Multimorbidity and Correlates of Comorbid Depression and Generalized Anxiety Disorder in a Nationally Representative US Sample.

ABSTRACT: Generalized anxiety disorder (GAD) and major depressive disorder (MDD) frequently occur together, but sociodemographic, behavioral, and diagnostic correlates of this comorbidity have not been comprehensively studied. Data from the nationally representative US sample surveyed in the National Epidemiologic Survey on Alcohol and Related Conditions-III ( N = 36,309) were used to define three groups, individuals with a) both past-year GAD and MDD ( n = 909, 16.9%), b) GAD only ( n = 999, 18.6%), and c) MDD only ( n = 3471, 64.5%). The comorbid group was compared with each single-diagnosis group on sociodemographic, behavioral, and diagnostic characteristics based on effect sizes (risk ratios and Cohen's d ) rather than p values because of the large sample sizes. Multivariable-adjusted logistic regression analyses were used to identify factors independently associated with the comorbid group. Bivariate analysis showed that the comorbid group had more parental and childhood adversities, additional psychiatric disorders, and poorer mental health quality of life than both single-disorder groups. Multivariable-adjusted logistic regression of the comorbid group showed that on two of five factors, additional psychiatric diagnoses were significantly more frequent than in the GAD-only group, and that on three of six factors, additional psychiatric diagnoses were significantly more frequent than in the MDD-only group. There is a significantly higher burden of social adjustment problems, comorbid psychiatric disorders, and poorer mental health-related quality of life among individuals with comorbid GAD-MDD than those with single disorders. The adversities associated with this non-SUD psychiatric comorbidity are comparable to those associated with the more extensively studied comorbidity of psychiatric and substance use disorders and deserve further research and treatment.

Prevalence and Clinical Characteristics of Recreational and At-Risk/Problematic Gambling Among Low-Income U.S. Veterans: Results from the National Veteran Homeless and Other Poverty Experiences (NV-HOPE) Study.

This study examined associations between recreational gambling (RG) and at-risk/problem gambling (ARPG), and clinical measures of mental illness and substance use, functionality, homelessness, in a nationally representative sample of U.S. military veterans. Data were analyzed from 781 veterans who participated National Veteran Homeless and Other Poverty Experiences (NV-HOPE) study conducted in 2021. Chi-square tests, analyses of variance (ANOVAs) and logistic regressions analyses were conducted to examine unadjusted and adjusted associations between gambling group status and sociodemographic, psychiatric, substance use, functioning, and homelessness measures. A significant minority of low-income U.S. veterans reported gambling, with 24.9% (95% confidence interval [CI] 95% CI 21.12-28.76%) exhibiting RG and 6.7% (95% CI 3.88-9.42%) screening positive for ARPG. The prevalence of ARPG was higher among younger, non-White veterans. ARPG was associated with greater symptoms of substance use and anxiety; poorer physical functioning; history of any mental illness; lifetime history of homelessness; and having any student or car loans relative to NG. Veterans who had RG were more likely to screen positive for drug use disorders relative to NG. Results of the current study provide an up-to-date estimate of the current prevalence of RG and ARPG among low-income U.S. veterans and underscore the importance of routine screening, monitoring, and development of interventions for problematic gambling severity, as well as interventions for ARPG in this population. These findings may inform targeted intervention strategies for this vulnerable subpopulation.

Prevalence and Clinical Characteristics of Recreational and At-Risk/Problematic Gambling in a National Sample of U.S. Military Veterans.

