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Relations Among Social Support, PTSD Symptoms, and Substance Use in Veterans Daniel F. Gros, Julianne C. Flanagan, Kristina J. Korte, Adam C. Mills, Kathleen T. Brady, and Sudie E. Back Ralph H. Johnson Veterans Affairs Medical Center, Charleston, South Carolina, and Medical University of South Carolina Social support plays a significant role in the development, maintenance, and treatment of posttraumatic stress disorder (PTSD). However, there has been little investigation of social support with PTSD and its frequent comorbid conditions and related symptoms. Substance use disorders (SUDs) are 1 set of conditions that have yet to be investigated in combination with PTSD and social support. As compared with civilians, veterans are at increased risk for developing both PTSD and SUD. In this study, veterans (N 171) with symptoms of PTSD (76% met diagnostic criteria) and SUD (83% met diagnostic criteria for any dependence) were recruited and completed clinician-rated and self-report measures of PTSD, SUD, and social support. Overall, low social support was reported in the sample. When controlled for the other disorder’s symptoms, PTSD symptoms demonstrated a significant negative relation and SUD symptoms demonstrated a significant positive relation to social support. The PTSD findings are consistent with previous studies on PTSD and social support without SUD comorbidity. However, the SUD findings are inconsistent with previous studies, which focused primarily on older veterans.
Together, these findings highlight the significance of social support in individuals with PTSD and SUD and promote future research within comorbid presentations.
Keywords:posttraumatic stress disorder, social support, alcohol, veterans Posttraumatic stress disorder (PTSD) is a chronic, debilitating disorder associated with significant distress and impairment. PTSD is the most common mental health disorder among veterans, with approximately 15% of veterans meeting current diagnostic criteria (Seal, Bertenthal, Miner, Sen, & Marmar, 2007). The presence of comorbid substance use disorders (SUDs) with PTSD also is a substantial health concern among veterans. SUD co-occurs with PTSD among approximately 40% of veterans with PTSD (Petra- kis, Rosenheck, & Desai, 2011;Pietrzak, Goldstein, Southwick, & Grant, 2011), and those with co-occurring PTSD and SUD suffer a more complicated course of treatment and less favorable treat-ment outcomes compared with individuals with either disorder alone (Back, 2010;Back, Waldrop, & Brady, 2009;Cohen & Hien, 2006;McCauley, Killeen, Gros, Brady, & Back, 2012). Given the high prevalence and distress associated with comorbid PTSD and SUD, efforts aimed at identifying potential protective factors are especially important for advancing the prevention and treatment of the complex combination of these two conditions.
Social support is a potentially important feature in understand- ing how to prevent or treat PTSD. Findings consistently demon- strate that limited social support is associated with more severe PTSD symptoms (Brewin, Andrews, & Valentine, 2000) as well as more severe impairment and suicidal ideation (DeBeer, Kimbrel, Meyer, Gulliver, & Morissette, 2014). Social support also is pos- ited to be a key mechanism in the prevention and treatment of PTSD (Whealin, DeCarvalho, & Vega, 2008). Literature also has demonstrated that social support is a diverse construct in empirical measurement and its manifestations in day-to-day life. For exam- ple, literature indicates that social support available from different individuals in one’s social network (e.g., intimate partners, family members, military unit members and friends) may be differentially influential on symptoms and treatment engagement (Laffaye, Cavella, Drescher, & Rosen, 2008;Pietrzak, Johnson, Goldstein, Malley, & Southwick, 2009). In addition to the source of social support, specific forms of social support, such as positive social interactions, are negatively associated with pretreatment PTSD symptom severity whereas high perceived emotional support is positively associated with increased PTSD treatment response (Price, Gros, Strachan, Ruggiero, & Acierno, 2013).
Social support, including the lack thereof, is a salient correlate of SUD treatment engagement and outcome (Manuel, McCrady, Epstein, Cook, & Tonigan, 2007;McCrady, 2004;Zywiak, Long- This article was published Online First October 27, 2016.
Daniel F. Gros, Julianne C. Flanagan, Kristina J. Korte, Adam C. Mills, Kathleen T. Brady, and Sudie E. Back, Mental Health Service, Ralph H.
Johnson Veterans Affairs Medical Center, Charleston, South Carolina, and Department of Psychiatry and Behavioral Sciences, Medical University of South Carolina.
