results have been inconsistent and may be influenced by the selection of drinking outcome. This study aimed to examine relations between PTSD, negative urgency, and the five factor models of personality with multiple alcohol consumption patterns, including maximum drinks in a day, number of binge drinking episodes, at-risk drinking, and average weekly drinks in a sample of 397 Operation Enduring Freedom/Operation Iraqi Freedom/Operation New Dawn (OEF/OIF/OND) Veterans. The pattern of results suggested that the association between personality, PTSD, and drinking may depend on which drinking outcome is selected. For example, maximum drinks in a day was significantly associated with younger age, male gender, low agreeableness, and an interaction between negative urgency and PTSD, whereas number of binge drinking days was significantly associated with younger age, extraversion, low agreeableness, and negative urgency. This study highlights the heterogeneity of drinking patterns among Veterans and the need for careful consideration and transparency of outcomes selection in alcohol research.

Adapting Mindfulness Training for Military Service Members With Chronic Pain

INTRODUCTION

Rates of chronic pain in military personnel are disproportionately high. Chronic pain is often associated with mental health and substance use disorders as comorbid conditions, making treatment of chronic pain complex. Mindfulness-based interventions (MBIs) are a promising behavioral approach to managing chronic pain and psychosocial sequelae. The unique nature of the military context may require adaptations to original MBIs for successful delivery in active-duty military populations. This study adapted the mindfulness-based stress reduction (MBSR) program to create a mindfulness training program that was relevant to active-duty Army personnel experiencing chronic pain. This article delineates the adaptation process employed to modify the MBSR program to the military context and discusses the resulting training program.

MATERIALS AND METHODS

The adaptation process consisted of three iterative stages: 1) Drafting the preliminary intervention protocol with recommendations from stakeholders, including military healthcare providers; 2) Refining the preliminary protocol after pretesting the sessions with research team members and a military Veteran advisory committee; and 3) Delivering the preliminary protocol to one cohort of active-duty Soldiers with chronic pain, collecting feedback, and further refining the intervention protocol.

RESULTS

Military-related adaptations to MBSR addressed three areas: military culture, language and terminology, and practical and logistical factors relevant to implementation in the military setting. This adaptation process resulted in a live, online program with six, weekly, sessions. Feedback from a military Veteran advisory committee resulted in modifications, including increasing military-relevant examples; preliminary testing with the target population resulted in additional modifications, including shortening the sessions to 75 min and structuring discussions more efficiently.

CONCLUSIONS

The adaptation process was successful in generating an engaging mindfulness training program that was highly relevant to the military context. Obtaining input from stakeholders, such as military healthcare providers and active-duty soldiers, and iterative feedback and modification, were key to the process. Moreover, the program was designed to maintain the integrity and core elements of MBIs while adapting to military culture. A future randomized controlled trial design will be used to evaluate the effectiveness of the intervention in improving chronic pain in military personnel. This program is responsive to the military's call for nonpharmacologic treatments for chronic pain that are easily accessible. If effective, the mindfulness program has the potential for widespread dissemination to complement standard care for Service Members experiencing chronic pain.

Qualitative Study of NAMI Homefront Family Support Program

The National Alliance on Mental Illness's Homefront program is a 6-week peer-taught program for family members of veterans and active duty soldiers. Homefront is associated with increased empowerment, coping, and knowledge, but little is known about member experiences. This study used telephone interviews to identify program components that are helpful or need improvement, and to compare the online and in-person program formats. Seventeen participants (7 online) and 17 instructors (3 online) were interviewed and qualitative data analysis suggested that the most helpful components were group discussion, lessons on veteran-specific issues, and coping skills workshops. Some suggested expanding Homefront to 8 or 10 weeks. The online program was convenient for those unable to attend otherwise, but participants cited some dissatisfaction with the discussion format. Instructors described teaching the program as rewarding and noted learning from the curriculum. Understanding the experiences of participants may inform the development of future psychoeducation programs.

