Nicholas A. Livingston

• Ph.D.
• Principal Investigator at National Center for PTSD

The PTSD checklist for the DSM-5 (PCL-5) is among the most widely used measures of posttraumatic stress disorder (PTSD) symptoms. Although its psychometrics are well studied, the measurement invariance properties of the PCL-5 have not yet been closely examined. This study examined the measurement invariance properties of the PCL-5 across gender and...

A randomized clinical trial was conducted comparing the effectiveness of motivational interviewing (MI) versus MI with trauma‐informed affirmative care (AC; i.e., MI+AC) to reduce adverse psychiatric symptoms and facilitate entry into formal mental health services for sexual and gender minority (SGM) men who experienced sexual trauma. The sample co...

Marginalized individuals are routinely subjected to oppression-based stress experiences, which are linked to negative mental health outcomes, including posttraumatic stress disorder (PTSD) and a myriad of interrelated psychiatric symptoms that exacerbate distress and complicate effective treatment. However, oppression-based stressors that do not fi...

Novel and automated means of opioid use and relapse risk detection are needed. Unstructured electronic medical record data, including written progress notes, can be mined for clinically relevant information, including the presence of substance use and relapse—critical markers of risk and recovery from opioid use disorder (OUD). In this study, we us...

Veterans with a history of military sexual trauma (MST+) are more likely to have substance use disorders (SUD) and may be at an elevated risk of premature death, driven in part by acute causes of death associated with SUD, such as suicide and overdose, as well as those associated with MST (e.g., suicide). However, the risks of veteran status, SUD,...

Background: Veterans with substance use disorders (SUDs) are at elevated risk of dying by suicide. We examine sex and age differences in rates and means of suicide death among veterans with alcohol (AUD) and/or opioid use disorder (OUD) diagnoses. Methods: Cohort study of all veterans with AUD and/or OUD diagnoses who received Veterans Health Admin...

In the United States (US), lesbian, gay, bisexual, transgender, and queer (LGBTQ) people experience disproportionate rates of suicidality associated with minority stress. This study aimed to investigate whether nonverbal expressions of experienced stigma (i.e., shame) predicted suicidal ideation among LGBTQ individuals with a focus on location-base...

Background: The COVID-19 pandemic had dramatic adverse impacts on people with opioid use disorder (OUD), as evidenced by significant disruptions to care and unprecedented increases in drug overdoses. In this study, we evaluated the impacts of COVID-19 on utilization of emergency and inpatient care, and fatal and non-fatal overdoses among veterans w...

This study examined mental health treatment nonutilization among sexual minority versus heterosexual Veterans with demonstrated psychiatric need. Data were analyzed from 820 Veterans with psychiatric need who participated in the National Health and Resilience in Veterans Study, which surveyed a nationally representative sample of U.S. military Vete...

Bisexual+ (e.g., bisexual, pansexual, queer) women experience higher rates of sexual violence (SV) and posttraumatic stress disorder (PTSD) than heterosexual and lesbian women, as well as unique identity‐related minority stress. We examined between‐ and within‐person associations between bisexual minority stress and PTSD symptoms related to SV in a...

Introduction: We sought to examine how COVID-19 affected opioid use disorder (OUD)-specific health care utilization for insured individuals with preexisting OUD during the first year of the pandemic. Methods: In this retrospective cohort study, using data from the Merative TM MarketScan V R Commercial and Medicaid data, we examined pre-and post-pan...

Objective: The purpose of the study was to compare lesbian, gay, bisexual, transgender, queer+ (LGBTQ+) veterans’ and nonveterans’ prevalence of potentially traumatic events (PTEs) and other stressor exposures, mental health concerns, and mental health treatment. Method: A subsample of veterans and nonveterans who identified as LGBTQ+ (N = 1,291; 8...

Background Gender-affirming hormone therapy (GAHT) is a common medical intervention sought by transgender and gender diverse (TGD) individuals. Initiating GAHT in accordance with clinical guideline recommendations ensures delivery of high-quality care. However, no prior studies have examined how current GAHT initiation compares to recommended GAHT...

Purpose: This scoping review summarizes the literature on suicide-specific psychological interventions among lesbian, gay, bisexual, transgender, queer, and other sexual and gender minority (LGBTQ+) people to synthesize existing findings and support future intervention research and dissemination. Methods: Electronic databases PsycInfo and PubMed we...