Gambling among U.S. military veterans is common, with more extensive involvement linked to gambling disorder and associated problems. This study examined associations between recreational gambling (RG) and at-risk/problem gambling (ARPG), and clinical measures (psychiatric disorders, substance use), behaviors (suicidality, homelessness, arrests) and functioning in a nationally representative sample of U.S. military veterans. Data were analyzed from 4069 veterans who participated in the National Health and Resilience in Veterans Study. Chi-square tests, analyses of variance (ANOVAs) and logistic regressions were conducted to examine unadjusted and adjusted associations between gambling group status and lifetime and current psychiatric diagnoses and behavioral and functioning measures. A significant minority of U.S. veterans reported gambling, with 27.3% (95% confidence interval [CI] 25.5-29.1%) exhibiting RG and 4.9% (95% CI 4.0-5.9%) screening positive for ARPG. The prevalence of ARPG was higher among younger, non-White, male veterans, while RG was more prevalent among retired veterans and those with higher household incomes relative to non-gambling (NG) individuals. ARPG was associated with greater trauma burden, lifetime and current psychiatric diagnoses, mental health treatment, alcohol and drug use disorders, suicidal ideation, homelessness, arrests, and poorer functioning relative to NG and RG, with stronger magnitude differences relative to NG. RG was associated with substance use disorders and arrest histories relative to NG. Results of the current study provide an up-to-date estimate of the current prevalence of RG and ARPG among U.S. veterans and underscore the importance of routine screening and monitoring of gambling problems, as well as interventions for ARPG in this population.

A population-wide perspective on the reach of substance use disorders: Parental exposure, diagnostic remission, and current disorders.

BACKGROUND AND OBJECTIVES: Parental substance use disorder (SUD) increases the risk for childhood adversities. Lifetime and current SUDs are associated with functional impairment and psychiatric comorbidity. Research shows that these abate with diagnostic remission. However, a hierarchically ordered heuristic profile of adult subpopulations affected by SUDs has not been explored. METHODS: We used data from the National Epidemiologic Survey on Alcohol and Related Conditions Wave III (NESARC-III; N = 36,309) to compare four subpopulations defined by the following hierarchy: (1) neither parental nor lifetime SUD (un-affected group); (2) parental SUD but no personal SUD; (3) past but not current SUD (diagnostic remission); and (4) current SUD. We conducted bivariate comparisons and multivariable-adjusted logistic regression to identify characteristics independently differentiating each group. RESULTS: Almost half of the US adult population (108.9 million) were at risk from SUDs. Relative to the unaffected group (56.1%), the parental-exposure-only group (13.9%) experienced diverse parental and childhood adversities and increased risk for psychiatric disorders. Compared to the parental-exposure-only group those in the remitted group (14.1%) were more likely to report behavioral problems and lifetime psychiatric multimorbidities. Those with current SUD (15.9%) had a poorer mental health-related quality of life. DISCUSSION AND CONCLUSIONS: This heuristic SUD hierarchy is associated with increasing adversities affecting almost half the US population, although only 15.9% meet the criteria for a current disorder. SCIENTIFIC SIGNIFICANCE: Our findings provide a rigorous population-based estimate of the staggering public health impact of SUDs in the United States and suggest that almost half of the US population is either directly or indirectly affected by SUDs.

"Lives of despair" at risk for "deaths of despair": tracking an under-recognized, vulnerable population.

PURPOSE: The substantial and unexpected increase in "deaths of despair" in the US (e.g., deaths from drug overdose, suicide, and alcohol-related liver diseases) reported by economists Case and Deaton in 2015 raises questions about the number and characteristics of US adults potentially living "lives of despair" with these problems. METHODS: We used data from the National Epidemiologic Survey on Alcohol and Related Conditions Wave III (NESARC-III) to examine population estimates and characteristics of adults with lifetime history of substance use disorder (SUD) and suicide attempt, or either condition alone, as compared to those with neither. RESULTS: An estimated 7.2 million adults had both lifetime SUD and suicide attempt and 78.8 million had either. Those with both faced far more psychosocial adversities, familial adverse experiences and psychiatric disorders compared to those with the other two groups, and reported greater mental health service utilization. Multivariable analysis showed that psychiatric multimorbidity and violence were the strongest correlates of having both conditions as compared to neither while those with either condition fell in between. CONCLUSION: A substantial number of US adults live with a lifetime SUD and suicide attempt with a multiplicity of additional socioeconomic, psychiatric and familial problems. While their utilization of mental health care service exceeds those with either or neither conditions, quality of life remained much poorer, suggesting that mental health treatment alone may not be enough to mitigate their sufferings, and a combination of both social policy support and quality mental health care may be needed.