This research was supported by the National Institute on Drug Abuse (NIDA) grant DA030143 (Principal Investigator [PI]: S. E. B.), the De- partment of Veteran Affairs Clinical Science Research and Development Career Development Award CX000845 (PI: D. F. G.), the National Insti- tute on Child Health and Human Development and the Office of Research on Women’s Health grant K12HD055885 (PI: J. C. F.), and by the National Institute of Alcohol Abuse and Alcoholism grant T32AA007474 (K. J. K.).
The views expressed in this article are those of the authors and do not necessarily reflect the position or policy of NIDA, the Department of Veterans Affairs, or the U.S. government.
Correspondence concerning this article should be addressed to Daniel F.
Gros, Mental Health Service 116, Ralph H. Johnson VAMC, 109 Bee Street, Charleston, SC 29401. E-mail:[email protected] Psychology of Addictive BehaviorsIn the public domain 2016, Vol. 30, No. 7, 764 –770http://dx.doi.org/10.1037/adb0000205 764 abaugh, & Wirtz, 2002). Individuals with PTSD and co-occurring SUD are more likely than individuals without SUD to have nu- merous health and psychosocial complications, and lower social support has been documented in those with PTSD and co- occurring disorders than in individuals with a single diagnosis (Blanco et al., 2013;Bowe & Rosenheck, 2015;Campbell et al., 2007;Kaier, Possemato, Lantinga, Maisto, & Ouimette, 2014; Pietrzak et al., 2011). Indeed, the nature of PTSD and SUD symptomatology; the complicating factors that accompany comor- bidity; and associated behaviors such as poor communication related to emotional numbing, aggressive behavior secondary to hyperarousal symptoms, or anger and distrust secondary to chronic substance use behaviors may hinder the availability, and hence the protective utility, of adaptive social support among veterans. How- ever, the research examining the association between PTSD co- morbidities and social support remains limited.
One of the few existing studies that examined the effects of PTSD and co-occurring disorders on social support included a large sample (N 1,825) of veterans from Operation Enduring Freedom (OEF)/Operation Iraqi Freedom (OIF). In this study, Brancu and colleagues (2014)found that PTSD was associated with greater distress and lower social support. Veterans with PTSD and a co-occurring mental health disorder did not demonstrate lower social support than veterans with PTSD alone. One factor that may partially explain these findings is the heterogeneity of comorbidities observed in the study, which included a wide variety of mental health diagnoses. Perhaps examining the effects of comorbidity on social support at the disorder level may reveal more distinct patterns of association (e.g., PTSD and SUD). For example,DeBeer and colleagues (2014)examined the role of social support on suicidal ideation using a more homogenous group of individuals with PTSD and comorbid mood disorders.
The findings demonstrated that low social support interacted with PTSD and mood symptoms, resulting in greater suicidal ideation than those with higher levels of social support.
Given the equivocal findings among the limited existing re- search, there is need for further investigation in this area with a particular focus on common patterns of PTSD comorbidity, such as that with SUD. Developing an improved understanding of these complex associations may facilitate the development and modifi- cation of treatment approaches to enhance social support and thereby improve treatment engagement and outcome among indi- viduals with co-occurring PTSD and SUD. Thus, the purpose of the current study was to address this gap in the literature by examining social support among veterans with PTSD and co- occurring SUD. Given the complicated clinical presentation of this comorbid group, it was predicted that (a) greater severity of PTSD symptoms and (b) greater severity of SUD symptoms would be associated with lower levels of perceived social support. Method Participants Veterans (N 171) seeking treatment for comorbid PTSD and SUD were recruited from Veterans Affairs (VA) treatment clinics, newspaper and Internet advertisements, and flyers posted at local mental health clinics and colleges. Inclusion criteria involved (a) being a veteran, reservist, or member of the National Guard; (b)being 18 – 65 years old; (c) significant symptoms of PTSD and SUD; (d) substance use in the past 90 days; and (e) fluency in English. Exclusion criteria included (a) current or history of psy- chotic symptoms or bipolar affective disorders, (b) current suicidal or homicidal ideation and intent, (c) current eating disorder or dissociative identity disorder, (d) individuals already participating in ongoing PTSD or SUD treatment, and (e) severe cognitive impairment as indicated by a Mini Mental Status Exam score 21.
