Elsevier

Drug and Alcohol Dependence

Volume 194, 1 January 2019, Pages 6-12
Drug and Alcohol Dependence

Full length article
Differences in protective factors among U.S. Veterans with posttraumatic stress disorder, alcohol use disorder, and their comorbidity: Results from the National Health and Resilience in Veterans Study

https://doi.org/10.1016/j.drugalcdep.2018.09.011Get rights and content

Highlights

  • Comorbid PTSD/AUD had lower social/psychosocial protective factors than AUD-only.

  • Social/psychosocial factors partially mediated PTSD and suicidal ideation.

  • Psychosocial factor partially mediated link between PTSD and suicide attempts.

Abstract

Background

Comorbid posttraumatic stress disorder (PTSD) and alcohol use disorder (AUD) are associated with greater clinical and functional impairments than either disorder alone, including higher rates of suicidality and reduced functioning and quality of life. Although PTSD/AUD is associated with more severe risk factors relative to either disorder alone, it is unclear whether PTSD/AUD and its related impairments are also associated with lower levels of protective factors.

Methods

We examined two composite factors of protective qualities derived from exploratory factor analyses—social connectedness (i.e., structural social support, perceived social support, secure attachment style) and protective psychosocial characteristics (i.e., resilience, purpose in life, dispositional optimism and gratitude, and community integration), in a nationally representative sample of U.S. Veterans (using data from the National Health and Resilience in Veterans Study) with PTSD alone, AUD alone, and comorbid PTSD/AUD.

Results

Veterans with PTSD and PTSD/AUD scored significantly lower than those with AUD alone but did not differ from each other on measures of social connectedness and protective psychosocial characteristics (ps < .001). Both factors partially mediated the relationship between diagnostic status (PTSD or PTSD/AUD vs. AUD alone) and suicidal ideation (ORs = 0.58-0.62), as well as between diagnostic status and functioning/quality of life (psychosocial protective characteristics, β = 0.39; social connectedness, β = 0.16). Only protective psychosocial characteristics (OR = 0.54) emerged as a partial mediator between diagnostic status and lifetime suicide attempts.

Conclusions

U.S. Veterans with PTSD and PTSD/AUD score lower on measures of protective factors than Veterans with AUD. These factors may be important targets for prevention and treatment efforts.

Introduction

Posttraumatic stress disorder (PTSD) and alcohol use disorder (AUD) frequently co-occur in the Veteran population. In a nationally representative sample of Veterans, one of every five Veterans with AUD also screened positive for PTSD (Norman et al., 2018). This rate is even higher among Veterans seeking VA care, with up to two-thirds of Veterans with AUD also having a diagnosis of PTSD (Seal et al., 2011). Comorbid PTSD/AUD is associated with more severe clinical and functional problems relative to PTSD or AUD alone, including increased risk of suicide and reduced functioning and quality of life (Blanco et al., 2013; Norman et al., 2018; Rojas et al., 2014). In a recently published study of a nationally representative sample of U.S. Veterans, those with comorbid PTSD/AUD were more likely than those with AUD alone to report suicidal ideation and suicide attempts, and scored lower on measures of physical, mental, and cognitive functioning, and quality of life (Norman et al., 2018). Further, compared to Veterans with PTSD alone, Veterans with comorbid PTSD/AUD were three times more likely to have attempted suicide in their lifetimes. Given that Veterans account for over 14 percent of completed suicides in the U.S. in 2015 (Department of Veterans Affairs, 2018), understanding the relationship between PTSD/AUD and suicidality may be critical to targeting this public health concern.

Although the association between PTSD/AUD and risk of suicidality and reduced quality of life is well-documented (Blanco et al., 2013; Norman et al., 2018), less is known regarding factors which may also contribute to this relationship. While comorbid PTSD/AUD is associated with more severe risk factors in comparison to either disorder alone (e.g., emotion dysregulation; Goldstein et al., 2017; Tripp et al., 2015), it may be that lower levels of protective factors also characterize those with PTSD/AUD and contribute to the greater clinical and functional impairments associated with this comorbidity. Identifying whether lower levels of protective factors contribute to suicidality and reduced quality of life amongst Veterans with PTSD/AUD may help inform preventative and intervention efforts for this at-risk and underserved population.

Studies using data from the National Health and Resilience in Veterans Study (NHRVS) have examined a comprehensive range of protective factors in Veterans with PTSD (Pietrzak and Cook, 2013; Wisco et al., 2014), but not in Veterans with comorbid PTSD/AUD. Findings from these studies suggest that Veterans with PTSD score lower than those without PTSD on two composite factors that assess protective factors: social connectedness (e.g., structural social support, perceived social support, secure attachment style) and protective psychosocial characteristics (e.g., individual-level characteristics such as perceived resilience, purpose in life and dispositional gratitude; Pietrzak and Cook, 2013; Wisco et al., 2014). Higher scores on these measures were also associated with lower odds of PTSD diagnosis and distinguished between resilient and distressed Veterans even after adjustment for a broad range of sociodemographic, military, and other psychosocial characteristics (Pietrzak and Cook, 2013; Wisco et al., 2014). Given the increased suicide risk and reduced functioning and quality of life associated with PTSD/AUD (Norman et al., 2018; Rojas et al., 2014), it may be that this comorbidity is associated with lower levels of protective factors than PTSD or AUD alone. Understanding whether protective factors differ between those with PTSD/AUD and either disorder alone may advance understanding regarding the greater clinical and functional impairments associated with PTSD/AUD.