Lifetime risk and correlates of incarceration in a nationally representative sample of U.S. adults with non-substance-related mental illness.

PURPOSE: High rates of psychiatric disorders in correctional facilities have fueled widespread concern about the "criminalization of mental illness." While the link between incarceration, substance abuse, and antisocial-personality disorder is well established, the relationship between non-substance-related psychiatric disorders and incarceration has not been thoroughly investigated. This study examines the association of mental illness, excluding substance use disorders, with risk for incarceration in US adults. METHODS: Nationally representative data from the National Epidemiologic Survey on Alcohol and Related Conditions-III (NESARC-III) were used to compare the proportions of respondents with lifetime incarceration among those with no lifetime history of DSM-5 disorders, or with lifetime history of mental illness, substance use disorders, dual diagnosis, and antisocial personality/conduct disorder. Logistic regression analysis was used to examine the independent association of incarceration with mental illness alone, both in comparison to and net of associations with sociodemographic and behavioral characteristics. RESULTS: Among adults with mental illness alone, 6.7% reported past incarceration, compared to 4.8% with no history of DSM-5 disorders, and 20-40% in other DSM-5 diagnostic groups. Sociodemographic and behavioral risk factors were more strongly associated with incarceration (c-statistics = 0.74 and 0.77, respectively), than mental illness (c-statistic = 0.56). Schizophrenia or other psychoses and borderline personality disorder were independently associated with incarceration, but with effect sizes no greater than eight other sociodemographic or behavioral risk factors. CONCLUSION: A weak association of mental illness alone with incarceration was found, despite high level of public attention to "criminalization of mental illness."

Religious institutions as a link to substance use treatment: Characterizing the potential service population through national survey data.

Background: Relatively few Americans with current alcohol or drug use disorders receive outpatient or residential treatment. Outreach initiatives at local places of religious worship have been proposed as a way of facilitating such service use, but the number and characteristics of adults who may be reached in this way has not been studied. Methods: Data from the 2012-2013 National Epidemiologic Survey on Alcohol and Related Conditions-III, a nationally representative cross-sectional survey of U.S. adults were used to estimate the number of and proportion of adults with substance use disorders (SUDs) who attended monthly religious service and did not receive SUD treatment in the past year and used multinomial logistic regression to compare them to three SUD groups who did or did not receive treatment and/or attend religious services. Results: A total of 5,795 respondents representing 35.8 million Americans met criteria for a past-year SUD, of whom 8.3 million (23.1%) attended religious services monthly and did not receive substance use treatment. This more often African-American group had substantially fewer socio-demographic disadvantages (e.g., unemployment), behavioral problem indicators (e.g., police involvement), a higher quality of life score and less likelihood of an illicit drug use diagnosis than those who received treatment and either did or did not attend religious services. Conclusion: Almost one quarter of adults with a SUD attend religious services monthly and do not receive SUD treatment. Although they have fewer adversities than people who receive treatment, outreach to this population may link this substantial group of people to needed services.Highlights/reviewNational survey data suggest 8 of 36 million Americans with substance use diagnoses' (23%) do not receive specialized SUD treatment, but they do attend religious services monthly or more.This group, notably, has less numerous problems, such as unemployment, police involvement, and drug use disorder, and have higher quality of life scores than those who receive treatment for SUD.Outreach and linkage initiatives with religious institutions may facilitate use of services by this population.

Women's Use of Substance Use Disorder Treatment Services: Rates, Correlates, and Comparisons to Men.