Co-Occurrence of Obsessive-Compulsive Disorder and Substance Use Disorders Among U.S. Veterans: Prevalence and Mental Health Utilization

Obsessive-compulsive disorder (OCD) and substance-use disorders (SUDs) co-occur at high rates, which is related to poorer psychosocial outcomes. Prior work suggests that, among veterans in the Veterans Health Administration (VHA), OCD is underdiagnosed and undertreated, which can compound negative effects of OCD and SUD co-occurrence. This study identified patterns of OCD and specific SUD co-occurrence and their effect on mental health and substance-use screening measures and mental healthcare utilization. Using VHA administrative data, we identified veterans with an OCD diagnosis from 2010 to 2016 (N = 38,157); 36.70% also had a SUD diagnosis. Specific SUD rates are alcohol-use disorder, 17.17%; cannabis-use disorder, 5.53%; opioid-use disorder, 3.60%; amphetamine-use disorder, 1.49%; cocaine-use disorder, 3.37%; and tobacco-use disorder, 26.50%. Veterans with co-occurring OCD and SUD used more mental health services throughout the data capture period. Findings suggest that OCD and SUD co-occur at high rates within the VHA, and that this is associated with more burden to the healthcare system. Targeted screening and treatment efforts may help address the needs of this population.

Screening Veterans for Syphilis: Implementation of the Reverse Sequence Algorithm

We evaluated the syphilis reverse sequence algorithm (RSA) in a Veteran Affairs facility, finding 5.5% reactive Treponema pallidum enzyme immunoassay (EIA) tests. In a subset of EIA+/VDRL-/TP-PA+ cases, 48% were previously treated. Of veterans with unknown/no prior therapy, only 45% had documentation of subsequent treatment, suggesting suboptimal interpretation of RSA results.

A systematic review of randomized trials of mind-body interventions for PTSD

OBJECTIVE

To systematically review outcomes from randomized controlled trials (RCTs) of mind-body treatments for PTSD.

METHODS

Inclusion criteria based on guidelines for assessing risk of bias were used to evaluate articles identified through electronic literature searches.

RESULTS

Twenty-two RCTs met inclusion standards. In most of the nine mindfulness and six yoga studies, significant between-group effects were found indicating moderate to large effect size advantages for these treatments. In all seven relaxation RCT's, relaxation was used as a control condition and five studies reported significant between-group differences on relevant PTSD outcomes in favor of the target treatments. However, there were large within-group symptom improvements in the relaxation condition for the majority of studies.

CONCLUSIONS

Although many studies are limited by methodologic weaknesses, recent studies have increased rigor and, in aggregate, the results for mindfulness, yoga, and relaxation are promising. Recommendations for design of future mind-body trials are offered.

Binge-drinking and non-partner aggression are associated with gambling among Veterans with recent substance use in VA outpatient treatment

BACKGROUND

Gambling is relatively under-assessed in Veterans Affairs (VA) substance use disorder (SUD) treatment settings, yet shared characteristics with substance addiction suggest the importance of understanding how gambling behaviors present in Veterans seeking SUD care.

METHOD

We evaluated substance use, mental health, and violence-related correlates of past 30-day gambling among 833 Veterans (93% male, M age 48years, 72% Caucasian) seeking treatment in VA outpatient mental health and SUD clinics who completed screening for a randomized clinical trial.

RESULTS

A total of 288 (35%) Veterans reported past 30-day gambling. Among those who gambled, 79% had cravings/urges to gamble, whereas between 20%-27% of gamblers reported perceived relationship, legal, and daily life problems related to gambling, as well as difficulty controlling gambling. A logistic regression analysis revealed that age, recent binge-drinking, and non-partner physical aggression were associated with recent gambling.

CONCLUSIONS

Gambling was associated with binge-drinking and non-partner physical aggression, supporting potential shared characteristics among these behaviors such as impulsivity and risk-taking, which may complicate SUD treatment engagement and effectiveness. Findings support the need to screen for gambling in the VA, and to adapt treatments to include gambling as a potential behavioral target or relapse trigger, particularly among heavy drinking patients.

An examination of alcohol risk profiles and co-occurring mental health symptoms among OEF/OIF veterans

INTRODUCTION

Compared to the general population, veterans of the wars in Afghanistan and Iraq (OEF/OIF) are more likely to engage in hazardous alcohol use and meet criteria for mental health disorders including Posttraumatic Stress Disorder (PTSD) and Major Depressive Disorder. Less is known how distinct profiles of alcohol use behavior relate to mental health symptoms.

METHOD

The current study examined the extent that indicators of alcohol use (i.e., drinks per week, peak blood alcohol concentration, and alcohol-related problems) are categorized into different alcohol risk profiles utilizing a person-centered approach. We also examined how mental health symptoms (i.e., PTSD, depression, and anxiety-related symptoms) were associated with the alcohol risk profiles. Participants were 252 Veterans who reported consuming alcohol within the past month.

