Non-affirmation minority stress, internalized transphobia, and subjective cognitive decline among transgender and gender diverse veterans aged 45 years and older.

OBJECTIVES: To examine the associations of two measures of minority stress, non-affirmation minority stress and internalized transphobia, with subjective cognitive decline (SCD) among transgender and gender diverse (TGD) veterans. METHOD: We administered a cross-sectional survey from September 2022 to July 2023 to TGD veterans. The final analytic sample included 3,152 TGD veterans aged ≥45 years. We used a generalized linear model with quasi-Poisson distribution to calculate prevalence ratios (PR) and 95% confidence intervals (CIs) measuring the relationship between non-affirmation minority stress and internalized transphobia and past-year SCD. RESULTS: The mean age was 61.3 years (SD = 9.7) and the majority (70%) identified as trans women or women. Overall, 27.2% (n = 857) reported SCD. Adjusted models revealed that TGD veterans who reported experiencing non-affirmation minority stress or internalized transphobia had greater risk of past-year SCD compared to those who did not report either stressor (aPR: 1.09, 95% CI: 1.04-1.15; aPR: 1.19, 95% CI: 1.12-1.27). CONCLUSION: Our findings demonstrate that proximal and distal processes of stigma are associated with SCD among TGD veterans and underscore the need for addressing multiple types of discrimination. Above all, these results indicate the lasting sequelae of transphobia and need for systemic changes to prioritize the safety and welfare of TGD people.

Caregiver Experiences and Roles in Care Seeking During COPD Exacerbations: A Qualitative Study.

BACKGROUND: Chronic obstructive pulmonary disease (COPD) is a progressive, debilitating illness characterized by exacerbations that require timely intervention. COPD patients often rely on informal caregivers-relatives or friends-for assistance with functioning and support. Caregivers perform roles that may be particularly important during acute exacerbations in monitoring symptoms and seeking medical intervention. However, little is known about caregivers' roles and experiences as they support their patients during exacerbations. PURPOSE: To explore the experiences, roles in care seeking, and needs of caregivers during COPD exacerbations. METHODS: Semi-structured interviews were conducted with 24 caregivers of Veterans with COPD who experienced a recent exacerbation. Interviews were recorded, transcribed, and analyzed using inductive content analysis. RESULTS: Five themes arose: (a) caregivers reported continuously monitoring changes in patients symptom severity to identify exacerbations; (b) caregivers described emotional reactions evoked by exacerbations and constant vigilance; (c) caregivers described disagreements with their patient in interpreting symptoms and determining the need for care seeking; (d) caregivers noted uncertainty regarding their roles and responsibilities in pursuing care and their approaches to promote care varied; and (e) expressed their need for additional information and support. Caregivers of patients with COPD often influence whether and when patients seek care during exacerbations. Discrepancies in symptom evaluations between patients and caregivers paired with the lack of information and support available to caregivers are related to delays in care seeking. Clinical practice should foster self-management support to patient-caregiver dyads to increase caregiver confidence and patient openness to their input during exacerbations.

Prevalence of Gastrointestinal Symptoms and Irritable Bowel Syndrome Among Individuals With Symptomatic Posttraumatic Stress Disorder.

GOALS: Our aim was to describe the prevalence of irritable bowel syndrome (IBS) and other gastrointestinal symptoms in a sample of veterans with posttraumatic stress disorder (PTSD) and to examine the relationship between gastrointestinal symptoms, PTSD severity, depression severity, and number of prior traumatic events reported. BACKGROUND: IBS and PTSD can co-occur; yet, little research has focused on describing the gastrointestinal symptoms and prevalence of IBS among veterans with PTSD. MATERIALS AND METHODS: We examined baseline data from a randomized clinical trial of behavioral interventions for veterans with PTSD. Veterans completed questionnaires assessing gastrointestinal symptoms (Gastrointestinal Patient-Reported Outcome Measures Information Systems; PROMIS) and lifetime traumatic events. Multivariable regression analyses were performed to examine associations between gastrointestinal symptoms and the number of prior traumas reported PTSD severity, and depression symptom severity. RESULTS: One hundred eighty-four veterans with a diagnosis of PTSD were included. Twenty-five percent met the Rome III criteria for IBS. Veterans reported gastrointestinal symptoms including abdominal/belly pain (36%), diarrhea (21%), constipation (18%), and bloating/gas (17%). In multivariable analyses, greater PTSD severity was associated with worse constipation ( P =0.008), diarrhea ( P =0.005), and gas/bloating ( P =0.001) when controlling for age and sex. Higher levels of depressive symptoms severity were associated with greater abdominal/belly pain ( P =0.04). CONCLUSIONS: Among a sample of veterans with PTSD, rates of IBS and abdominal/belly pain are greater than general US population reference values. Although levels of constipation and bloating/gas are lower than general US population reference values, increased severity of PTSD was associated with increased gastrointestinal symptoms.

