Substance use disorders in Iraq and Afghanistan veterans in VA healthcare, 2001-2010: Implications for screening, diagnosis and treatment

University of California, San Francisco and San Francisco Veterans Affairs Medical Center, San Francisco, CA 94121, USA.
Drug and alcohol dependence (Impact Factor: 3.42). 07/2011; 116(1-3):93-101. DOI: 10.1016/j.drugalcdep.2010.11.027
Source: PubMed


The prevalence and correlates of alcohol use disorder (AUD) and drug use disorder (DUD) diagnoses in Iraq and Afghanistan veterans who are new users of Department of Veterans Affairs (VA) healthcare nationwide has not been evaluated.
VA administrative data were used in retrospective cross-sectional descriptive and multivariable analyses to determine the prevalence and independent correlates of AUD and DUD in 456,502 Iraq and Afghanistan veterans who were first-time users of VA healthcare between October 15, 2001 and September 30, 2009 and followed through January 1, 2010.
Over 11% received substance use disorder diagnoses: AUD, DUD or both; 10% received AUD diagnoses, 5% received DUD diagnoses and 3% received both. Male sex, age < 25 years, being never married or divorced, and proxies for greater combat exposure were independently associated with AUD and DUD diagnoses. Of those with AUD, DUD or both diagnoses, 55-75% also received PTSD or depression diagnoses. AUD, DUD or both diagnoses were 3-4.5 times more likely in veterans with PTSD and depression (p < 0.001).
Post-deployment AUD and DUD diagnoses were more prevalent in subgroups of Iraq and Afghanistan veterans and were highly comorbid with PTSD and depression. Stigma and lack of universal screening may have reduced the number of DUD diagnoses reported. There is a need for improved screening and diagnosis of substance use disorders and increased availability of integrated treatments that simultaneously address AUD and DUD in the context of PTSD and other deployment-related mental health disorders.

