Moira Haller

Developmental cascades: Linking adolescent substance use, affiliation with substance use promoting peers, and academic achievement to adult substance use disorders

Using a high-risk community sample (N = 405), the current study examined developmental cascades among substance use, affiliation with substance use promoting peers, and academic achievement over an 18-year period and tested whether these pathways mediated the influence of parental alcoholism on adult alcohol and drug use disorders. Results showed that the influence of parental alcoholism on adult drug disorders was mediated by developmental cascades across all three domains, whereas the influence of parental alcoholism on adult alcohol disorders was mediated through affiliation with substance use promoting peers and persistence in binge drinking. Adolescent drug use had more implications for adult outcomes than did adolescent alcohol use, which was less likely to spill over into other domains of functioning. Findings indicated that adolescent risk factors had indirect rather than unique effects on adult substance use disorders, suggesting that adolescent risk is not immutable and is largely mediated by later influences.

Risk pathways among traumatic stress, posttraumatic stress disorder symptoms, and alcohol and drug problems: A test of four hypotheses.

The present study utilized longitudinal data from a community sample (n = 377; 166 trauma-exposed; 54% males; 73% non-Hispanic Caucasian; 22% Hispanic; 5% other ethnicity) to test whether pretrauma substance use problems increase risk for trauma exposure (high-risk hypothesis) or posttraumatic stress disorder (PTSD) symptoms (susceptibility hypothesis), whether PTSD symptoms increase risk for later alcohol/drug problems (self-medication hypothesis), and whether the association between PTSD symptoms and alcohol/drug problems is attributable to shared risk factors (shared vulnerability hypothesis). Logistic and negative binomial regressions were performed in a path analysis framework. Results provided the strongest support for the self-medication hypothesis, such that PTSD symptoms predicted higher levels of later alcohol and drug problems, over and above the influences of pretrauma family risk factors, pretrauma substance use problems, trauma exposure, and demographic variables. Results partially supported the high-risk hypothesis, such that adolescent substance use problems increased risk for assaultive violence exposure but did not influence overall risk for trauma exposure. There was no support for the susceptibility hypothesis. Finally, there was little support for the shared vulnerability hypothesis. Neither trauma exposure nor preexisting family adversity accounted for the link between PTSD symptoms and later substance use problems. Rather, PTSD symptoms mediated the effect of pretrauma family adversity on later alcohol and drug problems, thereby supporting the self-medication hypothesis. These findings make important contributions to better understanding the directions of influence among traumatic stress, PTSD symptoms, and substance use problems.

Does Reintegration Stress Contribute to Suicidal Ideation Among Returning Veterans Seeking PTSD Treatment

Although posttraumatic stress disorder (PTSD) and other psychiatric symptoms are well-established risk factors for suicidal ideation among returning veterans, less attention has been paid to whether the stress of reintegrating into civilian society contributes to suicidal ideation. Utilizing a sample of 232 returning veterans (95% male, mean age = 33.63 years) seeking PTSD treatment, this study tested whether reintegration difficulties contribute to suicidal ideation over and above the influence of PTSD symptoms, depression symptoms, and potential substance misuse. Logistic regressions indicated that reintegration stress had a unique effect on suicidal ideation over and above PTSD and depression symptoms. Reintegration stress interacted with substance misuse to predict suicidal ideation, such that the effect of reintegration stress on suicidal ideation was much larger for those with potential substance misuse. Exploratory analyses also examined which types of reintegration difficulties were associated with suicidal ideation, and found that difficulty maintaining military friendships, difficulty getting along with relatives, difficulty feeling like you belong in civilian society, and difficulty finding meaning/purpose in life were all significantly associated with suicidal ideation, beyond the effects of psychiatric symptoms and potential substance misuse. Findings highlight the importance of addressing reintegration stress for the prevention of suicide among returning veterans. Implications for treatment are discussed.

Shame versus trauma-related guilt as mediators of the relationship between PTSD symptoms and aggression among returning veterans

OBJECTIVE It is well established that posttraumatic stress disorder (PTSD) is associated with various forms of aggression, though the mechanisms by which PTSD is related to aggression are not fully understood. Some research suggests that the tendency to experience shame, but not guilt, contributes to aggression in individuals with a history of interpersonal trauma. This study tested the hypothesis that trait shame but not trauma-related guilt would mediate the relationship between PTSD symptoms and verbal and physical aggression in veterans with combat/military-related trauma seeking PTSD treatment. METHOD In a sample of 127 returning veterans (95% male, mean age = 32.93), negative binomial path analyses tested multiple mediational models in which shame versus trauma-related guilt (separate models entered the effects of global guilt, guilt cognitions, and guilt distress) were examined as mediators of PTSD symptoms on verbal and physical aggression separately. RESULTS Results indicated that shame partially mediated the association of PTSD symptoms with verbal aggression but not physical aggression when accounting for trauma-related guilt. Although PTSD symptoms were associated with higher scores on all aspects of trauma-related guilt, guilt did not significantly mediate relations between PTSD symptoms and verbal or physical aggression when accounting for shame. CONCLUSION These results indicate that it is worthwhile to examine whether addressing shame in PTSD treatment may also reduce verbal aggression in returning veterans. (PsycINFO Database Record

