Alcohol-Related Problems As Moderators of PTSD Symptom Change During Use of a Web-Based Intervention for Hazardous Drinking and PTSD.

OBJECTIVE: Alcohol-related problems (e.g., physical, interpersonal, intrapersonal, impulse control, social responsibility) can have an impact on posttraumatic stress disorder (PTSD) symptoms during treatment. Evidence-based online self-help tools exist to target alcohol use and related problems and co-occurring PTSD symptoms. It is unknown to what degree individuals with varying alcohol-related problems respond differently to web-based interventions for hazardous alcohol use and PTSD. The current study evaluated specific alcohol-related problems as potential moderators of PTSD symptom changes during the VetChange online intervention while controlling for average daily alcohol use, gender, race, and age. METHOD: We conducted a secondary analysis of a randomized controlled trial that included 600 post-9/11 veterans (518 men and 82 women). Mixed-effects regression models of alcohol-related problems on PTSD severity scores over time were performed separately in an initial intervention group (IIG; n = 404) and a delayed intervention group (DIG; n = 196) that was used as a comparison condition. RESULTS: Interpersonal problems emerged as a moderator of PTSD symptom changes in IIG such that veterans endorsing greater interpersonal problems demonstrated larger reductions in PTSD symptoms throughout VetChange. There were no significant moderation effects in DIG. Non-White veterans reported significantly higher PTSD symptoms during VetChange. Post hoc analyses indicated that veterans with higher interpersonal problems were more likely to engage in online intervention content focused on identifying high-risk drinking situations and coping with symptoms. CONCLUSIONS: Findings imply that veterans reporting alcohol-related interpersonal problems may benefit the most from, and be more motivated to use, online interventions for hazardous alcohol use and PTSD symptoms.

Network analysis of reasons for and against changing alcohol use among veterans engaged in a web-based intervention for hazardous drinking and PTSD symptoms.

Better understanding of reasons for and against change may be an effective strategy for supporting drinking reduction or abstinence among Iraq and Afghanistan veterans. The current study explored connections between reasons for and against changing hazardous alcohol use, as well as the relative importance of a given reason. Data from 366 veterans (86% male, 77% White) between the ages of 21 and 56 (M = 31.8, SD = 7.3) were obtained from a nationwide web-based alcohol and posttraumatic stress disorder randomized clinical trial. Participant-generated reasons for and against change were used to estimate two separate network models. The network of motives for changing alcohol use was generally well connected with predominately positive associations. Veterans reporting motivation to change alcohol use to improve functioning, enhance self-worth, and decrease alcohol-related consequences tended to have higher than average motivation to reduce or abstain from alcohol use. Alternatively, the network structure of motives against changing alcohol use demonstrated a nearly equal number of positive and negative associations. Whereas reasons to cope and sleep may imply higher than average motivation to continue drinking the same, veterans reporting reasons to reduce anxiety and have fun tended to have lower than average motivation to continue drinking. The current study may inform content modifications to self-help tools to more quickly and effectively target users' motivations from the beginning. Capitalizing on intervention users' motivations early may promote sustained engagement or improve therapeutic impact among those who only use the intervention for a short period of time.

Comparing substance use treatment initiation and retention between telehealth delivered during COVID-19 and in-person treatment pre-COVID-19.

BACKGROUND AND OBJECTIVES: A large portion of veterans referred to substance use disorder (SUD) treatment do not attend their first appointment or leave treatment prematurely. Telehealth options may increase access to care and treatment attendance. This study compared treatment initiation and retention between in-person treatment pre-COVID-19 and telehealth treatment during COVID-19 in a VA hospital outpatient alcohol and drug treatment clinic. METHODS: Electronic health record data were collected on 373 veterans out of 481 referrals. Mixed logistic and negative binomial regression models were used for estimating the effect of treatment modality on treatment initiation and retention, respectively. RESULTS: The odds of initiating treatment were 2.6 times greater when referred to a telehealth appointment during COVID-19 compared to an in-person appointment pre-COVID-19. Months retained in treatment postinitiation was similar between treatment modalities. Each month in treatment corresponded to a subsequently lower rate of treatment session attendance and by the fourth month, the average number of sessions attended was significantly lower for those receiving in-person treatment compared to those receiving telehealth treatment. CONCLUSIONS AND SCIENTIFIC SIGNIFICANCE: The odds of initiating SUD treatment and rate of treatment attendance over time was greater for services delivered via telehealth during COVID-19 compared to in-person pre-COVID-19. Extending telehealth services as an option for individual and group SUD treatment may promote treatment initiation and potentially higher rate of attendance over time. This study provides additional evidence for the feasibility and utility of rapidly expanding telehealth for veterans seeking outpatient substance use treatment.

