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1.  Predictors of Mental Healthcare Utilization in Veterans with PTSD Symptoms and Hazardous Drinking 
Military medicine  2016;181(10):1200-1206.
OBJECTIVES
Describe outpatient mental health service use in a sample of recent combat Veterans with PTSD symptoms and hazardous alcohol use and investigate predictors of mental healthcare utilization.
METHODS
In this prospective study, 126 Veterans with full or subthreshold PTSD and hazardous alcohol use completed a baseline assessment and reported mental health service use through a twelve month follow-up period. Logistic regressions were used to identify factors predicting mental healthcare utilization.
RESULTS
Veterans who were employed were 63% less likely to use outpatient mental healthcare in the 12 months following baseline. Additionally, for each 1 point increase in negative mental healthcare beliefs, participants were 70% less likely to use outpatient mental healthcare. For each 1 point worsening in social support and leisure functioning, participants were 2.2 times more likely to use outpatient mental healthcare.
CONCLUSIONS
The current study indicates that negative mental health beliefs are barriers to mental healthcare while unemployment and poor social support/leisure functioning are predictors of mental healthcare utilization for recent combat Veterans with PTSD symptoms and hazardous alcohol use. Patient and system level interventions for these factors are discussed to guide efforts to improve mental healthcare among this high-need population.
doi:10.7205/MILMED-D-15-00495
PMCID: PMC5409109  PMID: 27753552
Post-traumatic stress disorder; hazardous alcohol use; mental healthcare utilization; barriers; facilitators
2.  The effect of depression on the association between military service and life satisfaction 
Purpose
The purpose of this study was to examine the effect of depression on the association between a history of military service and life satisfaction among a nationally representative sample of US males.
Methods
Data from 57,905 men were obtained from the 2006 Behavioral Risk Factor Surveillance (BRFSS) survey that assessed depression, history of military service, and life satisfaction. Multivariable logistic regression was conducted, controlling for demographics and physical health characteristics.
Results
In non-depressed men, a history of military service was associated with higher odds of life satisfaction, OR (95%CI) = 1.39 (1.07, 1.81). However, the interaction between depression and a history of military service was significant, OR (95%CI) = 0.56 (0.38–0.84), such that a history of military service was associated with equivalent odds of satisfaction in depressed men, OR (95%CI) = 0.78 (0.56–1.09).
Conclusions
Intervention efforts targeting depression in men with a history of military service may have a significant impact on their well being. Future research should replicate these findings, examine potential mechanisms of the effects, and study the utility of life satisfaction measures in this population.
doi:10.1007/s11136-011-0104-4
PMCID: PMC5064428  PMID: 22286221
3.  Coping, PTSD Symptoms and Alcohol Involvement in Trauma-Exposed College Students in the First Three Years of College 
The objective of the present study was to examine prospective, bidirectional associations among posttraumatic stress disorder (PTSD) symptoms, coping style, and alcohol involvement (use, consequences), in a sample of trauma-exposed students just entering college. We also sought to test the mechanistic role that coping may play in associations between PTSD symptoms and problem alcohol involvement over time. Participants (N=734) completed measures of trauma exposure, PTSD symptoms, coping, and alcohol use and consequences in September of their first college year (Y1) and again each September for the next two years (Y2–3). We observed reciprocal associations between PTSD and negative coping strategies. In our examination of a mediated pathway through coping, we found an indirect association from alcohol consequences and PTSD symptoms via negative coping, suggesting that alcohol consequences may exacerbate posttraumatic stress over time by promoting negative coping strategies. Trauma characteristics such as type (interpersonal vs. non-interpersonal) and trauma re-exposure did not moderate these pathways. Models also were invariant across gender. Findings from the present study point to risk that is conferred by both PTSD and alcohol consequences for using negative coping approaches, and through this, for posttraumatic stress. Interventions designed to decrease negative coping may help to offset this risk, leading to more positive outcomes for those students who enter college with trauma exposure.