Although social connectedness has yet to be examined in Veterans with comorbid PTSD/AUD, converging data suggest that the individual components of social connectedness (i.e., structural social support, perceived social support, secure attachment style) are negatively associated with comorbid PTSD/AUD. With regard to structural and perceived social support, studies utilizing civilian samples have found PTSD/AUD is associated with differences on both forms of social support compared to either disorder alone (Blanco et al., 2013; Drapkin et al., 2011; Dutton et al., 2014; Riggs et al., 2003). For example, civilians with PTSD/AUD are less likely to be living with a romantic partner (Drapkin et al., 2011; Riggs et al., 2003) or be married (Blanco et al., 2013), and are more likely to report apprehension regarding their social network and more problems with family support (Dutton et al., 2014) than those with either disorder alone. Further, attachment style also appears to differ across Veterans with comorbid PTSD/AUD and those with either disorder alone. In one study of treatment-seeking Veterans, Veterans with comorbid PTSD and hazardous substance use (HSU) scored higher on a measure of avoidant attachment than those with HSU alone, although they did not differ from Veterans with PTSD alone (Owens et al., 2014). Collectively, these findings indicate that individuals with PTSD/AUD may have lower levels of social connectedness relative to those with PTSD or AUD alone.

Accumulating evidence suggests that protective psychosocial characteristics, such as perceived resilience, purpose in life, and dispositional gratitude, may be negatively associated with comorbid PTSD/AUD. While studies have not yet compared protective psychosocial characteristics in individuals with PTSD/AUD to those with single disorders, extant research suggests that certain characteristics are negatively associated with PTSD and AUD alone. For example, perceived resilience has been found to be negatively associated with both PTSD and AUD alone. With regard to PTSD, a substantial body of evidence suggests that higher levels of perceived resilience, in conjunction with other protective factors, is associated with lower PTSD symptom severity and reduced odds of having the disorder (Pietrzak et al., 2010, 2009; Wisco et al., 2014). Similarly, both retrospective (Bartone et al., 2017; Green et al., 2014; Green et al., 2010) and longitudinal studies (Green et al., 2014) indicate that perceived resilience is negatively associated with AUD in veteran samples. Taken together, these findings suggest that both social connectedness and protective psychosocial characteristics warrant further investigation in a comorbid PTSD/AUD sample.

To address the aforementioned gaps in the literature, the primary aim of the current study was to compare aspects of social connectedness and protective psychosocial characteristics in a nationally representative sample of U.S. military Veterans with comorbid PTSD/AUD relative to either disorder alone. The secondary aim was to evaluate whether social connectedness and protective psychosocial characteristics may mediate the relation between diagnostic status (PTSD and PTSD/AUD vs. AUD alone) and suicidality (i.e., current suicidal ideation and lifetime suicide attempts) and overall functioning and quality of life. We hypothesized that 1) Veterans with comorbid PTSD/AUD would score lower on measures of social connectedness and protective psychosocial characteristics than those with PTSD or AUD alone; and 2) protective factors would partially mediate the association between diagnostic status and higher rates of current suicidal ideation and lifetime suicide attempts, and lower functioning and quality of life.

Section snippets

Participants and procedure

Data were analyzed from the National Health and Resilience in Veterans Study (NHRVS), which surveyed a nationally representative sample of U.S. veterans. Participants were recruited through GfK Knowledge Networks, Inc.’s KnowledgePanel, which is a research panel that covers approximately 98% of U.S. adults. GfK Knowledge Networks randomly samples households using the U.S. Postal Service’s Deliver Sequence File (DSF), which includes individuals with and without listed telephone numbers,

Results

In the full sample, the majority of participants identified as Caucasian (weighted 70.2%) and male (weighted 88.4%). Weighted prevalence analyses revealed that 13.7% screened positive for current PTSD alone, 10.8% for AUD alone, and 2.8% for comorbid PTSD/AUD. Table 1 provides a detailed summary of the sociodemographic, clinical, and military characteristics of the sample by PTSD and AUD status. The groups differed on a number of variables, including age, gender, marital and employment status,

Discussion

The purpose of this study was to evaluate the relation between PTSD, AUD, and comorbid PTSD/AUD and scores on measures of social connectedness and protective psychosocial characteristics in a nationally representative sample of Veterans. We also evaluated whether lower levels of these protective factors contributed to the relationship between PTSD/AUD, and suicide risk and reduced functioning/quality of life.

In partial support of the first hypothesis, Veterans with PTSD/AUD scored significantly

Role of the funding source

The National Health and Resilience Study is funded by the U.S. Department of Veterans Affairs National Center for Posttraumatic Stress Disorder.