Life satisfaction following treatment-related reductions in alcohol use and PTSD symptoms: Results from VetChange.

OBJECTIVE: Rates of hazardous alcohol consumption and co-occurring posttraumatic stress disorder (PTSD) are high among returning combat veterans and may adversely affect satisfaction with life (SWL). Improving life satisfaction represents a potential secondary outcome of web-based interventions for alcohol use and PTSD. Understanding the relationship between intervention targets and SWL may help inform future interventions and provide clarity regarding how improvements are manifesting. We examined returning veterans enrolled in VetChange, an evidence-based web intervention for co-occurring alcohol use and PTSD, to determine changes in SWL over time and as a function of changes in alcohol consumption and PTSD symptoms. METHOD: Participants included 222 returning veterans who reported hazardous drinking. Veterans engaged in a nationwide implementation of VetChange and completed measures of average weekly drinks (AWD), PTSD symptoms, and SWL at baseline, 1, 3, and 6 months. We investigated the effects of changes in PTSD and AWD between baseline and 1 month on SWL over 6 months using linear mixed-effects modeling. RESULTS: Across all veterans, SWL increased by 19% over 6 months. AWD and PTSD decreased between baseline and 1 month, but only change in PTSD predicted changes in SWL over the 6-month interval. CONCLUSIONS: Reductions in PTSD symptoms within the first month of intervention use, and not reductions in drinking, predicted increased SWL over 6 months. SWL is an important marker for recovery and related quality of life, and an important assessment and intervention target of web-based interventions. Interventions may also target SWL, as improvements in SWL promote future recovery and sustained improvement. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Web-Based Problem-solving Training With and Without Peer Support in Veterans With Unmet Mental Health Needs: Pilot Study of Feasibility, User Acceptability, and Participant Engagement.

BACKGROUND: eHealth tools have the potential to meet the mental health needs of individuals who experience barriers to accessing in-person treatment. However, most users have less than optimal engagement with eHealth tools. Coaching from peer specialists may increase their engagement with eHealth. OBJECTIVE: This pilot study aims to test the feasibility and acceptability of a novel, completely automated web-based system to recruit, screen, enroll, assess, randomize, and then deliver an intervention to a national sample of military veterans with unmet mental health needs; investigate whether phone-based peer support increases the use of web-based problem-solving training compared with self-directed use; and generate hypotheses about potential mechanisms of action for problem-solving and peer support for future full-scale research. METHODS: Veterans (N=81) with unmet mental health needs were recruited via social media advertising and enrolled and randomized to the self-directed use of a web-based problem-solving training called Moving Forward (28/81, 35%), peer-supported Moving Forward (27/81, 33%), or waitlist control (26/81, 32%). The objective use of Moving Forward was measured with the number of log-ins. Participants completed pre- and poststudy measures of mental health symptoms and problem-solving confidence. Satisfaction was also assessed post treatment. RESULTS: Automated recruitment, enrollment, and initial assessment methods were feasible and resulted in a diverse sample of veterans with unmet mental health needs from 38 states. Automated follow-up methods resulted in 46% (37/81) of participants completing follow-up assessments. Peer support was delivered with high fidelity and was associated with favorable participant satisfaction. Participants randomized to receive peer support had significantly more Moving Forward log-ins than those of self-directed Moving Forward participants, and those who received peer support had a greater decrease in depression. Problem-solving confidence was associated with greater Moving Forward use and improvements in mental health symptoms among participants both with and without peer support. CONCLUSIONS: Enrolling and assessing individuals in eHealth studies without human contact is feasible; however, different methods or designs are necessary to achieve acceptable participant engagement and follow-up rates. Peer support shows potential for increasing engagement in web-based interventions and reducing symptoms. Future research should investigate when and for whom peer support for eHealth is helpful. Problem-solving confidence should be further investigated as a mechanism of action for web-based problem-solving training. TRIAL REGISTRATION: ClinicalTrials.gov NCT03555435; http://clinicaltrials.gov/ct2/show/NCT03555435.