RESULTS

Latent profile analysis indicated a four-class solution yielded the best-fitting model, and profiles were named based on their respective levels and patterns of alcohol use. Mental health symptoms were significantly different among the four profiles. Profiles of veterans who endorsed more alcohol-related problems (i.e., the "Severe alcohol behavior" and "Steady drinkers with functional impairment") also reported comorbid clinical symptoms of PTSD, depression, and anxiety. The "Binge drinkers with no functional impairment" and "Mild alcohol behavior" profiles reported the lowest levels of mental health symptoms.

DISCUSSION

Findings highlight the unique relationship between distinct alcohol risk profiles and mental health outcomes. Targeted interventions and treatment options based on unique alcohol risk profiles may be helpful in tailoring prevention and intervention efforts in detecting co-occurring mental health symptoms among OEF/OIF veterans.

Sexual Behaviors and Sexually Transmitted Infections Among Male Veterans and Nonveterans

Little is known about the sexual health of male veterans. This study used nationally representative data from the 2011 to 2013 National Survey of Family Growth to compare sexual behaviors and history of sexually transmitted infections (STIs) between male veterans and nonveterans. The sample included 3,860 men aged 18 to 44 years who reported ever having sex with a man or woman. The key independent variable was veteran status. Sexual behavior outcomes included ≥6 lifetime female partners, ≥10 lifetime partners of either sex, ≥2 past-year partners of either sex, having past-year partners of both sexes, and condom nonuse at last vaginal sex. STI outcomes included past-year history of chlamydia, gonorrhea, or receiving any STI treatment; lifetime history of herpes, genital warts, or syphilis; and an aggregate measure capturing any reported STI history. Logistic regression models were used to evaluate associations between veteran status and each outcome. In models adjusting for age, race/ethnicity, education, income, and marital status, veterans had significantly greater odds than nonveterans of having ≥6 lifetime female partners (OR = 1.5, 95% CI [1.02, 2.31]). In models adjusting for age and marital status, veterans had significantly greater odds of having partners of both sexes in the past year (OR = 4.8, 95% CI [1.2, 19.8]), and gonorrhea in the past year (OR = 3.2, 95% CI [1.2, 8.5]). Male veterans were thus significantly more likely than nonveterans to have STI risk factors. Health care providers should be aware that male veterans may be at higher risk for STIs and assess veterans’ sexual risk behaviors.

Prevalence of, risk factors for, and consequences of posttraumatic stress disorder and other mental health problems in military populations deployed to Iraq and Afghanistan

This review summarizes the epidemiology of posttraumatic stress disorder (PTSD) and related mental health problems among persons who served in the armed forces during the Iraq and Afghanistan conflicts, as reflected in the literature published between 2009 and 2014. One-hundred and sixteen research studies are reviewed, most of which are among non-treatment-seeking US service members or treatment-seeking US veterans. Evidence is provided for demographic, military, and deployment-related risk factors for PTSD, though most derive from cross-sectional studies and few control for combat exposure, which is a primary risk factor for mental health problems in this cohort. Evidence is also provided linking PTSD with outcomes in the following domains: physical health, suicide, housing and homelessness, employment and economic well-being, social well-being, and aggression, violence, and criminality. Also included is evidence about the prevalence of mental health service use in this cohort. In many instances, the current suite of studies replicates findings observed in civilian samples, but new findings emerge of relevance to both military and civilian populations, such as the link between PTSD and suicide. Future research should make effort to control for combat exposure and use longitudinal study designs; promising areas for investigation are in non-treatment-seeking samples of US veterans and the role of social support in preventing or mitigating mental health problems in this group.

STI diagnosis and HIV testing among OEF/OIF/OND veterans

IMPORTANCE

Patients with sexually transmitted infection (STI) diagnosis should be tested for human immunodeficiency virus (HIV), regardless of previous HIV test results.

OBJECTIVE

Estimate HIV testing rates among recent service Veterans with an STI diagnosis and variation in testing rates by patient characteristics.

DESIGN, SETTING, AND PARTICIPANTS

The sample comprised 243,843 Veterans who initiated Veterans Health Administration (VHA) services within 1 year after military separation. Participants were followed for 2 years to determine STI diagnoses and HIV testing rates. We used relative risks regression to examine variation in testing rates.