Integrated Cognitive Behavioral Therapy Versus Cognitive Processing Therapy for Adults With Depression, Substance Use Disorder, and Trauma

The comorbidity of substance use disorder (SUD), depression, and PTSD is common among veterans. Prior research has shown that among veterans with SUD and depression, those with PTSD did not maintain cognitive-behavioral treatment gains as well as those without PTSD. Thus, the current study was designed to evaluate whether adding trauma-focused treatment following an initial group-based integrated cognitive behavioral treatment (ICBT) for SUD and depression improved treatment outcomes. Participants were 123 veterans (89% male) recruited from the VA San Diego Healthcare System. All participants received ICBT in twice weekly, group-delivered sessions for 12 weeks (Phase 1). Participants were then randomized to receive 12 sessions of individual follow-up sessions (Phase 2) utilizing either ICBT or cognitive processing therapy that was modified to integrate SUD treatment (CPT-M). Results indicated that PTSD and depression symptoms slightly improved at the end of Phase 1 group ICBT and further improved through Phase 2 individual treatment (except for participants without PTSD who received CPT-M), with treatment gains maintained one year later. Substance use significantly improved at the end of Phase 1 group ICBT and these improvements were maintained through Phase 2 and the one year follow-up. Participants in the trauma-focused Phase 2 treatment (CPT-M) exhibited similar levels of symptom reduction and maintenance of treatment gains as those in the non-trauma-focused Phase 2 treatment (ICBT). However, there was a slight advantage for Phase 2 CPT-M over Phase 2 ICBT with respect to heavy drinking outcomes for individuals with PTSD. Overall, the combination of group ICBT followed by either CPT-M or ICBT individual therapy appears to be effective for veterans with depression, SUD, and trauma history.

Alcohol-Related Consequences Mediating PTSD Symptoms and Mental Health–Related Quality of Life in OEF/OIF Combat Veterans

Veterans returning from Operation Enduring Freedom and Operation Iraqi Freedom (OEF/OIF) have been found to be at increased risk for post-traumatic stress disorder (PTSD) and alcohol use disorders, leading to negative mental health-related quality of life (MHRQoL). The current study examined the unique impact of alcohol consumption levels versus alcohol-related consequences on the relationship between PTSD symptoms and MHRQoL in a sample of OEF/OIF combat veterans (N = 205, median age 29, 95% men). Mediation analyses indicated that the effect of PTSD symptoms on MHRQoL was explained only by alcohol-related consequences and not by alcohol consumption. Findings highlight the importance of including alcohol-related consequences in clinical assessment and intervention programs for OEF/OIF veterans. Additionally, this study enhances knowledge regarding the underlying mechanisms of functional impairment related to PTSD and alcohol use disorders.

Examining pretreatment differences between veterans in residential versus outpatient treatment for alcohol use disorder and comorbid combat-related PTSD

ABSTRACT Objective: Veterans with alcohol use disorder (AUD) and co-occurring posttraumatic stress disorder (PTSD) have access to various residential and outpatient treatment programs through the VA Healthcare System. There is a need to better understand the characteristics and needs of veterans who engage in residential versus outpatient treatment in order to help inform veteran care and decisions about treatment services. Methods: The present study examined whether veterans with both AUD and combat-related PTSD who were enrolled in residential (n = 103) or outpatient treatment programs (n = 76) differed on pretreatment psychiatric symptoms, substance use and associated problems/behaviors, or demographics. Veterans completed self-report measures (which referenced symptoms in the past 30 days or 2 weeks) within the first week of PTSD/AUD treatment. Results: Veterans in residential treatment had slightly worse PTSD symptoms compared to outpatient veterans; the groups reported similar levels of depression symptoms. Residential veterans had higher frequency of drug use, were more confident in their ability to be abstinent, attended more self-help meetings, spent more time around risky people or places, were more satisfied with their progress toward recovery goals, were more bothered by arguments with family/friends, and spent fewer days at work or school compared to outpatient veterans; the groups did not differ on drinking (frequency of use, binge drinking) or cravings. With respect to demographics, residential veterans were more likely to be married and non-Hispanic Caucasian (rather than minority races/ethnicities) compared to outpatient veterans. Conclusions: The finding that PTSD symptoms were more severe among veterans in residential substance use treatment highlights the importance of taking advantage of this crucial opportunity to engage veterans in evidence-based PTSD treatment. Consistent with other research, findings also indicated that individuals entering residential care have a higher level of impairment than those beginning outpatient care.