Health outcomes among detoxification patients: The role of chronic pain.

Understanding associations between chronic pain and health outcomes among detoxification patients may help improve treatment outcomes and abstinence rates. Exercise is a modifiable lifestyle factor that may reduce the effect of pain on outcomes in this population. The current study examined whether baseline pain, exercise, and their interaction were associated with psychiatric and medical severity, and abstinence self-efficacy, over six months following detoxification. Participants were veteran patients in alcohol or opioid detoxification treatment (N = 298) who were followed for six months (91.1%). Psychiatric severity and abstinence self-efficacy improved over the six months after detoxification; medical severity was stable. More intense pain at baseline was associated with poorer psychiatric and medical outcomes during the post-detoxification period. Regular exercise at baseline was associated with less psychiatric severity and more abstinence self-efficacy during the post-detoxification period. A significant pain by exercise interaction at baseline indicated that regular exercise was associated with more abstinence self-efficacy during the post-detoxification period only among participants with less intense pain. Pain by exercise interactions was not significant for the outcomes of psychiatric and medical severity. Among detoxification patients, exercise may be beneficial in improving outcomes among those with less intense pain.

Rates and predictors of brief intervention for women veterans returning from recent wars: Examining gaps in service delivery for unhealthy alcohol use.

BACKGROUND: Approximately one in four women veterans accessing the Department of Veterans Affairs (VA) engage in unhealthy alcohol use. There is substantial evidence for gender-sensitive screening (AUDIT-C = 3) and brief intervention (BI) to reduce risks associated with unhealthy alcohol use in women veterans; however, VA policies and incentives remain gender-neutral (AUDIT-C = 5). Women veterans who screen positive at lower-risk-level alcohol use (AUDIT-C = 3 or 4) may screen out and therefore not receive BI. This study aimed to examine gaps in implementation of BI practice for women veterans through identifying rates of BI at different alcohol risk levels (AUDIT-C = 3-4; =5-7; =8-12), and the role of alcohol risk level and other factors in predicting receipt of BI. METHODS: From administrative data (2010-2016), we drew a sample of women veterans returning from recent wars who accessed outpatient and/or inpatient care. Of 869 women veterans, 284 screened positive for unhealthy alcohol use at or above a gender-sensitive cut-point (AUDIT-C ≥ 3). We used chart review methods to abstract variables from the medical record and then employed logistic regression comparing women veterans who received BI at varying alcohol risk levels to those who did not. RESULTS: While almost 60% of the alcohol positive-risk sample received BI, among the subset of women veterans who screened positive for lower-risk alcohol use (57%; AUDIT-C = 3 or 4) only 34% received BI. Nurses in primary care programs were less likely to deliver BI than other types of clinicians (e.g., physicians, psychologists, social workers) in mental health programs; further, nurses in women's health programs were less likely to deliver BI than other types of clinicians in mixed-gender programs; Those women veterans with more medical problems were no more likely to receive BI than those with fewer medical problems. CONCLUSIONS: Given that women veterans are a rapidly growing veteran population and a VA priority, underuse of BI for women veterans screening positive at a lower-risk level and those with more medical comorbidities requires attention, as do potential gaps in service delivery of BI in primary care and women's health programs. Women veterans health and well-being may be improved by tailoring screening for a younger cohort of women veterans at high-risk for, or with co-occurring disorders and then training providers in best practices for BI implementation.

Differential alcohol treatment response by gender following use of VetChange.

OBJECTIVE: Proportionally more women use online alcohol interventions but also report less robust treatment outcomes compared to men. Less is known about outcome disparities among veteran women, who are a growing demographic nationally. The current study examined gender differences among returning veteran men and women who used VetChange, a web-based intervention for hazardous drinking and posttraumatic stress symptoms (PTSS). METHOD: Using data from a nationwide implementation study of returning combat veterans (n = 222), we performed hierarchical linear modeling to examine gender differences in alcohol and PTSS outcomes over six months following VetChange registration. Additional analyses examined gender differences in proportional changes in hazardous drinking and at each assessment point. RESULTS: Returning veterans reported significant decreases in alcohol use and PTSS over time, yet men evidenced significantly greater reduction in average weekly drinks and drinks per drinking day compared to women. Follow up analyses indicated that women were significantly less likely than men to achieve low-risk drinking by one month post-registration. Proportional change in alcohol use yielded marginal and non-significant trends that were, nonetheless, consistent with the overall pattern of gender differences. CONCLUSION: These results contribute to emerging literature suggesting that women use online alcohol use interventions at proportionately higher rates than do men, but do not reduce their drinking as much as men. There are a number of potential content changes that could improve outcomes for returning veteran women using online interventions, and data-driven adaptations based on stakeholder input are recommended.