doi:10.1037/a0038348
PMCID: PMC4285146  PMID: 25528048
4.  The Relationship Between Post-Deployment Factors and PTSD Severity in Recent Combat Veterans 
Combat traumas precipitate PTSD, however non-traumatic deployment and post-deployment factors may also contribute to PTSD severity. The Deployment Risk and Resilience Inventory was used to investigate pre, peri and post-deployment factors associated with current PTSD severity in 150 recent combat veterans with PTSD and hazardous alcohol use. Hierarchal linear regression analyzed what factors independently predicted PTSD severity when controlling for socio-demographic characteristics and combat specific variables. Four post-deployment factors independently predicted PTSD severity: unemployment, alcohol use, social support, stressful (non-traumatic) life events. The centrality of trauma in the maintenance of PTSD and clinical implications for treatment providers are discussed.
doi:10.1037/mil0000027
PMCID: PMC4397563  PMID: 25892847
Combat; post-deployment; PTSD; risk; resilience
5.  Rates of DSM–IV–TR Trauma Exposure and Posttraumatic Stress Disorder Among Newly Matriculated College Students 
The negotiation of the freedoms and responsibilities introduced as adolescents begin college may be particularly challenging for those with a trauma history and traumatic stress sequelae (posttraumatic stress disorder; PTSD). The present study examined the prevalence of and risk for trauma and PTSD in a large sample of college students. Matriculating students (N = 3,014; 1,763 female, 1,251 male) at two U.S. universities completed online and paper assessments. Sixty-six percent reported exposure to a Criterion A trauma. Nine percent met criteria for PTSD. Female gender was a risk factor for trauma exposure. Gender and socioeconomic status (SES) were associated with trauma severity. Although in bivariate models, gender and SES were associated with PTSD, multivariate analyses suggested this risk was a function of trauma severity. Thus, students enter college with significant trauma histories and PTSD symptoms. Findings highlight the potential for outreach to incoming students with trauma and point to research directions to enhance understanding of the psychological needs of entering college students.
doi:10.1037/a0021260
PMCID: PMC4301258  PMID: 25621098
college; trauma; PTSD; socio-demographic risk; gender
6.  Transition and Change: The Prospective Effects of Post-Traumatic Stress on Smoking Trajectories in the First Year of College 
College matriculation begins a period of transition that is marked by new freedoms and responsibilities by and increases in a variety of risky behaviors, including smoking. Trauma and post-traumatic stress disorder (PTSD) are well-established risk factors for smoking outcomes, and thus may be a point of intervention for college smoking. Yet, no studies have examined associations among trauma, PTSD, and smoking in college students. The present study provides such an examination. Matriculating student smokers (N=346) completed surveys in September (T1) and at five subsequent time points (T2-T6) over their first year of college. With latent growth analysis, we modeled smoking trajectories conditioned on PTSD symptom status (i.e., No PTSD Symptoms vs. Partial PTSD vs. Full PTSD). Results showed that, although smoking tended to decline during the first semester for all groups, significant risk for escalation in smoking during the second semester was conferred specifically by the presence of PTSD at matriculation. Interventions that offer support and resources to students entering college with PTSD may help to prevent smoking behaviors from escalating, and may ultimately prevent the adoption of daily smoking in later adulthood.
doi:10.1037/a0029085
PMCID: PMC4020287  PMID: 22888814
College; Smoking; Trajectories
7.  Trauma and Posttraumatic Stress Symptoms Predict Alcohol and Other Drug Consequence Trajectories in the First Year of College 
Objective
College matriculation begins a period of transition into adulthood, one that is marked by new freedoms and responsibilities. This transition also is marked by an escalation in heavy drinking and other drug use, and a variety of use-related negative consequences. Trauma and symptoms of posttraumatic stress disorder (PTSD) may affect alcohol and drug problems, and thus may be a point of intervention. Yet no studies have examined trauma, PTSD, and alcohol and drug problem associations during this developmental period. The present study provides such an examination.
