Full length articleDifferences 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
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.
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2021, Journal of Psychiatric ResearchCitation Excerpt :Research suggests 55%–68% of veterans with a probable diagnosis of PTSD also likely meet AUD criteria (Dworkin et al., 2018; Smith et al., 2016; Wisco et al., 2014), and in a study of veterans with AUD seeking Veterans Affairs (VA) healthcare, 63% received a comorbid PTSD diagnosis (Seal et al., 2011). Compared to either disorder alone, individuals with comorbid PTSD/AUD report greater severity on both PTSD and alcohol measures, and are more likely to experience a range of negative health correlates and outcomes (Blanco et al., 2013; Drapkin et al., 2011; Driessen et al., 2008; Norman et al., 2018; Ouimette et al., 2006; Possemato et al., 2015; Straus et al., 2019; Tate et al., 2007). Concurrent or integrated treatments (i.e., targeting both PTSD and alcohol use) are effective in reducing PTSD symptoms and alcohol use among this population (Roberts et al., 2015; Simpson et al., 2017).
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2020, Journal of Dental SciencesCitation Excerpt :Finally, resilience was not associated with khat chewing and due to the paucity of research assessing the association of resilience with khat chewing it was difficult to compare our findings with other similar studies. However, resilience was found associated negatively with both alcohol use and misuse overtime and post-traumatic stress disorders.11–13 Future research is required to take into account the role of other factors (e.g. self-control, self-esteem, self-efficacy and emotional intelligence) and the pathways by which these factors influence the depression and resilience in the uptake of khat chewing.