Public implementation of a web-based program for veterans with risky alcohol use and PTSD: A RE-AIM evaluation of VetChange.

BACKGROUND: Evidence-based web and mobile interventions are available for a range of mental health concerns. Little is known about how self-administered web interventions are used outside of controlled research trials, and there is a critical need to empirically examine real-world public implementation of such programs. To this end, the aim of the current study was to evaluate and describe outcomes of a nationwide public implementation of VetChange, a self-administered web intervention for veterans with problematic alcohol use and symptoms of PTSD. METHOD: The study used the RE-AIM framework to organize outcomes along five key dimensions: reach, effectiveness, adoption, implementation, and maintenance. This naturalistic observation study included program use information for all who registered an account with VetChange during the 2-year study period and who self-identified as a returning veteran. We collected program use data automatically via normal website operation; a subset of program users provided additional self-report outcome data. The study used linear multilevel mixed modeling to evaluate changes in alcohol use and PTSD symptoms over a six-month postregistration period. RESULTS: VetChange successfully reached a large, geographically diverse sample of returning veterans with risky drinking and PTSD symptoms. Despite variable, overall modest, rates of intervention use over time, registered users demonstrated significant improvements in drinking, PTSD, and quality of life, and participants maintained these outcomes at a six-month follow-up. CONCLUSIONS: Given the observed low cost per acquisition, positive clinical outcomes, and the potential to produce long-term cost savings through reduced health care burden associated with chronic alcohol use disorder and PTSD, this study demonstrates how web-based interventions can provide public health benefits and reduce long-term health care costs.

Understanding motives for and against hazardous drinking and change among returning veterans.

The prevalence of hazardous drinking is elevated among returning veterans of Iraq and Afghanistan wars, particularly among returning veterans and those with co-occurring posttraumatic stress disorder (PTSD) symptoms. Understanding the reasons for drinking as well as motivations for change can tremendously improve intervention efforts. Unfortunately, little is currently known regarding the motivations that might facilitate or hinder change among returning veterans. In the current study, we examined returning veterans' reasons to change or not change drinking through analysis of responses to an open-ended decisional balance exercise. We included 366 returning veterans selected from a larger sample of returning veterans enrolled in a web-based randomized-controlled trial of an online intervention for alcohol use and PTSD. We used qualitative content analysis to systematically classify responses into categories through identification of common themes. Top reasons to change/reduce drinking included reducing negative physical effects, improve finances, and expected social/interpersonal benefits of reduction or abstaining. Top reasons to continue drinking/not change included facilitation of social interaction, promote sleep, and reduce tension. The current study adds to our phenomenological understanding of motivations for and against changing drinking among returning veterans. Whereas many motives were consistent with those of nonveteran samples, others appear to distinguish, and are uniquely salient among, returning veterans (e.g., to manage sleep and PTSD symptoms). These results provide insight into key assessment and intervention points regarding hazardous drinking among returning veterans. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Changes in alcohol use, PTSD hyperarousal symptoms, and intervention dropout following veterans' use of VetChange.

OBJECTIVE: Veterans of Iraq and Afghanistan conflicts report high rates of drinking, PTSD, and low rates of treatment engagement. Web interventions may help address unmet treatment need; unfortunately, little is known regarding outcomes or adherence to these interventions. In this study, we examined VetChange treatment outcomes and downstream effects of alcohol reduction on PTSD symptoms and intervention dropout rates over six months. METHOD: Participants included 222 veterans (77.5% men, 78.3% White) between 22 and 57 (mean age = 36.02, SD = 7.19). All VetChange users completed a brief alcohol assessment and received personal feedback, then received full access to intervention content including psychoeducation; motivational and cognitive-behavioral modules for relapse prevention, goal-setting, social support, stress, anger, and sleep management; and mood and drink tracking. Veterans completed self-report measures of alcohol use and PTSD symptoms at baseline, one, three, and six months. RESULTS: Alcohol use dropped by 43% over six months, p < .001, with the largest decrease occurring within the first month. Greater alcohol reduction in the first month predicted higher subsequent PTSD hyperarousal severity. Over half (52.3%) dropped out by month one, followed by 12.2% and 37.6% by months three and six. Hyperarousal symptoms, hypervigilance specifically, but not alcohol use predicted subsequent intervention dropout. CONCLUSION: These results highlight the importance of attending to the association between alcohol use and PTSD symptom change in web-based interventions for veterans. The fact that hyperarousal symptoms were associated with elevated risk for intervention dropout signifies the need for online intervention refinement aimed at tailoring content to time-varying symptom presentations.