Method
Matriculating college students (N=997) completed surveys in September (T1) and at five subsequent time points (T2-T6) over their first year of college. With latent growth analysis, trajectories of alcohol and drug-related consequences were modeled to examine how trauma (No Criterion A Trauma, Criterion A Only, No PTSD symptoms) and PTSD (partial or full) symptom status predicted these trajectories.
Results
Results showed substantial risk for alcohol- and other drug-related negative consequences that is conferred by the presence of PTSD at matriculation. Those with both partial and full PTSD started the year with more alcohol and drug consequences. These individuals showed a steeper decrease in consequences in the first semester, which leveled off as the year progressed. Both alcohol and drug consequences remained higher for those in the PTSD group throughout the academic year. Hyper-arousal symptoms showed unique effects on substance consequence trajectories. Risk patterns were consistent for both partial and full PTSD symptom presentations. Trajectories did not vary by gender.
Conclusions
Interventions that offer support and resources to students entering college with PTSD may help to ameliorate problem substance use and may ultimately facilitate a stronger transition into college and beyond.
doi:10.1037/a0028210
PMCID: PMC3365622  PMID: 22545739
8.  Modeling Associations between Posttraumatic Stress Symptoms and Substance Use 
Addictive behaviors  2009;35(1):64-67.
Comorbid substance use and posttraumatic stress disorders (SUD-PTSD) predict poorer treatment outcomes. Self-medication has been forwarded as a symptom-level explanatory model. However, research has yet to be conducted that can provide detailed examination of SUD and PTSD symptom fluctuations over time as posited by such a process. This pilot study examined associations between PTSD and substance dependence (SD) symptoms/substance use using two established methodologies that assess week-by-week symptom and substance use/dependence status. Outpatients (N = 35) in SUD treatment completed the Longitudinal Follow-Up Evaluation and the Time Lime Follow Back Interview, retrospectively reporting weekly PTSD and SD symptoms, and substance use over the previous 6-months. Results indicated that weekly PTSD symptom fluctuations were concurrently associated with the presence of alcohol and cocaine dependence symptoms and were associated with presence of opiate dependence symptoms in the following week. These findings support a self-medication conceptualization, underscore the utility of using a more detailed process analysis of PTSD and SD symptoms, and suggest that PTSD fluctuations are associated with substance problems, rather than with substance use per se.
doi:10.1016/j.addbeh.2009.08.009
PMCID: PMC2763948  PMID: 19729250
PTSD; substance use disorders; trauma; etiology
9.  Testing Gender Effects on the Mechanisms Explaining the Association between Post-Traumatic Stress Symptoms and Substance Use Frequency 
Addictive behaviors  2009;34(8):685-692.
The present study examines gender differences in the mechanisms that explain the association between PTSD symptoms and substance use frequency in a sample of 182 urban substance users. Specifically, the current study examined gender differences in the role of two potential explanatory variables, namely, difficulties controlling impulsive behavior when distressed (IMP), and a lack of emotional awareness and clarity (AW/CLAR). Multiple-group path modeling (across males and females) was used to examine gender differences in the path coefficients from PTSD symptoms to IMP and AW/CLAR, and from these latter variables to drug use frequency. Results indicated that PTSD symptoms were associated with IMP and AW/CLAR, and these path coefficients did not vary by gender. However, gender differences emerged when considering the path coefficients from AW/CLAR and IMP to substance use frequency. Specifically, for women, the association between PTSD and substance use was partially explained by IMP, whereas for men, the association between PTSD and substance use was partially explained by AW/CLAR. The current study is the first to examine gender differences in mechanisms accounting for the association between PTSD and substance use frequency, and these results also support the value and importance of examining gender differences in mechanisms underlying PTSD-SUD comorbidity.
doi:10.1016/j.addbeh.2009.04.005
PMCID: PMC2746089  PMID: 19423233
Post-traumatic Stress Symptoms; Substance Use; Urban; Gender Differences
10.  Effects of Military Trauma Exposure on Women Veterans’ Use and Perceptions of Veterans Health Administration Care 
Background
Few studies have addressed how military trauma exposure, particularly sexual assault and combat exposure, affects women veterans’ use and perceptions of Veterans Health Administration (VHA) care.