Estimating posttraumatic stress disorder severity in the presence of differential item functioning across populations, comorbidities, and interview measures: Introduction to Project Harmony.

Multiple factor analytic and item response theory studies have shown that items/symptoms vary in their relative clinical weights in structured interview measures for posttraumatic stress disorder (PTSD). Despite these findings, the use of total scores, which treat symptoms as though they are equally weighted, predominates in practice, with the consequence of undermining the precision of clinical decision-making. We conducted an integrative data analysis (IDA) study to harmonize PTSD structured interview data (i.e., recoding of items to a common symptom metric) from 25 studies (total N = 2,568). We aimed to identify (a) measurement noninvariance/differential item functioning (MNI/DIF) across multiple populations, psychiatric comorbidities, and interview measures simultaneously and (b) differences in inferences regarding underlying PTSD severity between scale scores estimated using moderated nonlinear factor analysis (MNLFA) and a total score analog model (TSA). Several predictors of MNI/DIF impacted effect size differences in underlying severity across scale scoring methods. Notably, we observed MNI/DIF substantial enough to bias inferences on underlying PTSD severity for two groups: African Americans and incarcerated women. The findings highlight two issues raised elsewhere in the PTSD psychometrics literature: (a) bias in characterizing underlying PTSD severity and individual-level treatment outcomes when the psychometric model underlying total scores fails to fit the data and (b) higher latent severity scores, on average, when using DSM-5 (net of MNI/DIF) criteria, by which multiple factors (e.g., Criterion A discordance across DSM editions, changes to the number/type of symptom clusters, changes to the symptoms themselves) may have impacted severity scoring for some patients.

Associations Between Lifetime Panic Attacks, Posttraumatic Stress Disorder, and Substance Use Disorders in a Nationally Representative Sample.

Objective: Rates of lifetime substance use disorder (SUD) are high among people with lifetime posttraumatic stress disorder (PTSD). Panic attacks are also prevalent among trauma survivors and people with SUD, yet studies on PTSD/SUD have rarely examined comorbid panic. This potentially creates additional barriers to effective treatment for people with PTSD/SUD, in that panic may be under-diagnosed among people with PTSD/SUD and consequently attenuate treatment outcome. Additionally, research on PTSD/SUD often combines people with alcohol use disorder (AUD) and people with drug use disorders (DUDs) into a single group despite evidence that these two PTSD/SUD subgroups differ along important sociodemographic and clinical variables. This study tested the hypothesis that among adults with lifetime PTSD, panic attacks would be associated with greater lifetime risk for both AUD and DUD. We also explored whether panic attacks were associated with specific DUDs that frequently co-occur with PTSD (cannabis, sedatives/tranquilizers, heroin/opioids, and cocaine). Methods: Data were drawn from the National Epidemiologic Survey on Alcohol and Related Conditions-III (NESARC-III), a cross-sectional national study. Adults with lifetime PTSD (N = 2,230) were classified into one of three groups based on diagnostic interview data: adults with PTSD/AUD (i.e., met criteria for PTSD and AUD but not DUD; n = 656), adults with PTSD/DUD (i.e., met criteria for PTSD and DUD, regardless of AUD diagnostic status; n = 643), or adults with PTSD-only (i.e., met criteria for PTSD but not AUD or DUD; n = 1,031). Results: Weighted logistic regression analyses showed that lifetime risk of PTSD/AUD and PTSD/DUD, each relative to PTSD-only, was greater for adults who were younger at the time of data collection, were male, and had a history of panic attacks. Panic attacks did not predict specific DUD diagnoses comorbid with PTSD in exploratory analyses adjusting for sociodemographic and clinical covariates. Conclusions: Findings highlight the importance of assessing and targeting panic in PTSD/SUD clinics, but suggest panic may not discriminate between specific DUDs that commonly co-occur with PTSD. Study limitations and future directions are discussed.