Contributors

Author ES drafted primary manuscript, participated in conceptualization of study, and contributed to interpretation of findings. SBN and MH conceived of study aims and hypotheses, interpreted study findings, and provided editing of manuscript. JLH and SMS provided editing of full manuscript. RHP and SMS acquired the data. RHP conceived of study aims and hypotheses, conducted the statistical analyses, interpreted the data, and edited the manuscript. All authors contributed and approved of the

Conflict of interest

The authors have no known conflicts of interest to disclose.

References (69)

  • E.J. Hawkins et al.

    Recognition and management of alcohol misuse in OEF/OIF and other Veterans in the VA: a cross-sectional study

    Drug Alcohol Depend.

    (2010)
  • K. Isaacs et al.

    Psychological resilience in U.S. military Veterans: a 2-year, nationally representative prospective cohort study

    J. Psychiatr. Res.

    (2017)
  • T.B. Kashdan et al.

    The curiosity and exploration inventory-II: development, factor structure, and psychometrics

    J. Res. Pers.

    (2009)
  • E.M. Kleiman et al.

    Gratitude and grit indirectly reduce risk of suicidal ideations by enhancing meaning in life: evidence for a mediated moderation model

    J. Res. Pers.

    (2013)
  • E.M. Kleiman et al.

    A meaningful life is worth living: meaning in life as a suicide resiliency factor

    Psychiatry Res.

    (2013)
  • E.M. Kleiman et al.

    Social support as a protective factor in suicide: findings from two nationally representative samples

    J. Affect. Disord.

    (2013)
  • C.M. Lemaire et al.

    Factors associated with suicidal ideation in OEF/OIF Veterans

    J. Affect. Disord.

    (2011)
  • S.D. McDonald et al.

    The diagnostic accuracy of the PTSD checklist: a critical review

    Clin. Psychol. Rev.

    (2010)
  • R.H. Pietrzak et al.

    Psychosocial buffers of traumatic stress, depressive symptoms, and psychosocial difficulties in veterans of Operations Enduring Freedom and Iraqi Freedom: the role of resilience, unit support, and postdeployment social support

    J. Affect. Disord.

    (2010)
  • R.H. Pietrzak et al.

    Suicidal ideation in treatment- seeking veterans of Operations Enduring Freedom and Iraqi Freedom: the role of coping strategies, resilience, and social support

    J. Psychiatr. Res.

    (2011)
  • R.H. Pietrzak et al.

    Successful aging among older veterans in the United States

    Am. J. Geriatr. Psychiatry

    (2014)
  • D.S. Riggs et al.

    Demographic and social adjustment characteristics of patients with comorbid posttraumatic stress disorder and alcohol dependence: potential pitfalls to PTSD treatment

    Addict. Behav.

    (2003)
  • N.P. Roberts et al.

    Psychological interventions for post- traumatic stress disorder and comorbid substance use disorder: a systematic review and meta-analysis

    Clin. Psychol. Rev.

    (2015)
  • S.M. Rojas et al.

    Understanding PTSD comorbidity and suicidal behavior: associations among histories of alcohol dependence, major depressive disorder, and suicidal ideation and attempts

    J. Anxiety Disord.

    (2014)
  • K.H. Seal et al.

    Substance use disorders in Iraq and Afghanistan veterans in VA healthcare, 2001–2010: implications for screening, diagnosis and treatment

    Drug Alcohol Depend.

    (2011)
  • C.D. Sherbourne et al.

    The MOS social support survey

    Soc. Sci. Med.

    (1991)
  • P.T. Bartone et al.

    Hardiness, avoidance coping, and alcohol consumption in war Veterans: a moderated-mediation study

    Stress Health

    (2017)
  • A. Bowe et al.

    PTSD and substance use disorder among Veterans: characteristics, service utilization and pharmacotherapy

    J. Dual Diagn.

    (2015)
  • K.A. Bradley et al.

    AUDIT-C as a brief screen for alcohol misuse in primary care

    Alcohol Clin. Exp. Res.

    (2007)
  • K.C. Bronk et al.

    Purpose, hope, and life satisfaction in three age groups

    J. Posit. Psychol.

    (2009)
  • K. Bush et al.

    The AUDIT alcohol consumption questions (AUDIT-C): an effective brief screening test for problem drinking. Ambulatory Care Quality Improvement Project (ACQUIP). Alcohol Use Disorders Identification Test

    Arch. Int. Med.

    (1998)
  • E.B. Carlson et al.

    Development and validation of a brief self-report measure of trauma exposure: the trauma history screen

    Psychol. Assess.

    (2011)
  • K.M. Connor et al.

    Development of a new resilience scale: the Connor- Davidson Resilience Scale (CD-RISC)

    Depress. Anxiety

    (2003)
  • D.A. Dawson et al.

    Effectiveness of the derived Alcohol Use Disorders Identification Test (AUDIT-C) in screening for alcohol use disorders and risk drinking in the US general population

    Alcohol. Clin. Exp. Res.

    (2005)
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