Randomized controlled trial of enhanced telephone monitoring with detoxification patients: 3- and 6-month outcomes.

Telehealth interventions have the potential to deter repeated detoxification episodes and improve outcomes. Using a sample of 298 detoxification inpatients, this randomized controlled trial compared Enhanced Telephone Monitoring (ETM) to usual care (UC) on the primary outcome of reducing subsequent detoxification, and secondary outcomes of linking patients to addiction treatment and mutual-help, and patients' experience of improved substance use and mental health outcomes. At the 3-month follow-up (i.e., at the end of the ETM intervention), compared to UC patients, ETM patients were significantly less likely to have received additional inpatient detoxification, but no more likely to have participated in 12-step groups or received outpatient addiction treatment. Even so, ETM patients had better alcohol, drug, and mental health outcomes. In contrast, at the 6-month follow-up, patients in ETM and UC generally did not differ on primary or secondary outcomes. Findings suggest that ETM deters additional detoxification episodes while the intervention is ongoing, but not after the intervention ends. Because telephone monitoring is low-intensity and low-cost, its extension over time may help reduce repeated detoxifications.

A randomized controlled trial of a gender-focused addiction model versus 12-step facilitation for women veterans.

BACKGROUND AND OBJECTIVES: Substance use disorder (SUD) has increased among women, including military veterans, yet SUD treatment was historically designed for males. This randomized controlled trial compared 12 individual sessions of a gender-focused SUD recovery model, A Woman's Path to Recovery (WPR) to an evidence-based, non-gender-focused SUD model, 12-Step Facilitation (TSF) for 66 women veterans with current severe SUD. METHODS: The primary outcome was substance use; secondary outcomes were associated problems (e.g., psychological); coping skills, and 12-step attendance, with assessment at baseline, end-of-treatment, and 3-month followup. RESULTS: Substance use decreased over time, with no difference between conditions. Decreases occurred from baseline to end-of-treatment and baseline to followup and, for drug severity, also from end-of-treatment to followup. Effect sizes were large for alcohol and medium otherwise. Secondary outcomes were largely consistent with this pattern of improvement. Urinalysis/breathalyzer supported self-report. Treatment attendance was 62% for WPR and 57% for TSF (not significantly different). Twelve-step group attendance, surprisingly, did not increase in either condition. DISCUSSION AND CONCLUSIONS: WPR provides a useful addition to women's SUD treatment options, with outcomes no different than an established evidence-based model, TSF. Both showed positive impact on substance use and related areas. Our lack of differences based on gender-focus may reflect women veterans being acculturated to a male military environment. Limitations include lack of an untreated control, a sample limited to veterans, and use of a large effect size for power assumptions. SCIENTIFIC SIGNIFICANCE: This is the first RCT of a gender-focused approach for women veterans with SUD. (Am J Addict 2018;27:210-216).

Web-based alcohol intervention for veterans: PTSD, combat exposure, and alcohol outcomes.

OBJECTIVE: The purpose of the current study was to evaluate the relationship between baseline levels of posttraumatic stress disorder (PTSD), combat exposure, and alcohol outcomes in a sample of Operation Enduring Freedom (OEF) and Operation Iraqi Freedom (OIF) veterans using a web-based self-management intervention (VetChange) for problem drinking. METHOD: The current study focuses on 523 veterans who participated in a larger randomized clinical trial. Analyses in the current study include (a) multivariable linear regression models to assess the relationship between PTSD, combat exposure, and alcohol variables at baseline, and (b) general linear models accounting for correlated data within subjects to analyze change over time for alcohol outcomes as a function of baseline PTSD symptoms, combat exposure, and covariates. RESULTS: There was a positive association between PTSD symptom severity and alcohol use and alcohol problem severity at baseline. However, participants with higher baseline PTSD symptoms demonstrated a significantly greater reduction in alcohol use during the intervention and a greater reduction in alcohol problems from baseline to 3-month follow-up. Combat exposure severity was positively associated with alcohol problems at baseline. However, veterans with higher exposure demonstrated a greater reduction in average weekly drinking between end of intervention and follow-up, and otherwise showed changes similar to participants with lower exposure. CONCLUSIONS: Higher levels of baseline PTSD symptoms and combat exposure severity did not prevent OEF/OIF veterans from achieving positive alcohol outcomes through participation in a self-management web intervention for problem drinking. (PsycINFO Database Record