In spite of evidence of increasing prevalence of substance use disorders (SUDs) among women, there is little information on gender differences in SUD treatment use. Nationally representative survey data were used to compare specialized SUD treatment among women and men with past-year DSM-5 SUD diagnoses (N = 5,789, 42.8% women). An estimated 10.7% of women and 9.9% of men (p = 0.45) received SUD treatment. Those who received treatment among both men and women had more problems than others. Five variables were independently associated with receipt of past-year treatment in both women and men and while five others were independently associated with receipt of treatment for only one gender. Interaction analysis, however, revealed no statistically significant gender differences in any correlate of treatment receipt. Although men were more likely to have SUDs than women, there were no significant differences by gender in rates or correlates of service use.

Gender Differences in Diagnostic Remission of Posttraumatic Stress Disorder (PTSD): Proportions and Correlates of Remission in a Nationally Representative U.S. Sample.

This study examines differences in a nationally representative sample, in proportions of men and women with lifetime diagnoses of Posttraumatic Stress Disorder (PTSD) who achieved diagnostic remission and gender-specific correlates. Data from the 2012-13 National Epidemiologic Survey on Alcohol and Related Conditions-III included 1,997 adults with a lifetime PTSD diagnosis (70.8% female and 29.2% male). Of these 25.3% of women and 24.3% of men experienced remission (ns). Women who remitted were older than other women, more likely to be retired, and less likely to report disability, past homelessness, suicide attempts, criminal history, violent behavior, or parental histories of drug problems or suicide. Men who remitted were less likely than other men to be separated/divorced, disabled, incarcerated after age 15, and reported fewer violent behaviors. Remission was significantly more strongly associated among women than men with greater age, emergency room visits, trauma and less with schizotypal personality. Although women were twice as likely to be diagnosed with PTSD, there were no significant gender differences in the proportions who experienced remission. Remission was associated with diverse sociodemographic and clinical disadvantages among both men and women but only four were statistically significantly different between genders.

Does Street Outreach Engage Its Intended Target Population? Clinical Experience in the Veteran's Health Administration Homeless Service Programs.

OBJECTIVE: Clinical street outreach programs serve people experiencing unsheltered homelessness, who have been shown to have greater medical and psychiatric comorbidities, and increased social and financial challenges. However, outreach programs may struggle in practice to engage the most vulnerable of these individuals. METHODS: Data from the Veterans Health Administration's (VHA's) Homeless Operations Management System (HOMES) from 2018 to 2019 (N = 101,998) were used to compare sociodemographic, clinical, and financial characteristics of literally homeless veterans contacted through street outreach to those who were self-referred or clinic-referred. RESULTS: Veterans engaged through street outreach reported substantially more days of unsheltered homelessness in the past month (mean (M) = 11.18 days, s.d.=13.8) than the clinic-referred group (M = 6.75 days, s.d.=11.1), and were more likely to have spent the past 30 days unsheltered (RR = 2.23). There were notably few other differences between the groups. CONCLUSION: Despite epidemiologic evidence in the literature showing higher medical, psychiatric, and social and financial vulnerabilities among unsheltered homeless individuals, our street outreach group was not found to be any worse off on such variables than the clinic-referred or self-referred groups, other than increased time unsheltered. Outreach workers seem to engage more unsheltered individuals, but do not necessarily engage those with such severe vulnerabilities. Dedicated outreach program funding, training, and support are needed to support street outreach to those with the most severe problems.

Who Uses Veterans Mental Health Services?: A National Observational Study of Male Veteran and Nonveteran Mental Health Service Users.