Treatment Attendance Among Veterans With Depression, Substance Use Disorder, and Trauma

ABSTRACT Objective: Low attendance in psychotherapy, particularly among individuals with comorbid disorders, is a pervasive challenge. The present study examined predictors of treatment attendance in a sample of veterans with depression, substance use disorder, and trauma. Methods: This is an analysis of data collected as part of a larger clinical trial involving outpatients at a Veterans Administration dual diagnosis clinic. Individuals were excluded if they had significant memory deficits, schizophrenia, bipolar disorder, or substantial travel constraints. Participants (N = 146) received 12 weeks of group-delivered integrated cognitive behavioral therapy for depression and substance use, followed by randomization to 12 additional weeks of individually delivered cognitive behavioral therapy (n = 62) or cognitive processing therapy (n = 61) modified to address substance use and trauma. Participants, therapists, and researchers were not blinded to group assignment. For this study, we included only the 123 participants who were randomized into the second phase, analyzing predictors of treatment attendance categorized into predisposing factors, enabling factors, and need factors. Results: Participants were primarily male (89%) and Caucasian (76%) and averaged 47 years old (SD = 12). Forty-four percent had alcohol use disorder, 16% had drug use disorder, and 40% had polysubstance use disorder. Most met criteria for PTSD (82%), with 44% having combat-related trauma, 33% sexual trauma, and 28% other trauma. Treatment attendance did not differ between groups. More education was associated with increased group (r = .19, p = .04) and individual session attendance (r = .28, p = .002). Individuals with chronic housing problems attended fewer group sessions (r = −.19, p = .04), while individuals with sexual trauma, compared to those with other traumas, attended more individual sessions (r = .23, p = .01). Number of group sessions attended was positively associated with individual session attendance. Conclusions: Few variables were significantly predictive of treatment attendance, possibly due to the complex nature of comorbid disorders. Including a focus on trauma was not associated with lower attendance. Special consideration may need to be given to education level, homelessness, and trauma when trying to engage and retain patients with comorbid disorders in treatment. This clinical trial is registered at www.clinicaltrials.gov as NCT00958217.

The Interactive Effects of Effort to Regulate Alcohol Use, Anxiety Disorders, and Affective Disorders on Long-Term Remission from Alcohol Dependence

Objective: This study examined how effort to regulate alcohol use may interact with anxiety and affective disorders to influence long-term remission from alcohol dependence. Method: Using participants (n = 96; 73% male; 66% children of alcoholics; 71% non-Hispanic Caucasian; 26% Hispanic) from a high-risk community study who showed evidence of recovered alcohol dependence at baseline, this study examined whether effort to regulate alcohol use at the baseline assessment significantly influenced the likelihood of maintaining remission from alcohol dependence for a period of five years or more. This study also examined whether having an anxiety or affective disorder interacted with effort to regulate alcohol use. All analyses controlled for treatment history, baseline alcohol use, parent alcoholism, age and gender. Results: Results from logistic regressions showed that effort to regulate alcohol use had a significant unique main effect on long-term maintenance of remission from alcohol dependence. Having an affective and/or anxiety disorder did not have a significant main effect on the maintenance of remission. However, having an anxiety/affective disorder significantly moderated the influence of effort to regulate alcohol use such that the protective effect of effort to regulate use on remission from alcohol dependence was only significant for those without an affective or anxiety disorder. Conclusions: Individuals who try harder to limit their drinking are more likely to maintain long-term remission from alcohol dependence. However, affective and anxiety disorders may undermine the protective effect of effort to regulate alcohol use on long-term remission.

The burden of co-occurring alcohol use disorder and PTSD in U.S. Military veterans: Comorbidities, functioning, and suicidality.

Alcohol use disorder (AUD) and posttraumatic stress disorder (PTSD) are among the most prevalent disorders in U.S. military veterans and often co-occur. To date, most studies have focused on treatment-seeking samples, although many veterans with AUD/PTSD do not seek treatment. We evaluated the prevalence of psychiatric comorbidities, functioning, and quality of life in a nationally representative sample of U.S. veterans (using data from the National Health and Resilience in Veterans Study) with AUD alone, PTSD alone, and comorbid AUD/PTSD to understand the incremental burden of having both disorders relative to either one. Among those with probable AUD, 20.3% met criteria for probable PTSD. Among those, with probable PTSD, 16.8% met criteria for probable AUD. Compared to veterans with AUD only, veterans with AUD/PTSD were more likely to screen positive for major depression (36.8% vs. 2.3%), generalized anxiety disorder (43.5% vs. 2.9%), suicidal ideation (39.1% vs. 7.0%); to have attempted suicide (46.0% vs. 4.1%); and to be receiving mental health treatment (44.8% vs. 7.5%). They also scored lower on cognitive (d = 0.50), mental (d = 0.51) and physical (d = 0.21) functioning, and quality of life (Cohen d = 0.46). Veterans with comorbid AUD/PTSD were more than three times as likely as veterans with PTSD only to have attempted suicide in their lifetimes (odds ratio = 3.1, 95% confidence interval = 1.8–5.3; 46.0% vs. 22.8%); they did not differ on other measures. Results underscore the burden of co-occurring AUD and PTSD in U.S. veterans, and the importance of engaging these veterans in treatment.