Data were collected as part of an ongoing randomized controlled trial sponsored by the National Institute on Drug Abuse investi- gating the efficacy of an integrated psychosocial treatment for co-occurring PTSD and SUD among veterans (Back et al., 2012). Procedure Potential participants were given a full description of the study procedures and asked to read and sign a consent form approved by the institutional review board before any study procedures or assessments were conducted. The baseline assessment involved semistructured clinical interviews, including the Clinician Admin- istered PTSD Scale (CAPS;Blake et al., 1995) and the Mini International Neuropsychiatric Interview (MINI;Sheehan et al., 1998). Participants also completed the PTSD Checklist-Military (PCL-M;Weathers, Litz, Herman, Huska, & Keane, 1993), the time line follow-back (TLFB;Sobell & Sobell, 1992), and the Deployment Risk and Resiliency Inventory (DRRI;King, King, Vogt, Knight, & Samper, 2006).
Measures CAPS.The CAPS is a clinician-rated scale designed to diag- nose current and lifetime PTSD (Blake et al., 1995). The CAPS targets the 17 specific PTSD symptoms from theDiagnostic and Statistical Manual of Mental Disorders, fourth edition (DSM–IV) to assess the intensity and frequency of each symptom on a 5-point Likert scale. The CAPS conducted at baseline was focused on past-month symptoms. Providers of the CAPS attended a 2- to 4-hr CAPS training, watched and corated at least two administrations of the CAPS, administered at least two CAPS under the direct super- vision of a corating supervisor, and demonstrated acceptable in- terrater reliability on their administrations. The CAPS has been shown to have adequate internal consistency, interrater reliability on the same interview, and test–retest reliability over different interviewers (Orsillo, 2002). The internal consistency in the pres- ent study was .91.
DRRI.The DRRI consists of 13 subscales to assess prede- ployment, active duty, and postdeployment factors in recently returning combat veterans (King et al., 2006). For the current study, the social support subscale was of interest—the DRRI-L (Post-Deployment Support; items include “I am carefully listened to and understood by family members or friends” and “Among my friends or relatives, there is someone I go to when I need good advice”). Work with veterans has shown the DRRI to demonstrate acceptable internal consistency for the subscales ( s .81) and convergent and discriminative validity (Vogt, Proctor, King, King, & Vasterling, 2008). The internal consistency in the present study was .74.
MINI.The MINI is a clinician-rated structured diagnostic interview designed to provide a brief, but accurate, assessment of 765 PAIN, PTSD, AND SUBSTANCE USE a wide range ofDSM–IVpsychiatric disorders, including mood and anxiety disorders as well as SUDs (Sheehan et al., 1998). The MINI was used to assess all of its targeted disorders with the exception of PTSD, which was assessed via the CAPS. Similar training procedures were used for the MINI as were used for the CAPS. The MINI has demonstrated adequate interrater and test– retest reliability across most disorders and has specifically shown good interrater reliability with other structured diagnostic inter- views (Sheehan et al., 1998).
PCL-M.The PCL-M is a 17-item self-report measure de- signed to assess PTSD symptom severity related to military/ combat-related trauma (Weathers et al., 1993). Respondents are presented with 17 specific symptoms of PTSD and asked to rate “how much you have been bothered by that problem in the last month” on a 5-point Likert scale. A score 50 or greater on the PCL-M is suggestive of a PTSD diagnosis (Forbes, Creamer, & Biddle, 2001;Weathers et al., 1993). The PCL-M has been shown to have excellent internal consistency in veterans, victims of motor vehicle accidents, and sexual assault survivors as well as excellent test–retest reliability in veterans. In addition, the PCL has demon- strated excellent convergent validity with alternative measures of PTSD (Orsillo, 2002). The internal consistency in the present study was .87.
TLFB.The TLFB is a retrospective measurement of daily substance use (Sobell & Sobell, 1992). The measure is com- pleted via a calendar format and at the direction of a trained assessor to enhance recall. In thepresent study, the TLFB as- sessed use of alcohol, stimulants (e.g., cocaine), opiates (e.g., heroin), marijuana, prescription drugs (e.g., prescription opioids, benzodiazepines, and psychostimulants), and nicotine over the past 60 days. The TLFB has demonstrated good psychometric proper- ties in the literature, including test–retest reliability, convergent and discriminant validity with other measures, and agreement with collateral informants and urine assays (Fals-Stewart, O’Farrell, Freitas, McFarlin, & Rutigliano, 2000).