MAIN OUTCOMES AND MEASURES

We used VHA administrative data to identify STI diagnoses and HIV testing and results.

RESULTS

Veterans with an STI diagnosis (n = 1815) had higher HIV testing rates than those without (34.9% vs. 7.3%, P<0.0001), but were not more likely to have a positive test result (1.1% vs. 1.4%, P = 0.53). Among Veterans with an STI diagnosis, testing increased from 25% to 45% over the observation period; older age was associated with a lower rate of testing, whereas race and ethnicity, multiple deployments, posttraumatic stress disorder, and substance abuse disorders were associated with a higher rate.

CONCLUSIONS AND RELEVANCE

Since VHA implemented routine HIV testing, overall rates of testing have increased. However, among Veterans at significant risk for HIV because of an STI diagnosis, only 45% had an HIV test in the most recent year of observation. Other patient characteristics such as alcohol and drug abuse were associated with being tested for HIV. Providers should be reminded that an STI is a sufficient reason to test for HIV.

RCT of a brief phone-based CBT intervention to improve PTSD treatment utilization by returning service members

OBJECTIVES

Many service members do not seek care for mental health and addiction problems, often with serious consequences for them, their families, and their communities. This study tested the effectiveness of a brief, telephone-based, cognitive-behavioral intervention designed to improve treatment engagement among returning service members who screened positive for posttraumatic stress disorder (PTSD).

METHODS

Service members who had served in Operation Enduring Freedom or Operation Iraqi Freedom who screened positive for PTSD but had not engaged in PTSD treatment were recruited (N=300), randomly assigned to either control or intervention conditions, and administered a baseline interview. Intervention participants received a brief cognitive-behavioral therapy intervention; participants in the control condition had access to usual services. All participants received follow-up phone calls at months 1, 3, and 6 to assess symptoms and service utilization.

RESULTS

Participants in both conditions had comparable rates of treatment engagement and PTSD symptom reduction over the course of the six-month trial, but receiving the telephone-based intervention accelerated service utilization (treatment engagement and number of sessions) and PTSD symptom reduction.

CONCLUSIONS

A one-time brief telephone intervention can engage service members in PTSD treatment earlier than conventional methods and can lead to immediate symptom reduction. There were no differences at longer-term follow-up, suggesting the need for additional intervention to build upon initial gains.

PTSD and comorbid AUD: a review of pharmacological and alternative treatment options

BACKGROUND

Although posttraumatic stress disorder (PTSD) and alcohol use disorders (AUD) frequently co-occur there are no specific treatments for individuals diagnosed with these comorbid conditions. The main objectives of this paper are to review the literature on pharmacological options for PTSD and comorbid AUD, and to summarize promising behavioral and alternative interventions for those with these dual diagnoses.

METHODS

We conducted a comprehensive search on PsycINFO and MEDLINE/PubMed databases using Medical Subject Headings terms in various combinations to identify articles that used pharmacotherapy for individuals with dual diagnoses of PTSD and AUD. Similar strategies were used to identify articles on behavioral and alternative treatments for AUD and PTSD. We identified and reviewed six studies that tested pharmacological treatments for patients with PTSD and comorbid AUD.

RESULTS

The literature on treatment with US Food and Drug Administration approved medications for patients with dual diagnosis of PTSD and AUD is very limited and inconclusive. Promising evidence indicates that topiramate and prazosin may be effective in reducing PTSD and AUD symptoms in individuals with comorbidity. Seeking safety has had mixed efficacy in clinical trials. The efficacy of other behavioral and alternative treatments (mindfulness-based, yoga, and acupuncture) is more difficult to evaluate since the evidence comes from small, single studies without comparison groups.

CONCLUSION

There is a clear need for more systematic and rigorous study of pharmacological, behavioral, and alternative treatments for patients with dual diagnoses of PTSD and AUD.

Accelerated Resolution Therapy for treatment of pain secondary to symptoms of combat-related posttraumatic stress disorder

BACKGROUND

As many as 70% of veterans with chronic pain treated within the US Veterans Administration (VA) system may have posttraumatic stress disorder (PTSD), and conversely, up to 80% of those with PTSD may have pain. We describe pain experienced by US service members and veterans with symptoms of PTSD, and report on the effect of Accelerated Resolution Therapy (ART), a new, brief exposure-based therapy, on acute pain reduction secondary to treatment of symptoms of PTSD.