Drinking goal choice and outcomes in a Web-based alcohol intervention: results from VetChange.

OBJECTIVES: The objectives of the paper are to describe characteristics of participants who chose moderation and abstinence drinking goals, and to examine post-treatment drinking outcomes based on patterns of goal choice during a Web-based alcohol intervention for returning U.S. Veterans. METHOD: We conducted a descriptive secondary analysis of a subsample of 305 of 600 Veterans who participated in a clinical trial of VetChange, an 8-module, cognitive-behavioural intervention. Participants self-selected abstinence or moderation drinking goals, initially at Module 3, and weekly during subsequent modules. Alcohol use and alcohol-related problems were measured using the Alcohol Use Disorders Identification Test (AUDIT), Quick Drink Screen (QDS), and Short Inventory of Problems (SIP-2R). RESULTS: Initial goal choices were 86.9% moderation and 13.1% abstinence. Approximately 20% of participants from each initial choice changed goals during the intervention; last goal choices were 68.6% moderation and 31.4% abstinence. Participants who initially chose moderation reported higher percent heavy drinking days at baseline; participants who initially chose abstinence were more likely to report recent substance abuse treatment and were older. Post-intervention levels of alcohol use and alcohol-related problems were significantly reduced in all goal-choice patterns (i.e., Moderation Only, Abstinence Only, Moderation to Abstinence, and Abstinence to Moderation; all measures p < 0.05 or less). Baseline drinking severity did not differentially relate to outcomes across goal-choice patterns. CONCLUSIONS: Participants in a Web-based alcohol intervention for returning U.S. Veterans demonstrated improvements in drinking regardless of whether they chose an abstinence or moderation drinking goal, and whether the goal was maintained or changed over the course of the intervention.

Patient and program factors that bridge the detoxification-treatment gap: a structured evidence review.

Although completion of detoxification (detox) and a successful transition from detox to substance use disorder (SUD) treatment and/or mutual-help groups are associated with better SUD outcomes, many patients do not complete detox or do not receive SUD care following detox. The purpose of this structured evidence review, summarizing data extraction on a yield of 26 articles, is to identify patient, program, and system factors associated with the outcomes of completion of alcohol detox and successful transitions from alcohol detox to SUD treatment and mutual-help group participation. The review found wide variability among studies in the rates at which patients complete a detox episode (45 to 95%) and enter SUD treatment or mutual-help groups after detox (14 to 92%). Within program factors, behavioral practices that contribute to both detox completion and transitioning to SUD care after detox entail involving the patient's family and utilizing motivational-based approaches. Such practices should be targeted at younger patients, who are less likely to complete detox. Although more studies using a randomized controlled trial design are needed, the evidence suggests that barriers to detox completion and transition to SUD care can be overcome to improve patient outcomes.

Temporal stability of DSM-5 posttraumatic stress disorder criteria in a problem-drinking sample.

The 5th edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) reformulated posttraumatic stress disorder (PTSD) based partially on research showing there were 4 main factors that underlie the symptoms of the disorder. The primary aim of this study was to examine the temporal stability of the DSM-5 factors as measured by the Posttraumatic Stress Disorder Checklist for DSM-5 (PCL-5; Weathers et al., 2010). Confirmatory factor analyses were conducted to examine the structure of DSM-5 PTSD, and temporal stability over 3 time points was examined to determine if the measure reflects a consistent construct over time. Our sample was 507 combat-exposed veterans of Iraq and Afghanistan who enrolled in an online intervention for problem drinking and combat-related stress (Brief et al., 2013). We administered the PCL-5 at baseline, 8-week postintervention, and 3-month follow-up assessments. The DSM-5 model provided an adequate fit to the data at baseline. Tests of equality of form and equality of factor loadings demonstrated stability of the factor structure over time, indicating temporal stability. This study confirmed the results of previous research supporting the DSM-5 model of PTSD symptoms (Elhai et al., 2012; Miller et al., 2013). This is the 1st study to demonstrate the temporal stability of the PCL-5, indicating its use in longitudinal studies measures the same construct over time.