Objective
The aim of the present study was to evaluate the effects of military sexual assault and combat exposure on women veterans’ use and perceptions of different aspects of VHA care.
Design
Cross-sectional telephone survey of a national sample of women veterans.
Participants
Women from the VA’s National Registry of Women Veterans.
Measurements
Sociodemographic characteristics, VHA care utilization, perceptions of care.
Results
Women veterans with histories of military sexual assault reported more use of VHA services, but less satisfaction, poorer perceptions of VHA facilities and staff, and more problems with VHA services compared to women veterans without histories of sexual assault. Combat exposure was related to more problems with VHA staff, although few other differences were observed for women with and without histories of combat exposure.
Conclusions
Findings provide information on areas that can be targeted with respect to caring for women veterans exposed to military sexual trauma and combat exposure, including improving interactions with VHA staff and the ease of using VHA services.
doi:10.1007/s11606-008-0589-x
PMCID: PMC2517864  PMID: 18414956
women’s health; sexual assault; combat exposure; veterans; access to care
11.  Barriers to Veterans Health Administration Care in a Nationally Representative Sample of Women Veterans 
Journal of General Internal Medicine  2006;21(Suppl 3):S19-S25.
BACKGROUND
Women veterans are generally less healthy than their nonveteran female counterparts or male veterans. Accumulating evidence suggests there may be barriers to women veterans' access to and use of Veterans Health Administration (VHA) care.
OBJECTIVE
To document perceived and/or actual barriers to care in a nationally representative sample of women veterans and examine associations with VHA use.
DESIGN
Cross-sectional telephone survey.
PARTICIPANTS
Women who are current and former users of VHA from VA's National Registry of Women Veterans.
MEASUREMENTS
Assessments of perceptions of VHA care, background characteristics, and health service use.
RESULTS
Perceptions of VHA care were most positive regarding facility/physical environment characteristics and physician skill and sensitivity and least positive regarding the availability of needed services and logistics of receiving VHA care (M=0.05 and M=−0.10; M=−0.23 and M=−0.25, respectively). The most salient barrier to the use of VHA care was problems related to ease of use. Moreover, each of the barriers constructs contributed unique variance in VHA health care use above and beyond background characteristics known to differentiate current users from former VHA users (Odds ratio [OR]=4.03 for availability of services; OR=2.63 for physician sensitivity and skill: OR=2.70 for logistics of care; OR=2.30 for facility/physical environment). Few differences in barriers to care and their association with VHA health care use emerged for women with and without service-connected disabilities.
CONCLUSIONS
Findings highlight several domains in which VHA decisionmakers can intervene to enhance the care available to women veterans and point to a number of areas for further investigation.
doi:10.1111/j.1525-1497.2006.00370.x
PMCID: PMC1513162  PMID: 16637940
women's health; veterans; access to care; health services research
12.  BRIEF REPORT: Utility of a Short Screening Scale for DSM-IV PTSD in Primary Care 
OBJECTIVE
To evaluate Breslau's 7-item screen for posttraumatic stress disorder (PTSD) for use in primary care.
DESIGN
One hundred and thirty-four patients were recruited from primary care clinics at a large medical center. Participants completed the self-administered 7-item PTSD screen. Later, psychologists blinded to the results of the screen-interviewed patients using the Clinician Administered PTSD Scale (CAPS). Sensitivity, specificity, and likelihood ratios (LR) were calculated using the CAPS as the criterion for PTSD.
RESULTS
The screen appears to have test-retest reliability (r=.84), and LRs range from 0.04 to 13.4.
CONCLUSIONS
Screening for PTSD in primary care is time efficient and has the potential to increase the detection of previously unrecognized PTSD.
doi:10.1111/j.1525-1497.2005.00292.x
PMCID: PMC1484617  PMID: 16423126
PTSD; primary care; screening; detection; diagnosis

Results 1-12 (12)