ABSTRACT: Mental health (MH) research among veterans receiving services from the Veterans Health Administration (VHA) is extensive and growing and informs many clinical practice guidelines. We used nationally representative survey data to examine the generalizability of this extensive body of research by comparing sociodemographic and clinical characteristics of male veteran veterans health service (VHS) users (n = 491) with veteran non-VHS users (n = 840) and nonveteran (n = 6300) MH service users. VHS users were older, more often reported Black race, and less likely to have private or Medicaid insurance, but had similar prevalence of psychiatric or substance use disorder diagnoses but with a greater prevalence of posttraumatic stress disorder (PTSD). VHS users reported higher rates of medical diagnoses, pain interference, and poorer physical and MH status. These results suggest that VHA MH research may be reasonably generalizable to US mental health service users with caveats regarding age, PTSD diagnosis, pain, and racial distribution.

Personality and Body Mass Index in U.S. Military Veterans: Results from the National Health and Resilience in Veterans Study.

The relationship between the "Big 5" personality dimensions and body mass index (BMI) were examined in a nationally representative sample (National Health and Resilience in Veterans Study) of male and female U.S. military veterans. Multivariable analyses were conducted to evaluate gender-specific associations between personality factors and BMI. Among male veterans, greater extraversion was associated with higher BMI, (ß = 0.18), while lower conscientiousness (ß = -0.18), agreeableness (ß = -0.18), and emotional stability (ß = -0.17) were associated with lower BMI. Among female veterans, only greater consciousness was associated with lower BMI. These associations were robust to effects of age, physical activity, depression, and posttraumatic stress disorder. The "Big 5" personality dimensions are differentially associated with BMI in male and female veterans. While conscientiousness was associated with lower BMI in both male and female veterans, three additional personality dimensions were linked to BMI in male veterans. Implications of these findings for obesity management are discussed.

Psychiatric Multimorbidity in a Specialized Program for Severely Mentally Ill Veterans.

It has been suggested that psychiatric multimorbidity may better characterize severely impaired psychiatric patients than individual severe mental illness (SMI) diagnoses, and that these patients may be better served by centers offering integrated co-located, psychiatric and social services than in conventional clinics providing one-to-one care. We tested the hypothesis that multimorbidity is a critical characteristic of Veterans treated at a co-located multi-service Veteran's Health Administration (VHA) program originally established to treat Veterans living with SMI. Administrative data from the VA Connecticut Health Care System from fiscal year 2012 were used to compare veterans using diverse mental health and social services at the Errera Community Care Center (ECCC), an integrated "one-stop shop" for SMI veterans, and those seen exclusively at standard outpatient mental health clinics. Bivariate and multiple logistic regression analyses were used to compare groups on demographic characteristics, psychiatric and medical diagnoses, service utilization, and psychotropic medication fills. Results: Of the 11,092 veterans included in the study, 2281 (20.6%) had been treated at the ECCC and 8811 (79.4%) had not. Multivariable analysis highlighted the association of treatment in the ECCC and younger age, lower income, homelessness, and especially multimorbidity including both multiple substance use and multiple psychiatric diagnoses. Programs originally designed to address the diverse needs of patients living with SMI and homelessness may be usefully characterized as treating patients with psychiatric multimorbidity, a term of greater clinical relevance. Effectiveness research is needed to evaluate the one-stop shop approach to their treatment.

Social determinants of mental health care systems: intensive community based Care in the Veterans Health Administration.

BACKGROUND: Since deinstitutionalization in the 1950s-1970s, public mental health care has changed its focus from asylums to general hospitals, outpatient clinics and specialized community-based programs addressing both clinical and social determinants of mental health. Analysis of the place of community-based programs within a comprehensive health system such as the Veterans Health Administration (VHA) may illuminate the role of social forces in shaping contemporary public mental health systems. METHODS: National VHA administrative data were used to compare veterans who exclusively received outpatient clinic care to those receiving four types of specialized community-based services, addressing: 1) functional disabilities from severe mental illness (SMI), 2) justice system involvement, 3) homelessness, and 4) vocational rehabilitation. Bivariate comparisons and multinomial logistic regression analyses compared groups on demographics, diagnoses, service use, and psychiatric prescription fills. RESULTS: An hierarchical classification of 1,386,487 Veterans who received specialty mental health services from VHA in Fiscal Year 2012, showed 1,134,977 (81.8%) were seen exclusively in outpatient clinics; 27,931 (2.0%) received intensive SMI-related services; 42,985 (3.1%) criminal justice services; 160,273 (11.6%) specialized homelessness services; and 20,921 (1.5%) vocational services. Compared to those seen only in clinics, veterans in the four community treatment groups were more likely to be black, diagnosed with HIV and hepatitis, had more numerous substance use diagnoses and made far more extensive use of mental health outpatient and inpatient care. CONCLUSIONS: Almost one-fifth of VHA mental health patients receive community-based services prominently addressing major social determinants of health and multimorbid substance use disorders.

