Health correlates of experiential and behavioral avoidance among trauma-exposed veterans.

INTRODUCTION: Avoidance is a well-documented risk factor for poor mental and physical health outcomes. However, limited research has explored this relationship specifically among trauma-exposed veterans, a population known to be particularly prone to avoidance behavior. Conceptually, avoidance is often divided into two distinct but overlapping constructs - experiential avoidance (resisting distressing internal states) and behavioral avoidance (avoiding or changing experiences that elicit distress). In this exploratory survey study, we examined associations between behavioral and experiential avoidance and mental, physical, and cognitive functioning, as well as quality of life. METHODS: Veterans with a trauma history (N = 89) completed a 121-item survey containing validated assessments to examine several mental and physical health and wellness-related variables. Correlations between experiential avoidance and outcome measures, and behavioral avoidance and outcome measures, were explored. Multivariable linear regression analyses were conducted to explore the association between experiential and behavioral avoidance on mental health outcomes. In addition, we conducted exploratory analyses in which we investigated these correlations in those who screened positive for PTSD versus those who did not, and between different types of behavioral avoidance and major outcomes. RESULTS: Experiential avoidance was moderately correlated with distress from depressive symptoms, distress related to past trauma, and health-related and cognitive dysfunction. Experiential Avoidance was weakly correlated with distress from anxiety symptoms and poorer quality of life. Behavioral avoidance was moderately correlated with distress from depressive and anxiety symptoms, distress related to past trauma, and cognitive dysfunction, and was weakly correlated with health-related dysfunction and poorer quality of life. Results from multivariable analyses revealed that experiential avoidance was associated with greater distress related to depressive symptoms and past trauma, and behavioral avoidance was associated with greater distress related to anxiety symptoms, depressive symptoms, and past trauma. CONCLUSIONS: Results suggest that avoidance negatively influences major domains of mental and physical health as well as functioning and health-related quality of life in trauma-exposed veterans. They further indicate that behavioral and experiential avoidance may be differentially linked to mental health outcomes. The results support the idea that avoidance may be an important marker for psychosocial functioning and may serve as a treatment target in trauma-exposed veterans.

Alcohol Use Disorder and Chronic Pain: An Overlooked Epidemic.

Alcohol use disorder (AUD) and chronic pain disorders are pervasive, multifaceted medical conditions that often co-occur. However, their comorbidity is often overlooked, despite its prevalence and clinical relevance. Individuals with AUD are more likely to experience chronic pain than the general population. Conversely, individuals with chronic pain commonly alleviate their pain with alcohol, which may escalate into AUD. This narrative review discusses the intricate relationship between AUD and chronic pain. Based on the literature available, the authors present a theoretical model explaining the reciprocal relationship between AUD and chronic pain across alcohol intoxication and withdrawal. They propose that the use of alcohol for analgesia rapidly gives way to acute tolerance, triggering the need for higher levels of alcohol consumption. Attempts at abstinence lead to alcohol withdrawal syndrome and hyperalgesia, increasing the risk of relapse. Chronic neurobiological changes lead to preoccupation with pain and cravings for alcohol, further entrenching both conditions. To stimulate research in this area, the authors review methodologies to improve the assessment of pain in AUD studies, including self-report and psychophysical methods. Further, they discuss pharmacotherapies and psychotherapies that may target both conditions, potentially improving both AUD and chronic pain outcomes simultaneously. Finally, the authors emphasize the need to manage both conditions concurrently, and encourage both the scientific community and clinicians to ensure that these intertwined conditions are not overlooked given their clinical significance.

Cognitive processing therapy (CPT) versus individual drug counseling (IDC) for PTSD for veterans with opioid use disorder maintained on buprenorphine.