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    • "Veterans are at particularly high risk for SUD-PTSD comorbidity (e.g., Carter, Capone, & Short, 2011). For example, among a sample of nearly half a million Iraq and Afghanistan veterans, 63–76% of those with an alcohol or drug use disorder also met criteria for PTSD (Seal et al., 2011). Further, meta-analytic studies indicate that PTSD symptom severity is strongly associated with aggressive behavior and that this association is stronger among veterans as compared to civilians (Orth & Wieland, 2006; Taft et al., 2011). "
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    ABSTRACT: This study examined posttraumatic stress disorder (PTSD) symptom severity and impulsivity as predictors of aggressive behavior among 133 male military veterans entering substance abuse treatment who endorsed difficulty controlling anger in the past year. At treatment intake, participants completed measures assessing PTSD symptom severity, impulsivity and aggressive behavior. Perpetration of aggressive behavior was reassessed 4 months later. Results from multivariate models indicated that PTSD symptom severity and impulsivity explained unique variance in aggressive behavior at intake but not follow-up. Mediation models indicated that the association between PTSD symptom severity and aggressive behavior was accounted for by impulsivity. The identification of impulsivity as a key mediator between trauma symptoms and aggressive behavior has significant clinical and research implications. Based on these findings, clinicians are encouraged to consider a standard assessment of impulsivity and the selection of interventions that target impulsivity as a trans-diagnostic process among at-risk client populations.
    Journal of Substance Abuse Treatment 11/2014; 50. DOI:10.1016/j.jsat.2014.10.014 · 3.14 Impact Factor
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    • "Of the 25% percent of Iraq/Afghanistan veterans who received a psychiatric diagnosis in the VHA prior to 2005, Seal and colleagues [28] also found that 56% suffered from multiple mental health conditions that may demand clinical attention. Other research has also documented high rates of substance-related problems with combat-exposed samples [29], [30], which represents another significant concern for this population. "
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    ABSTRACT: Background Combat-related posttraumatic stress disorder (PTSD) can be a difficult condition to treat and has been associated with serious medical and economic issues among U.S. military veterans. Distinguishing between treatment responders vs. non-responders in this population has become an important public health priority. This study was conducted to identify pre-treatment characteristics of U.S. veterans with combat-related PTSD that might contribute to favorable and unfavorable responses to high value treatments for this condition. Method This study focused on 805 patients who completed a VHA PTSD residential program between 2000 and 2007. These patients completed the PTSD Clinical Checklist at pre-treatment, post-treatment, and a four-month follow-up assessment. Latent growth curve analysis (LCGA) was incorporated to determine trajectories of changes in PTSD across these assessments and whether several key clinical concerns for this population were associated with their treatment responses. Study Findings LCGA indicated three distinct trajectories in PTSD outcomes and identified several clinical factors that were prospectively linked with changes in veterans' posttraumatic symptomatology. When compared to a group with high PTSD symptom severity that decreased over the program but relapsed at follow-up (41%), the near half (48.8%) of the sample with an improving trajectory had less combat exposure and superior physical/mental health. However, when compared to a minority (10.2%) with relatively low symptomatology that also remained somewhat stable, patients in the improving group were younger and also reported greater combat exposure, poorer physical/mental health status, and more problems with substance abuse before the start of treatment. Conclusions Findings suggest that veterans are most likely to benefit from residential treatment in an intermediate range of symptoms and risk factors, including PTSD symptom severity, history of combat exposure, and comorbid issues with physical/mental health. Addressing these factors in an integrative manner could help to optimize the effectiveness of treatments of combat-related PTSD in many cases.
    PLoS ONE 07/2014; 9(7):e101741. DOI:10.1371/journal.pone.0101741 · 3.23 Impact Factor
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    • "Post-traumatic stress disorder, a psychiatric condition that arises after exposure to a life threatening experience such as conditions experienced in combat war zone with or without blast exposure as a form of mTBI (75). This, by itself, poses a challenge in the clinical diagnosis in veterans who are exposed to mTBI since the symptoms may overlap between these conditions exacerbated by other comorbid conditions such as drug abuse or other neuropsychiatric complications (75, 76). A Rand Corporation study indicated that ~20% of returning service personnel (~300,000) have had a TBI and that there was substantial overlap of TBI with the occurrence of PTSD (77). "
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    ABSTRACT: Among the U.S. military personnel, blast injury is among the leading causes of brain injury. During the past decade, it has become apparent that even blast injury as a form of mild traumatic brain injury (mTBI) may lead to multiple different adverse outcomes, such as neuropsychiatric symptoms and long-term cognitive disability. Blast injury is characterized by blast overpressure, blast duration, and blast impulse. While the blast injuries of a victim close to the explosion will be severe, majority of victims are usually at a distance leading to milder form described as mild blast TBI (mbTBI). A major feature of mbTBI is its complex manifestation occurring in concert at different organ levels involving systemic, cerebral, neuronal, and neuropsychiatric responses; some of which are shared with other forms of brain trauma such as acute brain injury and other neuropsychiatric disorders such as post-traumatic stress disorder. The pathophysiology of blast injury exposure involves complex cascades of chronic psychological stress, autonomic dysfunction, and neuro/systemic inflammation. These factors render blast injury as an arduous challenge in terms of diagnosis and treatment as well as identification of sensitive and specific biomarkers distinguishing mTBI from other non-TBI pathologies and from neuropsychiatric disorders with similar symptoms. This is due to the "distinct" but shared and partially identified biochemical pathways and neuro-histopathological changes that might be linked to behavioral deficits observed. Taken together, this article aims to provide an overview of the current status of the cellular and pathological mechanisms involved in blast overpressure injury and argues for the urgent need to identify potential biomarkers that can hint at the different mechanisms involved.
    Frontiers in Neurology 11/2013; 4:186. DOI:10.3389/fneur.2013.00186
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