The impact of screening positive for hazardous alcohol use on the diagnostic accuracy of the PTSD Checklist for DSM-5 among veterans.

The Posttraumatic Stress Disorder (PTSD) Checklist for DSM-5 (PCL-5) is a widely used self-report measure of PTSD symptoms that has demonstrated strong psychometric properties across settings and samples. Co-occurring hazardous alcohol use and PTSD are prevalent among veterans, and the effects of alcohol use may impact the performance of the PCL-5. However, this possibility is untested. In this study, we evaluated the PCL-5 diagnostic accuracy for veterans who did and did not screen positive for hazardous alcohol use according to the Alcohol Use Disorders Identification Test-Consumption (AUDIT-C). Participants were 385 veterans recruited from Veterans Affairs primary care clinics. Results indicated that PCL-5 performance, AUC = .904, 95% CI [.870, .937], did not differ as a product of hazardous alcohol use. PCL-5 diagnostic utility was comparably high for veterans with, AUC = .904; 95% CI [.846, .962], and without, AUC = .904 95% CI [.861, .946], positive AUDIT-C screens. Although optimally efficient cutoff scores for veterans who screened positive were higher (i.e., 34-36) than for those with negative screens (i.e., 30), neither were significantly different from the overall PCL-5 cutoff score (i.e., 32), suggesting that neither veterans with nor without positive AUDIT-C screens require differential PCL-5 cutoff scores. The results do underscore the importance of using PCL-5 cutoff scores in concert with clinical judgment when establishing a provisional PTSD diagnosis and highlight the need for additional study of the impact of comorbidities on PCL-5 diagnostic accuracy and cutoff scores.

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.

The indirect effect from childhood maltreatment to PTSD symptoms via thought suppression and cognitive reappraisal.

BACKGROUND: Emotion regulation strategies may help explain the risk of experiencing posttraumatic stress disorder (PTSD) symptoms among adults with a history of child maltreatment. However, no study to date has examined the roles of both thought suppression and cognitive reappraisal in the association between childhood maltreatment and PTSD symptoms. OBJECTIVE: The current study sought to understand the associations between childhood maltreatment, thought suppression, cognitive reappraisal, and PTSD symptoms while controlling for negative affect and gender. PARTICIPANTS AND SETTING: Data were collected on 660 university students (71 % female) ages 18-25 between 2013 and 2014. Participants completed self-report measures of childhood maltreatment, PTSD symptoms, and emotion regulation strategies. METHOD: A structural equation model was tested to examine the direct and indirect effects from childhood maltreatment to PTSD symptoms via thought suppression and cognitive reappraisal, over and above gender and negative affect. RESULTS: Childhood maltreatment was directly associated with PTSD symptoms (ß = 0.28, SE = 0.04, p < .001). Childhood maltreatment also had a significant indirect effect on PTSD via cognitive reappraisal (ß = 0.01, CI 95 % [0.00, 0.03]), but not through thought suppression, although (ß = 0.01, CI 95 % [-0.00, 0.04]) thought suppression was significantly positively associated with PTSD symptoms (ß = 0.21, SE = 0.04, p < .001). CONCLUSION: The present study sheds light on the effect of childhood maltreatment and two commonly used emotion regulation strategies on PTSD symptoms.

Sensitivity to reward and punishment and alcohol outcomes: Metacognition as a moderator.

INTRODUCTION: The purpose of this study was to examine associations between inhibitory (sensitivity to punishment [SP], adaptive metacognition) and facilitatory (sensitivity to reward [SR], maladaptive metacognition) factors of alcohol consumption and problems among young adults. METHODS: Three hundred fifty-five young adults (ages 18-25, 61% female) recruited from Amazon Mechanical Turk and a large public midwestern university in the United States self-administered a Web survey. Two multiple regression models were tested. RESULTS: SR significantly moderated the effects of SP and the maladaptive metacognition (MC) subscale Uncontrollability/Danger on alcohol consumption. Alcohol problems were also significantly predicted by SR and Uncontrollability/Danger. The interaction between SR and SP on alcohol problems was conditional upon levels of the maladaptive MC subscale Lack of Cognitive Confidence, with a significant moderating effect only at high levels of Lack of Cognitive Confidence. CONCLUSIONS: Consistent with the literature, individuals with high levels of SR coupled with low SP are at risk for increased alcohol consumption. This effect on drinking behaviors is further influenced by maladaptive MC, such that individuals characterized by high SR and low SP are significantly more likely to report more alcohol-related problems if they believe that worrying is dangerous and uncontrollable or lack cognitive confidence; however as SP increases, this effect significantly diminishes.

The role of distress tolerance in the relationship between cognitive schemas and alcohol problems among college students.

INTRODUCTION: The current study tested the role of distress tolerance in the relationship between three early maladaptive cognitive schemas (Abandonment, Defectiveness/Shame, and Insufficient Self-Control) and alcohol problems among college students (N=364). Previous research suggests that maladaptive cognitive schemas may be a risk factor for alcohol-related problems. However, the mechanism underlying this association is unclear. One's tolerance for emotional distress may play an important role in understanding the nature of this association. METHODS: We tested a structural equation model where distress tolerance was expected to explain or moderate associations between early maladaptive schemas and alcohol outcomes. RESULTS: Results indicated distress tolerance partially mediated the relationships between schemas of Abandonment and Insufficient Self-Control and alcohol problems. Distress tolerance also significantly moderated the relationship between the Defectiveness/Shame schema and alcohol-related problems, reducing the strength of the association. CONCLUSIONS: Distress tolerance is a modifiable risk factor and the results of this study support the inclusion of emotional regulation strategies in the prevention and treatment of alcohol problems among young adults.