BACKGROUND AND OBJECTIVES: There are high rates of comorbidity between posttraumatic stress disorder (PTSD) and opioid use disorder (OUD). Evidence-based trauma-focused psychotherapies such as Cognitive Processing Therapy (CPT) are a first-line treatment for PTSD. Veterans with OUD are treated primarily in substance use disorder (SUD) clinics where the standard of care is drug counseling; they often do not have access to first-line PTSD treatments. This study tested whether CPT can be conducted safely and effectively in veterans with comorbid OUD treated with buprenorphine. METHODS: This 12-week, 2-site, randomized clinical trial (RCT) included open-label randomization to two groups: (a) CPT versus (b) Individual Drug Counselling (IDC) in veterans with PTSD and comorbid OUD who were maintained on buprenorphine (N = 38). RESULTS: Veterans randomized to either IDC (n = 18) or CPT (n = 20) showed a significant reduction in self-reported PTSD symptoms over time as measured by the PTSD checklist (PCL-5) but there were no treatment group differences; there was some indication that reduction in PTSD symptoms in the CPT group were sustained in contrast to the IDC group. Recruitment was significantly impacted by COVID-19 pandemic, so this study serves as a proof-of-concept pilot study. DISCUSSION AND CONCLUSIONS: Veterans with OUD and PTSD can safely and effectively participate in evidence-based therapy for PTSD; further work should confirm that trauma-focused treatment may be more effective in leading to sustained remission of PTSD symptoms than drug counseling. SCIENTIFIC SIGNIFICANCE: This is the first study to evaluate CPT for PTSD in the context of buprenorphine treatment for OUD.

Problem Opioid Use Among US Military Veterans: Prevalence, Correlates, and Psychiatric Characteristics.

OBJECTIVE: Problem opioid use (POU) is a serious public health crisis in the United States. However, little research has examined the prevalence, correlates, and psychiatric characteristics of POU in vulnerable segments of the population, such as US military veterans. METHODS: Data were analyzed from the National Health and Resilience in Veterans Study, which surveyed a nationally representative sample of 2441 US veterans. Multivariable logistic regression models were conducted to identify correlates and psychiatric correlates of POU (defined as a positive screen on the Tobacco, Alcohol, Prescription Medication, and Other Substance Use Tool). RESULTS: A total 3.0% (95% confidence interval, 2.0%-4.5%) of US veterans screened positive for POU. Black, non-Hispanic race/ethnicity (odds ratio [OR], 3.83), lifetime alcohol use disorder (OR, 3.38), major depressive disorder (MDD; OR, 2.52), greater number of medical conditions (OR, 1.15), and disability in instrumental activities of daily living (IADL); OR, 1.86) were independently associated with POU. A significant interaction between IADL disability and MDD was observed (OR, 10.73)-among veterans with IADL disability, those with MDD had more than 6-fold greater POU than those without MDD (20.6% vs 3.2%). Furthermore, POU was associated with 2- to 3-folds greater odds of current generalized anxiety disorder and current posttraumatic stress disorder, and lifetime suicide attempt. CONCLUSIONS: POU affects 3.0% of US veterans and is associated with Black race/ethnicity, lifetime physical and mental health morbidities, as well as current psychiatric disorders and lifetime suicide attempts. Results underscore the importance of assessing physical and mental health disorders in veterans at-risk for POU and addressing co-occurring psychiatric disorders associated with POU in this population.

Written exposure therapy for veterans with co-occurring substance use disorders and PTSD: Study design of a randomized clinical trial.

There are high rates of posttraumatic stress disorder (PTSD) among treatment-seeking veterans with substance use disorders (SUD). While addiction programs traditionally do not address PTSD, there is evidence that trauma treatments for individuals with this comorbidity have improved PTSD and SUD outcomes. Written exposure therapy (WET), a five-session evidence-based psychotherapy (EBP) for PTSD, has high patient satisfaction, and lower dropout compared to other EBPs for PTSD. WET may be ideally suited for clinical settings that may not have the trauma expertise found in PTSD specialty clinics, given it requires less training time, treatment sessions, preparation time, and therapist involvement than existing EBPs, and no homework assignments. This paper describes the design, methodology, and protocol of a randomized clinical trial to evaluate whether treatment as usual (TAU) plus WET (n = 51) is superior to TAU plus a neutral topic writing condition (n = 51) on both PTSD and addiction outcomes for veterans in SUD treatment. The primary hypothesis is that participants assigned to TAU+WET, compared to those in TAU+ neutral topic writing, will report reduced symptoms of PTSD. The secondary hypothesis is that veterans receiving WET will have greater decreases in number of days of substance use compared to TAU+ neutral topic controls at follow-up. Assessments will take place at baseline, post-treatment, 8-week, and 12-week follow-up. Exploratory aims will examine the association between heart rate variability and treatment outcomes. If results prove promising, they will support WET as an effective brief, easy to disseminate, adjunct to current SUD treatment for veterans with comorbid PTSD. Trial registration: ClinicalTrials.gov ID NCT05327504.

Problematic Alcohol Use Trajectories in U.S. Military Veterans during a Public Health Crisis: Results from a 3-year, Nationally Representative, Longitudinal Study.