An in-depth look at latent classes of DSM-5 psychiatric comorbidity among individuals with PTSD: Clinical indicators and treatment utilization.

OBJECTIVE: Posttraumatic stress disorder (PTSD) is associated with high comorbidity rates across the full range of psychiatric disorders. However, little is known about how psychiatric comorbidity manifests among people with PTSD, particularly with regard to concurrent diagnoses. METHOD: Latent class analysis (LCA) was used to characterize discrete classes of PTSD comorbidity using past year DSM-5 diagnostic standards among a large nationally representative epidemiologic sample of U.S. adults. Follow-up analyses compared participant characteristics across latent classes. RESULTS: The LCA was best characterized by five classes: low comorbidity, distress-fear, distress-externalizing, mania-fear-externalizing, and mania-externalizing. Excluding the low comorbidity class, proportions of borderline and schizotypal personality disorder were high across classes. CONCLUSION: Participant characteristics across classes of past year PTSD comorbidity are explored through the lens of case conceptualization and treatment planning utility.

Differences in functional and structural social support among female and male veterans and civilians.

PURPOSE: Social support is an important correlate of health behaviors and outcomes. Studies suggest that veterans have lower social support than civilians, but interpretation is hindered by methodological limitations. Furthermore, little is known about how sex influences veteran-civilian differences. Therefore, we examined veteran-civilian differences in several dimensions of social support and whether differences varied by sex. METHODS: We performed a cross-sectional analysis of the 2012-2013 National Epidemiologic Survey of Alcohol and Related Conditions-III, a nationally representative sample of 34,331 respondents (male veterans = 2569; female veterans = 356). We examined veteran-civilian differences in functional and structural social support using linear regression and variation by sex with interactions. We adjusted for socio-demographics, childhood experiences, and physical and mental health. RESULTS: Compared to civilians, veterans had lower social network diversity scores (difference [diff] = - 0.13, 95% confidence interval [CI] - 0.23, - 0.03). Among women but not men, veterans had smaller social network size (diff = - 2.27, 95% CI - 3.81, - 0.73) than civilians, attributable to differences in religious groups, volunteers, and coworkers. Among men, veterans had lower social network diversity scores than civilians (diff = - 0.13, 95% CI - 0.23, - 0.03); while among women, the difference was similar but did not reach statistical significance (diff = - 0.13, 95% CI - 0.23, 0.09). There was limited evidence of functional social support differences. CONCLUSION: After accounting for factors that influence military entry and social support, veterans reported significantly lower structural social support, which may be attributable to reintegration challenges and geographic mobility. Findings suggest that veterans could benefit from programs to enhance structural social support and improve health outcomes, with female veterans potentially in greatest need.

Relationship of Phosphatidylethanol Biomarker to Self-Reported Alcohol Drinking Patterns in Older and Middle-Age Adults.

BACKGROUND: Risky alcohol consumption is on the rise among older adults. Biomarkers such as phosphatidylethanol (PEth) have been used to evaluate the correspondence between an objective, laboratory-based biomarker and self-report of alcohol consumption. This study examined the relationship between PEth, self-report of alcohol consumption, and health indices in a sample of community-dwelling older to middle-age adults (aged 35 to 89) with healthy and risky levels of alcohol consumption. METHODS: Self-reports of alcohol consumption were collected using the Alcohol Use Disorders Identification Test (AUDIT) and Form 30. In addition, indices of health along with a blood sample to determine PEth values were collected (N = 183). RESULTS: PEth was correlated with age, AUDIT-C, AUDIT total, alcohol consumption, mood, and liver function measures but not with medical comorbidity or body mass index (J Gerontol B Psychol Sci Soc Sci 73, 2018, 633). Alcohol consumption over the past 30 days measured with Form 30 was the strongest predictor of PEth levels for both middle-age and older adults, with age a small contributing predictor. General alcohol consumption patterns for amount of alcohol consumed over a 30-day period revealed middle-age adults consumed larger amounts of alcohol compared with older adults, but older adults consumed alcohol on more days than middle-age adults. Middle-age participants evidenced higher PEth levels than older adults at comparable drinking rates. CONCLUSIONS: Overall, findings suggest a strong relationship between alcohol consumption and PEth levels with age a small but contributing factor to predicting PEth levels.