Objective: This qualitative study examines how states implemented COVID-19 public health emergency (PHE)-related policy flexibilities for opioid use disorder treatment from the perspective of behavioral health policymakers and recommends applying lessons learned to improve the long-term impact of the flexibilities on opioid use disorder treatment....

This study investigates associations between minority stressors, traumatic stressors, and post-traumatic stress disorder (PTSD) symptom severity in a sample of transgender and gender diverse (TGD) adults. We utilized surveys and clinical interview assessments to assess gender minority stress exposures and responses, and PTSD. Our sample (N = 43) in...

Sexual minority veterans are at heightened risk for mental health conditions compared with their heterosexual peers. Subpopulations of the sexual minority community, including veterans, are at even greater risk for mental health conditions. Despite this heightened risk, little is known about mental health treatment seeking among sexual minority vet...

Transgender and gender diverse (TGD) individuals are disproportionately exposed to traumatic and high-impact minority stressors, which can produce an array of transdiagnostic symptoms. Some clinical presentations align well with established evidence-based treatments, but others may require patient-centered modifications or combined approaches to ad...

Veterans who identify as gay, lesbian, bisexual, queer, and other minoritized sexual orientations (LGBQ+) experience significant stigma-related barriers to health care, including discrimination in care settings, which can lead to avoiding needed services. While research on general health care utilization is a growing area, mental health help seekin...

Comparisons of transgender and gender diverse (TGD) individuals’ mental health functioning with that of cisgender individuals rely almost exclusively on screening measures. The limited research with TGD individuals and omnibus assessment measures has primarily used previous iterations of the Minnesota Multiphasic Personality Inventories (MMPIs). Th...

Veterans face high risk for HIV and substance use, and thus could be disproportionately impacted by the HIV and substance use disorder (SUD) “syndemic.” HIV prevalence among veterans with SUD is unknown. To project HIV prevalence and lifetime HIV screening history among US veterans with alcohol use disorder (AUD), opioid use disorder (OUD), or both...

Background: COVID-19 significantly negatively impacted access to care among patients with opioid use disorder (OUD). The Veterans Health Administration (VHA) enacted policies to expand telehealth and medication for OUD (MOUD) during the public health emergency, which offset risk of treatment disruption. In this study, we evaluated gender difference...

Objective: Alcohol-related problems (e.g., physical, interpersonal, intrapersonal, impulse control, social responsibility) can impact 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-re...

Screening, brief intervention, and referral for alcohol misuse during primary care appointments is recommended to address high rates of unhealthy alcohol use. However, implementation of screening and referral practices into primary care remains difficult. Computerized Relational Agents programmed to provide alcohol screening, brief intervention, an...

College women face heightened risk of interpersonal trauma, which is associated with co-occurring posttraumatic stress disorder (PTSD) and alcohol use. As engagement in alcohol use can lead to negative repercussions, particularly for those using it to cope with psychological distress, it is important to further understand the variables that underli...

This study examined sociodemographic, military, and trauma characteristics, and mental health concerns that differ by sexual orientation in a nationally representative sample of U.S. military veterans. Data were analyzed from 4069 veterans who participated in the National Health and Resilience Veterans Study (NHRVS). Compared with veterans who self...

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 (...

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 inperson treatment pre-COVID-19 and te...

Background: Alcohol use is a significant concern nationally and research now highlights higher rates of alcohol attributable death (AAD) and years of potential life lost (YPLL) among lesbian, gay, and bisexual (LGB) veterans compared to non-LGB veterans. In this study, we examined specific causes of AAD and associated YPLL between LGB and non-LGB v...

Background: Findings from a person-level meta-analysis of online alcohol intervention trials suggest that women disproportionately seek out such interventions (Riper et al., 2018). Although women may be a “hidden population” that is particularly drawn to online alcohol interventions, trial design features may explain women’s apparent over-represent...

Background: In March 2020, Veterans Health Administration (VHA) enacted policies to expand treatment for Veterans with opioid use disorder (OUD) during COVID-19. In this study, we evaluate whether COVID-19 and subsequent OUD treatment policies impacted receipt of therapy/counseling and medication for OUD (MOUD). Methods: Using VHA’s nationwide ele...

Social connection consists of both the presence of and perceived closeness in social relationships. Perceptions of connection are thought to be particularly important in the development and treatment of excessive alcohol use. However, no review has delineated existing work regarding the prospective associations between perceived social connection a...