A growing number of studies have examined alcohol use during the COVID-19 pandemic. However, few longitudinal studies evaluated the prevalence and correlates of different trajectories of problematic alcohol use in vulnerable segments of the population, such as US veterans, over the 3-year course of the COVID-19 pandemic. Data were analyzed from the National Health and Resilience in Veterans Study, a nationally representative, longitudinal study of 2,441 US veterans. Latent growth mixture modeling was used to identify the trajectories and correlates of problematic alcohol use. Four trajectories were identified: consistent (N = 170, weighted 7.2%), decreasing (N = 38, weighted 2.2%), increasing (N = 22, weighted 1.2%), and low (N = 2,211, weighted 89.4%) problematic alcohol use. Greater household income, pre-pandemic drug use disorder (DUD), lower social support, and COVID-19 infection to self or non-household members were associated with an increasing relative to decreasing problematic alcohol use trajectory. Greater household income, adverse childhood experiences (ACEs), pre-pandemic DUD, lower social support, and greater COVID-related social restriction stress were associated with an increasing relative to a low problematic alcohol use trajectory. Younger age, male sex, ACEs, pre-pandemic DUD, lower pre-pandemic and greater decline in protective psychosocial characteristics, COVID-19 infection to non-household member, and lower COVID-related financial stress were associated with a consistent relative to a low problematic alcohol use trajectory. Overall, pre-pandemic greater income, DUD, and lower social support were associated with an increase in problematic alcohol use among US veterans during the COVID-19 pandemic. Results may help inform prevention efforts to mitigate problematic alcohol use during prolonged crises in this population.

Positive personality traits moderate persistent high alcohol consumption, determined by polygenic risk in U.S. military veterans: results from a 10-year, population-based, observational cohort study.

BACKGROUND: Understanding the interplay between psychosocial factors and polygenic risk scores (PRS) may help elucidate the biopsychosocial etiology of high alcohol consumption (HAC). This study examined the psychosocial moderators of HAC, determined by polygenic risk in a 10-year longitudinal study of US military veterans. We hypothesized that positive psychosocial traits (e.g. social support, personality traits, optimism, gratitude) may buffer risk of HAC in veterans with greater polygenic liability for alcohol consumption (AC). METHODS: Data were analyzed from 1323 European-American US veterans who participated in the National Health and Resilience in Veterans Study, a 10-year, nationally representative longitudinal study of US military veterans. PRS reflecting genome-wide risk for AC (AUDIT-C) was derived from a Million Veteran Program genome-wide association study (N = 200 680). RESULTS: Among the total sample, 328 (weighted 24.8%) had persistent HAC, 131 (weighted 9.9%) had new-onset HAC, 44 (weighted 3.3%) had remitted HAC, and 820 (weighted 62.0%) had no/low AC over the 10-year study period. AUDIT-C PRS was positively associated with persistent HAC relative to no/low AC [relative risk ratio (RRR) = 1.43, 95% confidence interval (CI) = 1.23-1.67] and remitted HAC (RRR = 1.63, 95% CI = 1.07-2.50). Among veterans with higher AUDIT-C PRS, greater baseline levels of agreeableness and greater dispositional gratitude were inversely associated with persistent HAC. CONCLUSIONS: AUDIT-C PRS was prospectively associated with persistent HAC over a 10-year period, and agreeableness and dispositional gratitude moderated this association. Clinical interventions designed to target these modifiable psychological traits may help mitigate risk of persistent HAC in veterans with greater polygenic liability for persistent HAC.

Comorbid alcohol use disorder and posttraumatic stress disorder: A proof-of-concept randomized placebo-controlled trial of buprenorphine and naltrexone combination treatment.