Refinement and Pilot Testing of a Brief, Early Intervention for PTSD and Alcohol Use Following Sexual Assault.

Experiencing a sexual assault can have long-lasting negative consequences including development of posttraumatic stress disorder (PTSD) and alcohol misuse. Intervention provided in the initial weeks following assault can reduce the development of these chronic problems. This study describes the iterative treatment development process for refining a brief intervention targeting PTSD and alcohol misuse for women with recent sexual assault experiences. Experts, treatment providers, and patients provided feedback on the intervention materials and guided the refinement process. Based on principles of cognitive change, the final intervention consists of one in-person session and four coaching calls targeting beliefs about the assault and about drinking behavior. Initial feasibility and acceptability data are presented for patients enrolled in an open trial (N = 6). The intervention was rated as helpful, not distressing, and interesting by patients and all patients completed the entire treatment protocol. A large decrease in PTSD symptoms pre- to post-intervention was observed. A small effect on decreasing alcohol consequences also emerged, although drinks consumed per week showed a slight increase, not a decrease, over the course of the intervention. Applications of this intervention and next steps for testing efficacy are presented.

Military Service and Military Health Care Coverage are Associated with Reduced Racial Disparities in Time to Mental Health Treatment Initiation.

We aimed to evaluate whether military service and access to veteran heath care coverage attenuates racial/ethnic disparities in time to mental health treatment initiation for posttraumatic stress disorder (PTSD), major depressive disorder, and/or alcohol-use disorder. Results are based on 13,528 civilians and 1392 veterans from NESARC-III. Among civilians, racial/ethnic minorities reported longer time to PTSD and depression treatment initiation than non-Hispanic whites. Among veterans, racial/ethnic minorities did not differ from whites in time to PTSD and depression treatment initiation, and showed shorter time to treatment initiation for alcohol-use disorder treatment. Racial/ethnic minorities with past year veteran health care coverage showed the strongest evidence for attenuated disparities.

Mindfulness-based cognitive therapy for the treatment of current depressive symptoms: a meta-analysis.

Mindfulness-based cognitive therapy (MBCT) appears to be a promising intervention for the prevention of relapse in major depressive disorder, but its efficacy in patients with current depressive symptoms is less clear. Randomized clinical trials of MBCT for adult patients with current depressive symptoms were included (k = 13, N = 1046). Comparison conditions were coded based on whether they were intended to be therapeutic (specific active controls) or not (non-specific controls). MBCT was superior to non-specific controls at post-treatment (k = 10, d = 0.71, 95% confidence interval [CI] [0.47, 0.96]), although not at longest follow-up (k = 2, d = 1.47, [-0.71, 3.65], mean follow-up = 5.70 months across all studies with follow-up). MBCT did not differ from other active therapies at post-treatment (k = 6, d = 0.002, [-0.43, 0.44]) and longest follow-up (k = 4, d = 0.26, [-0.24, 0.75]). There was some evidence that studies with higher methodological quality showed smaller effects at post-treatment, but no evidence that effects varied by inclusion criterion. The impact of publication bias appeared minimal. MBCT seems to be efficacious for samples with current depressive symptoms at post-treatment, although a limited number of studies tested the long-term effects of this therapy.

Hormone therapy, gender affirmation surgery, and their association with recent suicidal ideation and depression symptoms in transgender veterans.

BACKGROUND: Access to transition-related medical interventions (TRMIs) for transgender veterans has been the subject of substantial public interest and debate. To better inform these important conversations, the current study investigated whether undergoing hormone or surgical transition intervention(s) relates to the frequency of recent suicidal ideation (SI) and symptoms of depression in transgender veterans. METHODS: This study included a cross-sectional, national sample of 206 self-identified transgender veterans. They self-reported basic demographics, TRMI history, recent SI, and symptoms of depression through an online survey. RESULTS: Significantly lower levels of SI experienced in the past year and 2-weeks were seen in veterans with a history of both hormone intervention and surgery on both the chest and genitals in comparison with those who endorsed a history of no medical intervention, history of hormone therapy but no surgical intervention, and those with a history of hormone therapy and surgery on either (but not both) the chest or genitals when controlling for sample demographics (e.g., gender identity and annual income). Indirect effect analyses indicated that lower depressive symptoms experienced in the last 2-weeks mediated the relationship between the history of surgery on both chest and genitals and SI in the last 2-weeks. CONCLUSIONS: Results indicate the potential protective effect that TRMI may have on symptoms of depression and SI in transgender veterans, particularly when both genitals and chest are affirmed with one's gender identity. Implications for policymakers, providers, and researchers are discussed.