Impact of cannabis on non-medical opioid use and symptoms of posttraumatic stress disorder: a nationwide longitudinal VA study.

BACKGROUND: Multiple states have authorized cannabis as an opioid substitution agent and as a treatment for posttraumatic stress disorder (PTSD). OBJECTIVES: This study sought to investigate the relationship between cannabis use, non-medical opioid use, and PTSD symptoms among U.S. veterans. METHODS: From 1992-2011, veterans admitted to specialized intensive PTSD treatment participated in a national evaluation with assessments at intake and four months after discharge. Participants with non-medical opioid use ≥ 7 days during the 30 days preceding admission were divided into two groups: those with cannabis use ≥ 7 days, and those without cannabis use. These two groups were compared on measures of substance use and PTSD symptoms at baseline and 4-months outpatient follow-up. We hypothesized that, at both assessments, the group with baseline cannabis use would show less non-medical opioid use and less severe PTSD symptoms. RESULTS: Of 1,413 veterans with current non-medical opioid use, 438 (30.3%) also used cannabis, and 985 (69.7%) did not. At baseline, veterans with concurrent non-medical opioid and cannabis use had slightly fewer days of non-medical opioid use (p < .005; d = -0.16), greater use of other substances (p < .0001) and more PTSD symptoms (p = .003; d = 0.16), compared to veterans who used non-medical opioids but not cannabis. At follow-up, substance use or PTSD symptoms did not significantly differ. CONCLUSION: Cannabis use was not associated with a substantial reduction of non-medical opioid use, or either improvement or worsening of PTSD symptoms in this population. Hence, these data do not encourage cannabis use to treat either non-medical opioid use or PTSD.

Current drinking patterns in US veterans with a lifetime history of alcohol use disorder: Results from the National Health and Resilience in Veterans Study.

Background: Although more than 40% of US military veterans have lifetime histories of alcohol use disorder (AUD), little is known about the prevalence and correlates of current drinking patterns (i.e., abstinent, subthreshold, hazardous drinking) in this population. Objectives: To characterize the prevalence and key correlates of abstinence, subthreshold drinking, and hazardous drinking in a nationally representative sample of US veterans with lifetime AUD. Methods: Data from 1,282 veterans with lifetime AUD who participated in the National Health and Resilience in Veterans Study were analyzed using analyses of variance, chi-square analyses, and multinomial regression models. Results: Of the 1,282 veterans with lifetime AUD (of which 94.7% were males), 674 (48.2%) were past-year subthreshold drinkers, 317 (28.0%) were abstinent and 291 (23.8%) were hazardous drinkers. Abstinent veterans were older, less educated, less socially engaged, and had higher levels of religiosity than subthreshold and hazardous drinkers. They were also more likely to smoke, screen positive for PTSD, reported greater somatic symptoms than subthreshold drinkers, and had more physical difficulties and lifetime trauma than hazardous drinkers. Subthreshold drinkers were more likely than hazardous drinkers to be female and report physical health problems and less likely to smoke and be depressed. Conclusion: More than three-quarters of US veterans with lifetime AUD are currently abstinent or subthreshold drinkers. Factors associated with abstinence included older age, health problems, religiosity and social engagement. Results suggest a "J-shaped" relationship between current drinking patterns and health and psychosocial factors in veterans, with subthreshold drinkers generally having better health than abstinent and hazardous drinkers.