Objective: Transgender and gender diverse (TGD) people are at heightened risk of both Criterion A trauma exposure and other bias-related minority stressors (e.g., discrimination, rejection). In the absence of a unified trauma-minority stress theory, it remains unclear how to best conceptualize psychopathology for people who experience both trauma...

Background Unhealthy alcohol use is disproportionally experienced by individuals with minoritized sexual orientations. Unlike the general US population, for whom the burden of alcohol as it relates to mortality is consistently monitored across time with national survey data, the impact of unhealthy alcohol use among veterans with minoritized sexual...

Discrimination and victimization drive health disparities among sexual and gender minority (SGM) individuals, yet little is known about the relative impacts of specific experience types on hazardous substance use. Using data from 704 SGM adults, we examined SGM-related discrimination versus victimization and specific experiences as predictors of ha...

Objective: Sexual and gender minority (SGM) individuals experience high rates of discrimination, which is associated with increased cannabis use. Studies have also linked daily SGM discrimination to event-based mood states, but none have examined the degree to which cannabis buffers or potentially exacerbates mood in response to discrimination in r...

https://istss.org/public-resources/trauma-blog/2022-march/increasing-visibility-of-transgender-and-gender-di

Objective: Rates of hazardous alcohol consumption and co-occurring posttraumatic stress disorder (PTSD) are high among returning combat veterans and may adversely affect satisfaction with life (SWL). Improving life satisfaction represents a potential secondary outcome of web-based interventions for alcohol use and PTSD. Understanding the relationsh...

Background Inpatient detoxification is a common health care entry point for people with Opioid Use Disorder (OUD). However, many patients return to opioid use after discharge and also do not access OUD treatment. This systematic review reports on the features and findings of research on interventions developed specifically to improve substance use...

Purpose: The prevalence of posttraumatic stress disorder (PTSD) and other psychiatric disorders is high among military veterans and even higher among transgender veterans. Prior prevalence estimates have become outdated, and novel methods of estimation have since been developed but not used to estimate PTSD prevalence among transgender veterans. Th...

Transgender and gender diverse (TGD) individuals are at increased risk of various forms of psychopathology. Little research has been conducted with broadband measures of psychopathology and TGD individuals. The present study sought to examine how TGD individuals scored on Minnesota Multiphasic Personality Inventory-2-Restructured Form (MMPI-2-RF) s...

Objective: Questionnaire studies show people with minoritized sexual orientations (MSOs) face increased risk for conditions including posttraumatic stress disorder (PTSD). This study replicated Harrington et al.'s (2019) electronic health record probabilistic algorithm to evaluate lifetime PTSD prevalence in Veterans Health Administration (VHA)-usi...

Objective: Cannabis use disorder (CUD) is the most common non-alcohol related substance use disorder (SUD) in the United States and is especially prevalent among returning veterans. The long-term mental health correlates of CUD remain unknown, which is significant given the rise in legalization and also recreational and medicinal cannabis use natio...

Background: Treatment following detoxification is recommended to promote recovery from alcohol (AUD) and opioid use disorder (OUD), yet less than half of detoxification patients attend follow-up treatment post-discharge. The current scoping review focused on the landscape of interventions designed to improve post-detoxification outcomes. The aim wa...

Background: Alcohol screening and brief intervention have demonstrated efficacy but limited effectiveness and implementation in real-world primary care settings. Objective: To evaluate the effectiveness of a computerized Relational Agent programmed to provide alcohol screening, brief intervention and referral to treatment. We hypothesized that par...

Background: Many transgender patients experience gender dysphoria as a result of an incongruence between their gender identity and sex assigned at birth. Gender-affirming hormone therapy improves the quality of life for transgender patients seeking to increase alignment of their secondary sex characteristics and gender identity. However, little is...

The prevalence of co-occurring posttraumatic stress disorder (PTSD) and substance use disorder (SUD) remains exceptionally high among returning veterans, with numerous studies linking PTSD, but not specific PTSD symptoms, to future SUD risk. Further explication of PTSD symptom effects on future SUD risk will likely promote intervention development...

We sought to operationalize and validate data-driven approaches to identify transgender individuals in the U.S. Department of Veteran Affairs (VA) health care system through a retrospective analysis using VA administrative data from 2006 to 2018. Besides gender identity disorder (GID) diagnoses, a combination of non-GID data elements were used to i...

We sought to operationalize and validate data-driven approaches to identify transgender individuals in the U.S. Department of Veteran Affairs (VA) health care system through a retrospective analysis using VA administrative data from 2006 to 2018. Besides gender identity disorder (GID) diagnoses, a combination of non-GID data elements were used to i...