Effects of Initiating Abstinence from Alcohol on Daily Craving and Negative Affect: Results from a Pharmacotherapy Clinical Trial.

BACKGROUND: Craving and negative affect are distressing and commonly experienced during alcohol use disorder (AUD) treatment. Patients may assume that initiating abstinence will intensify their cravings and negative affect despite limited empirical data to support this assumption. This study extends and replicates, under improved methodological conditions, previous work that found reductions in daily craving associated with initiating abstinence. METHODS: Seventy-eight adults (80.8% male, 57.1% Caucasian) in a clinical trial testing prazosin for AUD provided daily reports of drinking, craving, and negative affect for up to 12 weeks (mean = 64.77 daily reports). Participants were classified into 3 subgroups based on whether and when they initiated 14 days of continuous abstinence, including (i) "abstinence initiators" who quit drinking during treatment (n = 17), (ii) "already abstainers" who were abstinent at the start of treatment (n = 20), and (iii) "continued drinkers" who never initiated abstinence (n = 41). The timing and degree of change in craving and negative affect were compared across these groups using multivariate growth curve modeling. RESULTS: All participant subgroups reported gradual reductions in craving over the course of treatment, with "abstinence initiators" reporting additional sudden reductions in craving upon initiating abstinence from alcohol. "Continued drinkers" reported higher levels of craving than "already abstainers" throughout the full course of treatment. Negative affect followed a different pattern of change, with "abstinence initiators" experiencing gradual reductions in negative affect after initiating abstinence but no changes prior to or immediately upon initiating abstinence, and with "already abstainers" and "continued drinkers" experiencing no changes in negative affect over time. CONCLUSIONS: Initiating abstinence is associated with immediate reductions in craving, followed by gradual reductions in both craving and negative affect. Results provide insight into the timing and magnitude of changes in theoretically and clinically important variables and may help patients anticipate when to expect improvement in craving and negative effect.

Identifying women veterans with unhealthy alcohol use using gender-tailored screening.

BACKGROUND AND OBJECTIVES: To assess the impact of gender-tailored alcohol screening criteria. METHODS: Among N = 1,349 women, we calculated the proportion screening positive for unhealthy alcohol use with non-tailored versus gender-tailored criteria (a gender-tailored binge-drinking item, lower screen-positive threshold, or both). RESULTS: Three percent more women screened positive with a modified binge-drinking question, most reporting risky drinking. Fifteen percent more women screened positive with a lower threshold; most did not report risky drinking. DISCUSSION AND CONCLUSIONS: Gender-tailored binge-drinking questions may improve detection of women's unhealthy alcohol use. SCIENTIFIC SIGNIFICANCE: These results can inform future efforts to improve alcohol screening for women. (Am J Addict 2018;27:97-100).

Military Sexual Assault in Transgender Veterans: Results From a Nationwide Survey.

There is limited understanding about the frequency of military sexual assault (MSA) in transgender veterans, characteristics associated with MSA, or subsequent mental and behavioral health problems. To address this gap, we used an online national survey of 221 transgender veterans to identify prevalence of MSA and to assess its association with demographic characteristics, past history of sexual victimization, and stigma-related factors. We also evaluated the association between MSA and several mental and behavioral health problems. Overall, 17.2% of transgender veterans experienced MSA, but rates differed significantly between transgender women (15.2%) and transgender men (30.0%). Using adjusted regression models, MSA was associated with adult sexual assault prior to military service, odds ratio (OR) = 4.05, 95% CI [1.62, 10.08], and distal minority stress during military service, OR = 2.98, 95% CI [1.28, 6.91]. With respect to health outcomes, MSA was associated with past-month posttraumatic stress disorder (PTSD) symptom severity, B = 10.18, 95% CI [3.45, 16.91]; current depression symptom severity, B = 3.71, 95% CI [1.11, 6.30]; and past-year drug use, OR = 3.17, 95% CI [1.36, 7.40]. Results highlight the vulnerability of transgender veterans to MSA, and the need for military prevention programs that acknowledge transgender individuals' heightened risk. Furthermore, clinicians should consider clinical screening for PTSD, depression, and drug use in transgender veterans who have a history of MSA.