Gender Difference in Substance Use and Psychiatric Outcomes Among Dually Diagnosed Veterans Treated in Specialized Intensive PTSD Programs.

OBJECTIVES: Posttraumatic stress disorder (PTSD) is a problem of growing importance among female veterans, which is especially challenging when accompanied by comorbid substance use disorder (SUD). Since women are still a small minority of Veterans Health Administration (VHA) patients, there is concern that outcomes among dually diagnosed women may be worse than among men. METHOD: National program evaluation data were collected at admission and 4 months after discharge from 7,074 dually diagnosed veterans including 203 women (2.9%) treated at 57 specialized intensive VHA PTSD treatment programs between 1993 and 2011. Multiple regression was used to compare clinical change in women and men adjusting for baseline differences. RESULTS: Women showed no significant differences from men in measures of substance use or total PTSD symptoms at admission although they were more likely to have experienced sexual trauma and less likely to report combat exposure. With adjustment for these differences, there were no significant gender differences in length of stay, satisfaction with treatment, or measures of change in substance use or total PTSD symptoms 4 months after discharge. Reductions in an index of days of substance use was associated with reduction in total PTSD symptoms among both women (R = 0.33; p = .01) and men (R = 0.44, p < .0001) with no significant gender difference. CONCLUSION: No significant gender differences were observed in substance use or PTSD outcomes, despite the extreme minority status of women in VHA programs. Highly vulnerable women can benefit as much as men, even when treatment is not formally tailored to address gender-specific needs.

Comparing Outcomes of Women-Only and Mixed-Gender Intensive Posttraumatic Stress Disorder Treatment for Female Veterans.

Although most female veterans treated in specialized intensive Veterans Health Administration (VHA) posttraumatic stress disorder (PTSD) programs receive services in settings in which over 95% of participants are men, two programs include only women. Whether outcomes for women with PTSD are superior in women-only programs has not been evaluated. National program evaluation data on 1,357 women veterans from 57 sites were collected at program entry and 4 months after discharge. With adjustment for differences in baseline characteristics, outcomes of women in two women-only programs (n = 469) were compared with those from 55 mixed-gender programs (n = 888), using mixed models with random effect for site. The primary outcome was total PTSD symptom level, with supplementary information on PTSD assessment subscales, substance use, and other outcomes. At program entry, female veterans in women-only programs had lower scores on measures of total PTSD symptoms, p = .013, d = -0.24, and on several subscales. Adjusting for these differences, there were no significant differences between program types in terms of PTSD total score or scores on secondary measures. In women-only programs, veterans had longer lengths of stay and were rated by their clinicians to have a higher level of commitment to therapy at discharge. Thus, women-only programs did not show superior outcomes; however, compared to participants in mixed-gender programs, those in women-only programs had longer lengths of stay, higher levels of commitment to therapy, and were more likely to participate in posttreatment outcome assessments following discharge.