Data Analysis Of the initial 171 participants, 28 participants were excluded because of missing data on any of the primary measures. An additional 11 participants were excluded because of errors in their reporting on the TLFB. There were no differences between the excluded and included participants on demographics (ps .26), psychiatric diagnoses (ps .72), social support (p .08), PTSD symptoms (ps .26), or alcohol use (p .29). All remaining participants were included in the analyses. A series of hierarchical regression analyses were conducted to identify the unique relations among social support and PTSD symptoms and substance use. In the first step of each of these analyses, demographic variables (i.e., age, gender, race, relationship status, and employment status) were entered as covariates. Social support (DRRI) was entered in the second step. The analyses were conducted multiple times, with each measure of PTSD symptom severity (CAPS and PCL-M) and substance use (TLFB—Alcohol Use, TLFB—Stimulant Use, TLFB—Opiate Use, TLFB—Marijuana Use, TLFB—Prescription Drug Misuse) entered as a dependent variable. In addition, the nonmatching variable was included in the first step (PTSD as covariate for SUD as dependent; SUD as covariate for PTSD as dependent variable). The distribution of all dependent variableswas investigated to inform final inclusion of variables. Separate models were run with the CAPS and PCL-M to investigate the reliability of the findings across clinician-rated and self-reported PTSD symptoms. The CAPS and PCL are considered “gold stan- dards” in the measurement of PTSD and are frequently studied together in this way (Orsillo, 2002). Results Demographics of the Sample The average participant was 41.7 years old (SD 12.0), male (90.9%), White (50.0%) or Black (47.1%), and unemployed (68.9%). Most participants were either married (31.1%) or di- vorced/widowed (44.7%). The average number of years of educa- tion was 13.8 years (SD 1.8), and 59.1% had been deployed to OEF, OIF, or Operation New Dawn (OND).
Most participants were diagnosed with PTSD (76.5%) and en- dorsed elevated symptoms consistent with a PTSD diagnosis on the PCL-M (M 59.3;SD 12.9). Most participants also were diagnosed with alcohol dependence (73.3%) and reported 25.0 total days used within the past 60 days (SD 21.2). Approxi- mately 38.9% also met criteria for current drug dependence. The average DRRI social support score was 46.6 (SD 8.8), and these scores were normally distributed within the sample (skewness 0.29; kurtosis 0.44).
Regression Analyses Before completing the regression analyses, the distribution of each dependent variable was investigated. TLFB—Alcohol Use, CAPS, and PCL-M variables were found to have acceptable skew- ness (range 0.671 to 0.528) and kurtosis (range 0.674 to 0.376) and were included in the regression analyses. However, TLFB— Stimulant Use, TLFB—Opiate Use, TLFB—Marijuana Use, and TLFB—Prescription Drug Misuse evidenced unacceptable skew- ness (range 2.560 –7.746) and kurtosis (range 5.631–67.361).
There were significant missing data in these variables that may have contributed to their skewness and kurtosis and greatly limited their possible interpretation. Thus, these variables were excluded from the analyses.
In the analyses with PTSD as the dependent variable (seeTable 1), social support was used to predict the scales assessing PTSD symptoms with separate models for the CAPS and PCL-M scores.
The first step included demographics and TLFB—Alcohol Use.
The first steps in both models were significant (Fs 2.17;ps 0.05). The second step added social support and significantly increased the variance explained in both models (F change s 7.8; ps .007). With the addition of the second step, social support emerged with significant relation to PTSD symptoms in each of the models (ts 2.7;ps .004) above and beyond alcohol use, whereas greater social support was predictive of less severe PTSD symptoms in the CAPS and PCL-M.