BACKGROUND: Effective pharmacologic treatments for comorbid alcohol use disorder (AUD) and posttraumatic stress disorder (PTSD) are lacking. Kappa (κ) opioid receptor antagonists may address this unmet need. Buprenorphine is a κ-opioid antagonist and a partial agonist of mu (µ) opioid receptors. Whereas naltrexone blocks all µ-mediated effects combining it with buprenorphine yields a pharmacologic net effect of opioid receptor antagonism. Because no κ-opioid receptor antagonist it available for clinical use, we tested this combination in a proof-of-concept study. METHODS: Consenting participants were enrolled in a Phase II, multisite, double-blind, randomized, placebo-controlled trial evaluating the effectiveness of sublingual (SL) buprenorphine combined with extended-release (XR) injectable naltrexone for the treatment of comorbid AUD and PTSD. Eligible participants (n = 75) were randomized (1:1:1) to receive either buprenorphine 2 mg/day plus naltrexone-XR (n = 35), buprenorphine 8 mg/day plus naltrexone-XR (n = 6) or SL plus injectable placebo (n = 34) for 12 weeks. The buprenorphine 8 mg/day plus naltrexone-XR arm was dropped early in the trial due to the negative impact of COVID-19 on enrollment. A binary primary outcome of response at week 8 was defined as a decrease from baseline of ≥10 points on the past week Clinician-Administered PTSD Scale (CAPS-5) and a reduction of ≥1 of past month alcohol risk level, as defined by the World Health Organization (WHO) and measured by the Timeline Follow-Back. RESULTS: Based on the results of a futility analysis, enrollment was stopped prior to reaching the initial goal of 90 participants. At the week eight primary timepoint, there were no statistically significant differences between buprenorphine plus naltrexone-XR and placebo group for the primary composite outcome (OR = 0.63; p-value = 0.52), or the subcomponents of the PTSD outcome (OR = 0.76; p-value = 0.69) and AUD outcome (OR = 0.17; p-value = 0.08). The placebo arm had a significantly higher proportion of participants with ≥1 WHO risk level reduction than the buprenorphine plus naltrexone-XR arm (OR = 0.18, p value = 0.02). CONCLUSIONS: This is the first study to evaluate the potential of κ-opioid receptor antagonism for the treatment of comorbid AUD and PTSD. The combination of buprenorphine and naltrexone-XR showed no significant improvement over placebo for the composite, PTSD, or alcohol measures.

Analysis of Drugs in Saliva of US Military Veterans Treated for Substance Use Disorders Using Supported Liquid Extraction and Surface-Enhanced Raman Spectral Analysis.

According to the Center for Disease Control, there were more than 107,000 US drug overdose deaths in 2021, over 80,000 of which due to opioids. One of the more vulnerable populations is US military veterans. Nearly 250,000 military veterans suffer from substance-related disorders (SRD). For those seeking treatment, buprenorphine is prescribed to help treat opioid use disorder (OUD). Urinalysis is currently used to monitor buprenorphine adherence as well as to detect illicit drug use during treatment. Sometimes sample tampering occurs if patients seek to generate a false positive buprenorphine urine test or mask illicit drugs, both of which can compromise treatment. To address this problem, we have been developing a point-of-care (POC) analyzer that can rapidly measure both medications used for treatment and illicit drugs in patient saliva, ideally in the physi-cian's office. The two-step analyzer employs (1) supported liquid extraction (SLE) to isolate the drugs from the saliva and (2) surface-enhanced Raman spectroscopy (SERS) to detect the drugs. A prototype SLE-SERS-POC analyzer was used to quantify buprenorphine at ng/mL concentrations and identify illicit drugs in less than 1 mL of saliva collected from 20 SRD veterans in less than 20 min. It correctly detected buprenorphine in 19 of 20 samples (18 true positives, 1 true negative and 1 false negative). It also identified 10 other drugs in patient samples: acetaminophen, amphetamine, cannabidiol, cocaethylene, codeine, ibuprofen, methamphetamine, methadone, nicotine, and norbuprenorphine. The prototype analyzer shows evidence of accuracy in measuring treatment medications and relapse to drug use. Further study and development of the system is warranted.

A systematic review evaluating PTSD treatment effects on intermediate phenotypes of PTSD.

OBJECTIVE: Although the efficacy of evidence-based treatments for posttraumatic stress disorder (PTSD) has been well established, high rates of treatment dropout and/or nonresponse or under-response to treatment suggest a need to explore novel treatment approaches. Most current research has focused on DSM-based categorical outcomes as primary indicators of treatment response, which may obscure the phenotypic heterogeneity of PTSD and limit the ability to map symptoms to underlying neurobiology. This systematic review aimed to identify intermediate phenotypes (IPs) of PTSD and evaluate IP sensitivity to PTSD treatments. METHOD: Five databases were searched for empirical studies published in English between January 1, 2010 and August 1, 2022 examining behavioral and pharmacological PTSD treatment effects on biobehavioral PTSD outcomes. RESULTS: Twenty-two studies met the inclusion criteria. Most studies evaluated behavioral treatment outcomes (n = 20), while only two studies evaluated pharmacological interventions. Five PTSD IPs were identified, including "impairments in working memory," "alterations in cognitive control," "unstable threat processing," "heightened fear or startle response," and "disturbances in sleep and wakefulness." This review offers preliminary support to suggest the utility of IP measures in assessing treatment efficacy; however, risk of bias and methodological limitations constrain the validity and generalizability of the results. CONCLUSIONS: The paucity of research combined with the heterogeneity of study methodologies and significant study limitations makes it difficult to draw strong conclusions regarding IP sensitivity to treatment. However, the existing body of research incorporating this framework shows potential for the IP approach to improve the translation of treatment efficacy from clinical trials to clinical settings. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