Differences by Veteran/civilian status and gender in associations between childhood adversity and alcohol and drug use disorders.

PURPOSE: To examine differences by US military Veteran status and gender in associations between childhood adversity and DSM-5 lifetime alcohol and drug use disorders (AUD/DUD). METHODS: We analyzed nationally representative data from 3119 Veterans (n = 379 women; n = 2740 men) and 33,182 civilians (n = 20,066 women; n = 13,116 men) as provided by the 2012-2013 National Epidemiologic Survey on Alcohol and Related Conditions (NESARC-III). We used weighted multinomial logistic regression, tested interaction terms, and calculated predicted probabilities by Veteran status and gender, controlling for covariates. To test which specific moderation contrasts were statistically significant, we conducted pairwise comparisons. RESULTS: Among civilians, women had lower AUD and DUD prevalence than men; however, with more childhood adversity, this gender gap narrowed for AUD and widened for DUD. Among Veterans, in contrast, similar proportions of women and men had AUD and DUD; with more childhood adversity, AUD-predicted probability among men surpassed that of women. Childhood adversity elevated AUD probability among civilian women to levels exhibited by Veteran women. Among men, Veterans with more childhood adversity were more likely than civilians to have AUD, and less likely to have DUD. CONCLUSIONS: Childhood adversity alters the gender gap in AUD and DUD risk, and in ways that are different for Veterans compared with civilians. Department of Defense, Veterans Affairs, and community health centers can prevent and ameliorate the harmful effects of childhood adversity by adapting existing behavioral health efforts to be trauma informed, Veteran sensitive, and gender tailored.

Do trauma type, stressful life events, and social support explain women veterans' high prevalence of PTSD?

OBJECTIVES: To examine factors that account for women veterans' higher prevalence of past-year DSM-5 posttraumatic stress disorder (PTSD) compared to women civilians and men veterans. METHODS: Cross-sectional analyses of the 2012-2013 National Epidemiologic Survey on Alcohol and Related Conditions-III (NESARC-III). Face-to-face interviews with 379 women veterans, 20,007 women civilians, and 2740 men veterans were conducted. Trauma type (child abuse, interpersonal violence, combat or war zone, and other), number of trauma types, past-year stressful life events, current social support, and DSM-5 PTSD were assessed using the Alcohol Use Disorder and Associated Disabilities Interview Schedule-5. Generalized linear models were used that accounted for the complex survey design. RESULTS: Women veterans had a higher unadjusted prevalence of past-year PTSD (11.40%) compared to their civilian (5.96%) and male (5.19%) counterparts. Individual predictor models indicated that the difference between women veterans' and civilians' prevalence of PTSD was attenuated when adjusting for number of trauma types, whereas the difference between men and women veterans was attenuated when adjusting for child abuse, interpersonal violence, and stressful life events. Nonetheless, while full adjustment in a multiple predictor model accounted for the difference in PTSD between women veterans and civilians, gender differences between men and women veterans remained. CONCLUSIONS: Number of trauma types, type of trauma, and social factors may together help explain women veterans' higher PTSD prevalence compared to women civilians, but do not fully account for differences between men and women veterans. Results highlight a need to explore additional explanatory factors and evaluate associations with longitudinal data.

Transgender Veterans' Satisfaction With Care and Unmet Health Needs.

BACKGROUND: Transgender individuals are overrepresented among Veterans. However, little is known regarding their satisfaction with Veterans Administration (VA) care and unmet health needs. OBJECTIVES: This study examined transgender Veterans' satisfaction with VA medical and mental health care, prevalence of delaying care, and correlates of these outcomes. RESEARCH DESIGN: We used data from transgender Veterans collected in 2014 through an online, national survey. SUBJECTS: In total, 298 transgender Veterans living in the United States. MEASURES: We assessed patient satisfaction with VA medical and mental health care and self-reported delays in seeking medical and mental health care in the past year. Potential correlates associated with these 4 outcomes included demographic, health, and health care variables. RESULTS: Over half of the sample used VA (56%) since their military discharge. Among transgender Veterans who had used VA, 79% were satisfied with medical care and 69% with mental health care. Lower income was associated with dissatisfaction with VA medical care, and being a transgender man was associated with dissatisfaction with VA mental health care. A substantial proportion reported delays in seeking medical (46%) or mental (38%) health care in the past year (not specific to VA). Screening positive for depression and/or posttraumatic stress disorder was associated with delays in seeking both types of care. CONCLUSIONS: Although the majority of transgender Veterans are satisfied with VA health care, certain subgroups are less likely to be satisfied with care. Further, many report delaying accessing care, particularly those with depression and/or posttraumatic stress disorder symptoms. Adapting health care settings to better engage these vulnerable Veterans may be necessary.