Aims Most inpatient alcohol detoxification patients do not seek treatment post-discharge, which increases the risk of relapse and re-hospitalization. To date, there have been no efforts to synthesize the evidence supporting the broad range of available interventions for this critical transition. The current study is a systematic review and evaluati...

Objectives Posttraumatic stress disorder (PTSD) and substance use share both directional (“self-medication”) and mutually-reinforcing associations over time. Research on gender differences regarding the co-occurrence of PTSD and substance use over time remains limited and largely focused on alcohol use; less is known regarding the co-occurrence of...

Objective Proportionally more women use online alcohol interventions but also report less robust treatment outcomes compared to men. Less is known about outcome disparities among veteran women, who are a growing demographic nationally. The current study examined gender differences among returning veteran men and women who used VetChange, a web-base...

Background Veterans report relatively high rates of intimate partner violence (IPV) due to high trauma exposure. Alcohol use disorder (AUD), which is more prevalent among veterans, is a risk factor for IPV use and recidivism following IPV intervention. Using data from a prior randomized control trial of a trauma-informed IPV intervention, we examin...

Background: Evidence-based web and mobile interventions are available for a range of mental health concerns. Little is known about how self-administered web interventions are used outside of controlled research trials, and there is a critical need to empirically examine real-world public implementation of such programs. To this end, the aim of the...

The COVID-19 pandemic struck in the midst of an ongoing opioid epidemic. To offset disruption to life-saving treatment for opioid use disorder (OUD), several federal agencies granted exemptions to existing federal regulations. This included loosening restrictions on medications for OUD (MOUD), including methadone and suboxone. In this commentary, w...

The prevalence of hazardous drinking is elevated among returning veterans of Iraq and Afghanistan wars, particularly among returning veterans and those with co-occurring PTSD symptoms. Understanding the reasons for drinking as well as motivations for change can tremendously improve intervention efforts. Unfortunately, little is currently known rega...

Purpose of review Trauma exposure is widespread but is especially common among lesbian, gay, bisexual, transgender, and queer (LGBTQ) individuals. LGBTQ individuals also experience higher rates of discrimination, victimization, and minority stress which can complicate posttraumatic stress disorder (PTSD) treatment but also represent independent int...

Posttraumatic stress disorder (PTSD) is associated with higher levels of alcohol use among returning veterans. Persistent PTSD symptoms can predict alcohol use over the span of hours, days, weeks, and months; however, knowledge of the strength of these associations beyond 1 year remains limited. In this study, we examined the 6-year course of co-oc...

Objective Returning veterans report high rates of hazardous drinking, posttraumatic stress disorder (PTSD), and evidence low rates of formal treatment engagement. Web-based interventions may help address unmet treatment need, yet little is known regarding factors associated with outcomes or adherence to these interventions over time. In this study,...

Background: Sexual and gender minorities (SGM) experience higher rates of depression and anxiety, which are linked to higher rates of discrimination and victimization. SGM individuals may conceal their SGM identities to decrease discrimination and victimization exposure; however, these experiences still occur, and concealment itself is often associ...

Purpose: Lesbian, gay, bisexual, and transgender (LGBT) veterans report discrimination in health care, which may be associated with negative health outcomes/behaviors and has implications for LGBT identity disclosure to providers. Quality provider communication may serve to offset some of the deleterious effects of discrimination; however, no resea...

Transgender and gender diverse (TGD) populations, including those that do not identify with gender binary constructs (man or woman) are increasingly presenting for treatment of posttrauma sequelae. Providers who offer services for trauma survivors including posttraumatic stress disorder (PTSD) treatment should be knowledgeable about evidence-based...

Link to full article: https://rdcu.be/bA3W7 Objective: The primary objectives of this paper were to 1) review empirical support for existing self-help smartphone applications for depression, anxiety, PTSD, and alcohol use disorders; 2) and evaluate whether commercially available self-help applications offer, or were derived from, empirically supp...

Objective: LGBT veterans experience high rates of trauma, discrimination, and minority stress. However, guidelines for case conceptualization and treatment remain limited. The aim of the current study was to examine the experiences of trauma and other high impact experiences among LGBT veterans to inform case conceptualization and treatment. Metho...

Past research suggests that rates of trauma exposure and Posttraumatic Stress Disorder (PTSD) are elevated among lesbian, gay, bisexual, and transgender (LGBT) veterans compared to heterosexual and cisgender veterans. Given higher rates of trauma exposure and PTSD, and the culture associated with the Department of Defense’s history of policies excl...