National trends of suicidal ideation and mental health services use among US adults with opioid use disorder, 2009-2020.

Background: The substantial increase in deaths by overdose and potential underlying suicidal intent in such deaths suggest the importance of understanding trends of suicidal ideation in individuals with opioid use disorder (OUD). This study aimed to examine the trends and correlates of past-year suicidal ideation (SI) and mental health service use among US adults with past-year OUD from 2009 to 2020. Methods: We used data from the National Survey on Drug Use and Health. Participants included non-institutionalized US civilians aged ≥18 with past-year OUD (n=5386). SI was measured by self-reported thoughts of killing oneself. Mental health service utilization was assessed with questions concerning receipt of any past-year outpatient or inpatient mental health services or prescription medications. We examined the prevalence and correlates of SI and adjusted odds ratios (aORs) for changes over time adjusting for potentially confounding sociodemographic and clinical characteristics. Further, trends in utilization of mental health services were explored. Findings: From 2009 to 2020, the prevalence of SI increased from 22.8% to 29.8% (average annual percent change, 3.64% [95% CI, 1.01-2.10%]) in adults with OUD. Subgroups including individuals aged 18-25 (aOR, 1.72 [95% CI, 1.09-2.71]; P=0.020), residing in non-metropolitan areas (aOR, 1.43 [95% CI, 1.04-1.97]; P = 0.029), with co-occurring past-year major depressive episode (aOR, 5.28 [95% CI, 4.27-6.53]; P < 0.001) and alcohol (aOR, 1.55 [95% CI, 1.23-1.97]; P < 0.001), cocaine (aOR, 1.42 [95% CI, 1.03-1.97]; P = 0.034), and sedative use disorders (aOR, 1.48 [95% CI, 1.11-1.98]; P = 0.008) were associated with SI after adjusting for covariates. No significant change in mental health service use was observed. Individuals with SI were 2.5 times more likely to report an unmet need for treatment compared to individuals without SI (53.6% vs 21.4%; P < 0.001). Interpretation: The prevalence of SI in adults with OUD increased substantially without a corresponding change in mental health service use. These results underscore the potential benefit of routine screening for suicidality and improved access to care for individuals with OUD, especially those with co-occurring depression and/or polysubstance use. Funding: None reported.

Academic Medical Centers and the U.S. Department of Veterans Affairs: A 75-Year Partnership Influences Medical Education, Scientific Discovery, and Clinical Care.

The historic academic affiliation program between the U.S. Department of Veterans Affairs and academic medical centers recently marked its 75th anniversary. The partnership has dramatically influenced medical education, research, and clinical care in the United States. In commemorating the anniversary, this article highlights areas in medicine that the partnership has influenced. The authors provide examples from their own experiences of particularly effective collaborations and describe some of the limitations they have encountered. Looking toward the future, they highlight other areas in which collaboration may be particularly effective.

Why are women more likely to attempt suicide than men? Analysis of lifetime suicide attempts among US adults in a nationally representative sample.

OBJECTIVE: While it is well-known that women are more likely to attempt suicide than men, little is known about risk and protective factors underlying this difference. METHODS: Using data from the National Epidemiologic Survey on Alcohol and Related Conditions Wave III (NESARC-III), we compared women and men with and without self-reported lifetime suicide attempts to identify sociodemographic, clinical, and behavioral characteristics that were associated with suicide attempts for each gender. We then examined the interaction of gender and risk factors to identify specific factors that have a significantly different association with the risk of suicide attempts by gender. Multivariate analyses identified factors that were independently associated with a significant interaction of gender and risk of suicide attempt and the extent to which these interactions accounted for the greater risk of suicide attempts among women. RESULTS: In unadjusted analysis, women had 1.78 greater odds of self-reported lifetime suicide attempts than men (95% confidence interval (CI), 1.61-1.96). While men and women shared similar risk and protective factors for suicide attempts, several factors were associated with significantly different risks for women than men. In multivariate analysis, these factors only partially accounted for the gender difference in lifetime risk of suicide attempt (adjusted odds ratio, 1.53; 95% CI, 1.12-2.08). CONCLUSIONS: Several risk factors for suicide attempts appear to have significantly different magnitude of association among women and men; however, these differences only partially account for gender difference in risk for suicide attempts, suggesting that other factors, not measured in this study, are at play.