Spanish Abstracts by Asociación Chilena de Estrés Traumático (ACET) La comparación entre el tratamiento intensivo del trastorno de estrés postraumático para mujeres solamente o de género mixto para mujeres veteranas PROGRAMAS TEPT PARA MUJERES SOLAMENTE O MIXTOS (Pg 1) PROGRAMAS DE TEPT SEVERO SOLO PARA MUJERES (Pg 2) Aunque la mayoría de las mujeres veteranas tratadas en programas intensivos de la Administración de Salud de los Veteranos (VHA en su sigla en inglés) para el trastorno del estrés postraumático (TEPT), reciben servicios en contextos en los cuales 95% de los participantes son hombres, dos programas incluyen solo mujeres. No se ha evaluado si los resultados para las mujeres con TEPT son superiores en los programas solamente para mujeres. Los datos de una evaluación nacional del programa en 1,357 mujeres veteranas pertenecientes a 57 lugares fueron recolectados al inicio y luego de 4 meses del alta. Al ajustar las diferencias en las características de la línea base, los resultados de las mujeres en dos programas solo para mujeres (n = 469) fueron comparados con aquellos de los 55 programas con género mixtos (n = 888), usando modelos mixtos con efecto aleatorio por sitio. El resultado principal fue el nivel total de la sintomatología TEPT, con información suplementaria en las subescalas de evaluación del TEPT, uso de sustancias, y otros resultados. Al inicio del programa, las veteranas mujeres tenían puntajes más bajos en las medidas del total de los síntomas del TEPT, p = .013, d = -0.24, y en varias subescalas. Al ajustar estas diferencias, no hubo diferencias significativas entre los tipos de programas en términos del puntaje total del TEPT o los puntajes en las medidas secundarias. En los programas solo para mujeres, las veteranas permanecieron por más tiempo y fueron evaluadas por sus terapeutas como teniendo un más alto nivel de compromiso con la terapia al momento del alta. Así, los programas con solo mujeres no mostraron resultados superiores; sin embargo, comparados a los participantes en los programas con género mixtos, aquellos programas con mujeres solamente tuvieron mayor permanencia, más altos niveles de compromiso con la terapia, y fueron más propensas a participar en las evaluaciones de los resultados posterior al tratamiento luego del alta.

Prevalence and multi-morbid correlates of homelessness among veterans with HIV infection nationally in the veterans health administration.

This study sought to evaluate the risk of homelessness among HIV positive users of Veterans Health Administration (VHA) services. National VHA administrative data from Fiscal Year (FY) 2012 (N = 5.4 million) were used to: (1) evaluate the unadjusted risk of homelessness among veterans with HIV; (2) identify common multi-morbid correlates of both HIV diagnosis and homelessness; and (3) to assess the independent risk of homelessness among veterans with HIV after adjusting for risk factors common to both conditions. Veterans with HIV were at substantial risk of homelessness (OR = 4.23 (95% CI 4.07-4.39)). However, with adjustment for shared co-variates (especially black race, low income, substance use, and psychiatric disorders) this risk declined substantially to 1.41 (95% CI 1.35-1.48). The high risk of homelessness among HIV positive veterans is largely attributable to multi-morbid risk factors common to both HIV and homelessness rather than to an independent effect of HIV, and requires multi-dimensional preventive psychosocial interventions.

Polysubstance Use Among Veterans in Intensive PTSD Programs: Association With Symptoms and Outcomes Following Treatment.

Objective: A distinct group of patients has recently been described who experience polysubstance use disorder characterized by use of multiple addictive substances. This study examines baseline characteristics and longitudinal outcomes of a group of such patients in specialized intensive Veterans Health Administration posttraumatic stress disorder (PTSD) programs and followed 4 months after discharge. Methods: Patients with diagnosed PTSD or subsyndromal PTSD and who used a single substance at baseline were compared to those who used two or three and more than three different addictive substances on measures of PTSD symptom severity and functioning. Comparisons were also adjusted for differences in total days of any substance use and other potentially confounding factors. Patients were reclassified according to the number of substances used at follow-up and again compared on symptoms and functioning. Results: Bivariate analysis of baseline data (N = 8,240) showed frequent polysubstance use (n = 3,695, 44.8% of the sample) and that use of greater numbers of substances was associated with more severe PTSD symptoms as well as more total days of substance use. At follow-up after treatment, 58.2% of the original sample (n = 4,797) was assessed. Polysubstance use was less frequent (n = 756, 15.8% of the follow-up sample), but showed a similar association with more severe symptoms, although differences were attenuated after adjusting for total days of substance use. Conclusions: Polysubstance use, conceptualized within the multimorbidity perspective, is associated with increased severity of PTSD symptoms among veterans with dual diagnoses requiring complex interventions, the evaluation of which will require innovative trial designs.