Objective: Sexual and gender minority (SGM) individuals experience elevated rates of minority stress, which has been linked to higher rates of nicotine and substance use. Research on this disparity to date is largely predicated on methodology that is insensitive to within-day SGM-based discrimination experiences, or their relation to momentary nico...

Sexual and gender minority individuals (lesbian, gay, bisexual, transgender, queer [LGBTQ]) experience elevated rates of minority stress and associated substance use relative to their heterosexual and cisgender counterparts. Although the minority stress– substance use relationship is well documented, less is currently known regarding day-to-day min...

Background: Epidemiological studies link lesbian, gay, bisexual and transgender (LGBT) status with negative health outcomes—disparities linked to higher rates of minority stress experienced throughout life (Meyer, 2003). However, the link between minority stress and health is complex, dynamic, and time varying (Hatzenbuehler, 2009). Capitalizing on...

A nationwide online survey targeting college and university-based LGBT student groups, community organizations, LGBT email listservs, and social media was utilized to collect data and measure the associations among victimization, childhood trauma and attributional style (AS) in relation to depressive symptomology in LGBT young adults. Participants...

The authors review research on the risk factors for, and prevalence of, psychological disorders as they relate to gender nonconformity in adolescence and adulthood. Findings from existing literature suggest gender nonconforming individuals are more likely to experience a variety of risk factors associated with psychopathology when compared with gen...

This study investigates the potential effects of statewide nondiscrimination laws on community stigma, as well as its relationship with psychosocial stressors and mental health outcomes. Gender minority individuals (N = 120) completed an online survey containing psychosocial and mental health outcome measures. The experiences of participants who re...

Objective: The current study examined the frequency with which randomized controlled trials (RCTs) of behavioral and psychological interventions for anxiety and depression include data pertaining to participant sexual orientation and nonbinary gender identities. Method: Using systematic review methodology, the databases PubMed and PsycINFO were...

Important mental and physical health disparities exist among lesbian, gay, and bisexual (LGB) individuals in substance abuse treatment. Thus, LGB individuals would benefit from continuity of care within substance abuse treatment that is responsive to their mental and physical health needs. Additional screening, training, outreach, and integration o...

Background: Sexual minority-based victimization, which includes threats or enacted interpersonal violence, predicts elevated suicide risk among sexual minority individuals. However, research on personality factors that contribute to resilience among sexual minority populations is lacking. Using the Five-Factor Model, we hypothesized that individua...

Aims: This study identified the physical andmental health needs and service utilization of lesbian, gay, and bisexual (LGB) individuals relative to heterosexual counterparts in substance abuse treatment. Based on prior research and the minority stress model (Meyer, 2003), we hypothesized that LGB individuals would have higher rates of physical and...

Background: Community participation is important to most people with disabilities despite the fact that common secondary conditions like pain, fatigue and depression may increase the difficulty of leaving home. Despite decades of research on these secondary conditions, little is known about how they are associated with being at home. Objective:...

Purpose: Community participation remains fundamental to contemporary models of disability. However, the effect of temporal scaling on the measurement of participation has not been explored. This study examined the similarities and differences between two different temporal scales (i.e., seven-day recall vs. in situ) on participation measurement....

OBJECTIVES: Increasingly, researchers and practitioners are recognizing transgender individuals’ mental health needs beyond the Gender Dysphoria diagnosis. Nonetheless, most existing research focuses on anxiety, depression, and substance use in localized transgender samples, yielding disparate results. This review aims to synthesize prevalence rate...

Research consistently demonstrates that sexual minority status is associated with increased risk of problematic substance use. Existing literature in this area has focused on group-specific minority stress factors (e.g., victimization and internalized heterosexism). However, no known research has tested the incremental validity of personality trait...

Background: The coming out process for lesbian, gay, and bisexual youth is associated with temporary elevations in alcohol and marijuana use (Rosario, Schrimshaw, & Hunter, 2004). Experiencing rejecting or invalidating reactions after disclosing one’s sexual minority status is predictive of current and future substance use (Rosario, Schrimshaw, & H...

Blackburn’s (2012) recent book invites readers to consider literacy as a tool for engaging lesbian, gay, bisexual, transgender, queer, and questioning (LGBTQQ) youth and their allies in the service of fostering a positive school climate. Her use of concrete examples, learned experiences from facilitating diverse literary performances, and insightfu...