Strategies to address participant misrepresentation for eligibility in Web-based research.

Emerging methodological research suggests that the World Wide Web ("Web") is an appropriate venue for survey data collection, and a promising area for delivering behavioral intervention. However, the use of the Web for research raises concerns regarding sample validity, particularly when the Web is used for recruitment and enrollment. The purpose of this paper is to describe the challenges experienced in two different Web-based studies in which participant misrepresentation threatened sample validity: a survey study and an online intervention study. The lessons learned from these experiences generated three types of strategies researchers can use to reduce the likelihood of participant misrepresentation for eligibility in Web-based research. Examples of procedural/design strategies, technical/software strategies and data analytic strategies are provided along with the methodological strengths and limitations of specific strategies. The discussion includes a series of considerations to guide researchers in the selection of strategies that may be most appropriate given the aims, resources and target population of their studies.

Web intervention for OEF/OIF veterans with problem drinking and PTSD symptoms: a randomized clinical trial.

OBJECTIVE: Veterans who served in Operation Enduring Freedom (OEF) and Operation Iraqi Freedom (OIF) commonly experience alcohol misuse and symptoms of posttraumatic stress disorder (PTSD) following their return from deployment to a war zone. We conducted a randomized clinical trial to evaluate the efficacy of a newly developed, 8-module, self-management web intervention (VetChange) based on motivational and cognitive-behavioral principles to reduce alcohol consumption, alcohol-related problems, and PTSD symptoms in returning combat veterans. METHOD: Six hundred participants, recruited through targeted Facebook ads, were randomized to either an Initial Intervention Group (IIG; n = 404) or a Delayed Intervention Group (DIG; n = 196) that waited 8 weeks for access to VetChange. Primary outcome measures were Drinks per Drinking Day, Average Weekly Drinks, Percent Heavy Drinking Days, and PTSD symptoms. Intent-to-treat analyses compared changes in outcome measures over time between IIG and DIG as well as within-group changes. RESULTS: IIG participants demonstrated greater reductions in drinking (p < .001 for each measure) and PTSD symptoms (p = .009) between baseline and end-of-intervention than did DIG participants between baseline and the end of the waiting period. DIG participants showed similar improvements to those in IIG following participation in VetChange. Alcohol problems were also reduced within each group between baseline and 3-month follow-up. CONCLUSIONS: Results indicate that VetChange is effective in reducing drinking and PTSD symptoms in OIF/OEF veterans. Further studies of VetChange are needed to assess web-based recruitment and retention methods and to determine VetChange's effectiveness in demographic and clinical sub-populations of returning veterans.

Web-Based Intervention for Returning Veterans with Symptoms of Posttraumatic Stress Disorder and Risky Alcohol Use.

A substantial number of military personnel who have served in Iraq (Operation Iraqi Freedom; OIF) and Afghanistan (Operating Enduring Freedom; OEF) develop symptoms of posttraumatic stress disorder (PTSD) in response to their military experiences and many of these same individuals will drink in a risky or problematic manner following deployment. If left untreated, PTSD symptoms and alcohol problems can become chronic and have a significant, negative impact on the lives of veterans, their families and communities. Further, OIF and OEF service members are often reluctant to seek treatment for mental health symptoms or alcohol problems secondary to stigma. In order to reach this population it is essential that new strategies and venues for delivering evidence-based care are explored. Web-based interventions are uniquely suited to this cohort of veterans in that they have the potential to reach a significant number of veterans who commonly use the Web and who might not otherwise receive care. This article will review the prevalence of PTSD and alcohol problems among OIF and OEF veterans, common barriers they experience with accessing care in traditional mental health settings, and what is known about the effectiveness of Web-based approaches for PTSD and alcohol problems. It also describes the components of a new Web-based intervention, developed by the authors, that uses motivational enhancement and cognitive-behavioral strategies to intervene with returning veterans who report PTSD symptoms and problem drinking. Recommendations for future directions in working with returning veterans with PTSD and alcohol problems will be offered.