Dose-related effects of ketamine for antidepressant-resistant symptoms of posttraumatic stress disorder in veterans and active duty military: a double-blind, randomized, placebo-controlled multi-center clinical trial.

This study tested the efficacy of repeated intravenous ketamine doses to reduce symptoms of posttraumatic stress disorder (PTSD). Veterans and service members with PTSD (n = 158) who failed previous antidepressant treatment were randomized to 8 infusions administered twice weekly of intravenous placebo (n = 54), low dose (0.2 mg/kg; n = 53) or standard dose (0.5 mg/kg; n = 51) ketamine. Participants were assessed at baseline, during treatment, and for 4 weeks after their last infusion. Primary analyses used mixed effects models. The primary outcome measure was the self-report PTSD Checklist for DSM-5 (PCL-5), and secondary outcome measures were the Clinician-Administered PTSD Scale for DSM-5 (CAPS-5) and the Montgomery Åsberg Depression Rating Scale (MADRS). There were no significant group-by-time interactions for PTSD symptoms measured by the PCL-5 or CAPS-5. The standard ketamine dose ameliorated depression measured by the MADRS significantly more than placebo. Ketamine produced dose-related dissociative and psychotomimetic effects, which returned to baseline within 2 h and were less pronounced with repeated administration. There was no evidence of differential treatment discontinuation by ketamine dose, consistent with good tolerability. This clinical trial failed to find a significant dose-related effect of ketamine on PTSD symptoms. Secondary analyses suggested that the standard dose exerted rapid antidepressant effects. Further studies are needed to determine the role of ketamine in PTSD treatment. ClinicalTrials.gov identifier: NCT02655692.

PTSD symptom heterogeneity and alcohol-related outcomes in U.S. military veterans: Indirect associations with coping strategies.

INTRODUCTION: This study investigated the role of coping strategies in mediating the relationship between the 7-factor model of posttraumatic stress disorder (PTSD) symptoms and alcohol misuse in veterans. METHODS: Data were analyzed from 615 veterans from a nationally representative study of U.S. veterans who met criteria for probable full or subthreshold PTSD. Path analyses examined the role of self-sufficient, socially-supported, and avoidant coping strategies in mediating associations between PTSD symptom clusters and alcohol use disorder (AUD), alcohol consumption, and alcohol-related consequences. RESULTS: Negative affect PTSD symptoms were associated with AUD through increased use of avoidant coping. Additionally, dysphoric arousal PTSD symptoms were associated with AUD; avoidant coping was associated with AUD and increased alcohol consumption; self-sufficient coping was associated with reduced AUD likelihood anhedonia symptoms with decreased use of self-sufficient coping; and negative affect with decreased use of socially-supported coping and increased use of avoidant coping. CONCLUSIONS: Results underscore the importance of avoidant coping strategies as potential mediators of the relation between PTSD symptoms and AUD. Interventions designed to mitigate engagement in avoidant coping strategies, and to bolster engagement in self-sufficient and socially-supported strategies may help reduce alcohol misuse in veterans with full or subthreshold PTSD.

Psychotherapy-supported MDMA treatment for PTSD.

A promising new Phase III study of MDMA plus psychotherapy for PTSD treatment by Mitchell and colleagues that appeared in Nature Medicine raises important new questions about the biology and optimal treatment of this disorder.

Disentangling the association between PTSD symptom heterogeneity and alcohol use disorder: Results from the 2019-2020 National Health and Resilience in Veterans Study.