Posttraumatic Stress Disorder and Alcohol Use Disorder: A Critical Review of Pharmacologic Treatments.

Treatment of alcohol use disorder (AUD) is complicated by the presence of psychiatric comorbidity including posttraumatic stress disorder (PTSD). This is a critical review of the literature to date on pharmacotherapy treatments of AUD and PTSD. A systematic literature search using PubMed MESH terms for alcohol and substance use disorders, PTSD, and treatment was undertaken to identify relevant randomized controlled trials (RCTs). The studies were independently evaluated (ILP and TLS) and those that evaluated the efficacy of a pharmacotherapy for individuals diagnosed with AUD and PTSD and were RCTs were selected. Studies were grouped in 3 categories: (i) those that evaluated first-line treatments for PTSD, (ii) those that evaluated medications to target AUD, and (iii) those that evaluated medications hypothesized to be effective in targeting alcohol consumption as well as PTSD symptoms. Nine RCTs were identified; 3 focused on medications to treat PTSD, 4 focused on AUD, and 3 to target both. One study included both a medication to treat PTSD and 1 to treat AUD so was discussed twice. All but 1 of the studies found that PTSD symptoms and drinking outcomes improved significantly over time. There is not 1 agent with clear evidence of efficacy in this comorbid group. The results for medications to treat PTSD are inconclusive because of contradictory results. There was weak evidence to support the use of medications to treat AUD among those with comorbidity with PTSD. Findings for medications that were hypothesized to treat both disorders were also contradictory. Most studies provided a combination of interventions to treat both disorders. Despite the contradictory results, this review suggests that individuals with AUD and comorbid PTSD can safely be prescribed medications used in noncomorbid populations and patients improve with treatment.

No Wrong Doors: Findings from a Critical Review of Behavioral Randomized Clinical Trials for Individuals with Co-Occurring Alcohol/Drug Problems and Posttraumatic Stress Disorder.

Prior reviews of behavioral treatments for individuals with comorbid alcohol and drug use disorders (substance use disorder SUD) and posttraumatic stress disorder (PTSD) have not systematically considered whether comparison conditions are matched to target treatments on time and attention. A systematic literature search using PubMed MESH terms for alcohol and substance use disorders, PTSD, and treatment identified relevant behavioral randomized clinical trials (RCTs) that evaluated PTSD-oriented exposure-based treatments, addiction-focused treatments, and coping-based treatments that do not involve exposure to trauma memories. Information pertaining to within-subject changes over time and between-subject differences, quality of control condition, recruitment efficiency, and assessment and treatment retention was synthesized. Alcohol and drug outcomes were described separately when possible. Twenty-four behavioral RCTs were identified: 7 exposure based, 6 addiction focused, and 11 coping based. Seven studies included SUD intervention comparison conditions matched to the target intervention on time and attention. Most of the 24 studies found that participants in both the experimental and control conditions improved significantly over time on SUD and PTSD outcomes. No study found significant between-group differences in both SUD and PTSD outcomes favoring the experimental treatment. Despite greater treatment dropout, there was greater improvement in some PTSD outcomes for exposure-based interventions than the control conditions, including when the control conditions were matched for time and attention. Addiction-focused and coping-based interventions did not generally show an advantage over comparably robust controls, although some coping-based interventions yielded better drug use outcomes than control conditions. When available, interventions that integrate exposure-based PTSD treatment and behavioral SUD treatment are recommended as they are associated with better PTSD outcomes than SUD care matched for time and attention. However, the results of this critical review also suggest that people with SUD/PTSD can benefit from a variety of treatment options, including standard SUD care.