METHODS

A randomized controlled trial of ART versus an attention control (AC) regimen was conducted among 45 US service members/veterans with symptoms of combat-related PTSD. Participants received a mean of 3.7 sessions of ART.

RESULTS

Mean age was 41.0 + 12.4 years and 20% were female. Most veterans (93%) reported pain. The majority (78%) used descriptive terms indicative of neuropathic pain, with 29% reporting symptoms of a concussion or feeling dazed. Mean pre-/post-change on the Pain Outcomes Questionnaire (POQ) was -16.9±16.6 in the ART group versus -0.7±14.2 in the AC group (p=0.0006). Among POQ subscales, treatment effects with ART were reported for pain intensity (effect size = 1.81, p=0.006), pain-related impairment in mobility (effect size = 0.69, p=0.01), and negative affect (effect size = 1.01, p=0.001).

CONCLUSIONS

Veterans with symptoms of combat-related PTSD have a high prevalence of significant pain, including neuropathic pain. Brief treatment of symptoms of combat-related PTSD among veterans by use of ART appears to acutely reduce concomitant pain.

Gender differences in substance use treatment utilization in the year prior to deployment in Army service members

Although military men have heavier drinking patterns, military women experience equal or higher rates of dependence symptoms and similar rates of alcohol-related problems as men at lower levels of consumption. Thus, gender may be important for understanding substance use treatment (SUT) utilization before deployment. Military health system data were analyzed to examine gender differences in both substance use diagnosis (SUDX) and SUT in 152,447 Army service members returning from deployments in FY2010. Propensity score analysis of probability of SUDX indicated that women had lower odds (AOR: 0.91, 95% CI: 0.86-0.96) of military lifetime SUDX. After adjusting for lifetime SUDX using propensity score analysis, multivariate regression found women had substantially lower odds (AOR: 0.61; 95% CI: 0.54-0.70) of using SUT the year prior to deployment. Findings suggest gender disparities in military-provided SUT and a need to consider whether military substance use assessment protocols are sensitive to gender differences.

Peak high-frequency HRV and peak alpha frequency higher in PTSD

Posttraumatic stress disorder (PTSD) is difficult to treat and current PTSD treatments are not effective for all people. Despite limited evidence for its efficacy, some clinicians have implemented biofeedback for PTSD treatment. As a first step in constructing an effective biofeedback treatment program, we assessed respiration, electroencephalography (EEG) and heart rate variability (HRV) as potential biofeedback parameters for a future clinical trial. This cross-sectional study included 86 veterans; 59 with and 27 without PTSD. Data were collected on EEG measures, HRV, and respiration rate during an attentive resting state. Measures were analyzed to assess sensitivity to PTSD status and the relationship to PTSD symptoms. Peak alpha frequency was higher in the PTSD group (F(1,84) = 6.14, p = 0.01). Peak high-frequency HRV was lower in the PTSD group (F(2,78) = 26.5, p < 0.00005) when adjusting for respiration rate. All other EEG and HRV measures and respiration were not different between groups. Peak high-frequency HRV and peak alpha frequency are sensitive to PTSD status and may be potential biofeedback parameters for future PTSD clinical trials.

Co-occurring Posttraumatic Stress Disorder and Alcohol Use Disorders in Veteran Populations

Co-occurring posttraumatic stress disorder (PTSD) and alcohol use disorders have become increasingly prevalent in military populations. Over the past decade, PTSD has emerged as one of the most common forms of psychopathology among the 1.7 million American military personnel deployed to Iraq and Afghanistan in Operation Enduring Freedom (OEF), Operation Iraqi Freedom (OIF), and Operation New Dawn (OND). Among veterans from all eras, symptoms of PTSD have been highly correlated with hazardous drinking, leading to greater decreases in overall health and greater difficulties readjusting to civilian life. In fact, a diagnosis of co-occurring PTSD and alcohol use disorder has proven more detrimental than a diagnosis of PTSD or alcohol use disorder alone. In order to effectively address co-occurring PTSD and alcohol use disorder, both the clinical and research communities have focused on better understanding this comorbidity, as well as increasing treatment outcomes among the veteran population. The purpose of the present article is threefold: (1) present a case study that highlights the manner in which PTSD and alcohol use disorder co-develop after trauma exposure; (2) present scientific theories on co - occurrence of PTSD and alcohol use disorder; and (3) present current treatment options for addressing this common comorbidity.