Veterans are at increased risk of comorbid posttraumatic stress disorder (PTSD) and alcohol use disorder (AUD) relative to civilians. Few studies have explored the association between distinct PTSD symptoms and AUD in veterans, and existing findings are highly discrepant. This study aimed to address this gap and equivocal association by evaluating which PTSD symptom clusters are most associated with AUD in a veteran sample using the 7-factor 'hybrid' model of PTSD. Data were analyzed from the 2019-2020 National Health and Resilience in Veterans Study (NHRVS), a nationally representative survey of 4069 U.S. veterans. Veterans completed self-report measures to assess current PTSD symptoms and AUD. Multivariable logistic regression and relative importance analyses were conducted to examine associations between the 7-factor model of PTSD symptoms and AUD. Adjusting for sociodemographic, military, trauma factors, and depressive symptoms, scores on the dysphoric arousal (20.7% relative variance explained [RVE]) and externalizing behaviors (19.0% RVE) symptom clusters were most strongly associated with AUD in the full sample, while externalizing behaviors (47.7% RVE), anxious arousal (23.9% RVE), and dysphoric arousal (12.4%) accounted for the majority of explained variance in veterans who screened positive for PTSD. Results of this nationally representative study of U.S. veterans highlight the importance of externalizing behaviors and arousal symptoms of PTSD as potential drivers of AUD in this population. The 7-factor hybrid model of PTSD provides a more nuanced understanding of PTSD-AUD associations, and may help inform risk assessment and more personalized treatment approaches for veterans with and at-risk for AUD.

Treatment outcomes in individuals diagnosed with comorbid opioid use disorder and Posttraumatic stress disorder: A review.

OBJECTIVES: Opioid use disorder (OUD) is a public health emergency. Evidence suggests that posttraumatic stress disorder (PTSD) is common among individuals with OUD; however, few studies evaluate whether concurrent diagnoses affect treatment outcomes. This review examines the impact of concurrent diagnoses of OUD and PTSD on treatment outcomes. METHODS: A search was performed using articles identified through June 30, 2020 in PubMed, PsycINFO, and EMBASE. Included peer-reviewed articles evaluated individuals with OUD and a PTSD diagnosis via standardized assessment and/or medical record diagnoses, and reported relationships between diagnosis and treatment outcomes and/or other psychiatric conditions. RESULTS: Out of 412 articles, 17 studies met inclusion criteria for this review (from 13 databases). Articles included had a total of n = 2190 with OUD, with n = 79 non-OUD comparison participants. Studies examining individuals with OUD revealed comorbid PTSD was associated with more severe addiction, higher rates of depression, attempted suicide, and psychosocial problems. CONCLUSIONS: Among individuals with OUD, presence of PTSD is associated with multiple mental health problems. The impact of PTSD on drug use is inconclusive. Although only 5 studies examined psychosocial PTSD treatment, all found PTSD-focused treatment to be effective for those with comorbid OUD. Overall, results suggest the need to better identify PTSD among those with OUD, and to develop and evaluate interventions that are brief, integrative, and easy to implement in clinical settings.

Prevalence, risk and protective factors of alcohol use disorder during the COVID-19 pandemic in U.S. military veterans.

BACKGROUND: There have been reports of increased alcohol consumption during the COVID-19 pandemic in the general population. However, little is known about the impact of the pandemic on the prevalence of alcohol use disorder (AUD), especially in high-risk samples such as U.S. military veterans. METHODS: Data were analyzed from the 2019-2020 National Health and Resilience in Veterans Study, which surveyed a nationally representative, prospective cohort of 3078 U.S. veterans. Pre-pandemic and 1-year peri-pandemic risk and protective factors associated with incident and chronic probable AUD were examined. RESULTS: A total of 6.9 % (n = 183) of veterans were classified as chronic probable AUD, 3.2 % (n = 85) as remitted from AUD, and 2.7 % (n = 71) as incident probable AUD during the pandemic; the prevalence of probable AUD in the full sample remained stable -10.1 % pre-pandemic and 9.6 % peri-pandemic. Younger age, greater pre-pandemic alcohol use severity, and COVID-related stressors were associated with incident AUD during the pandemic, whereas higher pre-pandemic household income was associated with lower risk of this outcome. Younger age, combat experience, lifetime substance use disorder, greater drug use severity, lower dispositional optimism, and more COVID-related worries and social restriction stress were associated with higher risk of chronic AUD. CONCLUSIONS: Nearly 1-in-10 US veterans screened positive for AUD 1-year into the pandemic; however, the pre- and 1-year peri-pandemic prevalence of probable AUD remained stable. Veterans who are younger, have served in combat roles, endorse more COVID-related stressors, and have fewer socioeconomic resources may be at higher risk for AUD during the pandemic.