In the analyses with alcohol use as the dependent variable (see Table 1), demographic variables, PTSD symptoms (separate mod- els for CAPS and PCL-M symptoms), and social support were used to predict alcohol use. The first step with demographics and PTSD symptoms was significant in the model with the CAPS (F 2.72;p .02), but not significant in the model with the PCL-M 766 GROS ET AL. (F 1.72;p .122). The second step with social support was significant in both models (Fs 2.92;ps .008), with significant R 2s(F change 9.4;ps .004) as well as the social support variable (ts 3.0;p .004), whereas greater social support was predictive of greater alcohol use symptoms. Discussion The present study investigated the relations among PTSD, co- occurring SUD, and social support in veterans. Consistent with our hypotheses, social support had a significant relation to PTSD symptoms as well as alcohol use. Social support was associated with PTSD and alcohol use above and beyond the comorbid condition (self-reported PTSD as covariate for SUD as dependent; self-reported SUD as covariate for PTSD as dependent variable), suggesting that social support had an independent relation with each cluster of symptoms in this sample. Increased social support was associated with less severe PTSD symptoms. However, the alcohol use findings were in the opposite direction, with increased social support associated with increased alcohol use. Interestingly, average social support in this sample appears lower than averages reported in two recent studies also using the DRRI, including a VA treatment-seeking sample of OEF/OIF veterans (Pietrzak et al.,2010) as well as National Guard soldiers returning from OIF with or without new-onset PTSD (Polusny et al., 2011). Together, these findings highlight the significance of social support in veterans with symptoms of PTSD and alcohol use.
The PTSD findings are consistent with previous findings for social support. Social support is associated with the lack of devel- opment of PTSD after trauma exposure (Kilpatrick et al., 2007; Pietrzak et al., 2010;Wilcox, 2010) and plays a significant role in the successful treatment of PTSD (Price et al., 2013). The current study is the first to investigate this relation in veterans with comorbid PTSD and SUD. Despite the noted relation between increased social support and increased alcohol use, increased so- cial support was associated with less severe PTSD symptoms. This finding is surprising because of the more severe symptoms when both disorders are present. That is, more severe PTSD symptoms are associated with increased SUD symptoms (McCauley et al., 2012). This relation among the three variables may further high- light the detrimental (decreased) nature of poor social support in PTSD independent of the presence of a SUD.
The current findings regarding the relation between alcohol use and social support were in contrast to our hypothesis as well as the previous literature (Ren, Skinner, Lee, & Kazis, 1999;Sacco, Table 1 Hierarchical Regression Analysis Testing Social Support Predicting PTSD Symptoms and Alcohol Use Step VariableBSE tF R 2 Clinician Administered PTSD Scale (CAPS) 1 Age 0.41 0.19 .20 2.16 3.08 .128 Gender 7.54 7.11 .90 1.06 Race 3.41 2.60 .11 1.31 Relationship Status 4.02 2.60 .13 1.55 Employment Status 2.72 4.67 .05 0.58 TLFB—Alcohol Use 0.23 0.09 .22 2.55 2 DRRI—Social Support 0.91 0.24 .32 3.79 4.97 .090 PTSD Checklist–Military (PCL-M) 1 Age 0.13 0.10 .12 1.28 2.18 .092 Gender 5.23 3.80 .12 1.38 Race 0.16 1.27 .01 0.12 Relationship Status 2.95 1.40 .19 2.11 Employment Status 0.71 2.50 .03 0.28 TLFB—Alcohol Use 0.07 0.05 .13 1.46 2 DRRI—Social Support 0.37 0.13 .24 2.80 3.09 .052 TLFB–Total Days Used–Alcohol (with CAPS) 1 Age 0.08 0.19 .04 0.41 2.72 .115 Gender 9.57 6.77 .12 1.42 Race 2.88 2.48 .10 1.16 Relationship Status 2.44 2.50 .09 1.00 Employment Status 7.14 4.42 .14 1.62 CAPS—PTSD 0.21 0.08 .22 2.55 2 DRRI—Social Support 0.83 0.23 .31 3.57 4.37 .082 TLFB–Total Days Used–Alcohol (with PCL-M) 1 Age 0.05 0.18 .03 0.29 1.72 .074 Gender 7.91 6.80 .10 1.16 Race 0.66 2.27 .03 0.29 Relationship Status 0.49 2.54 .19 0.19 Employment Status 9.51 4.37 .19 2.18 PCL—PTSD 0.23 0.16 .13 1.46 2 DRRI—Social Support 0.71 0.23 .27 3.08 2.93 .064 Note.TLFB time line follow-back; DRRI Deployment Risk and Resiliency Inventory. p .05. p .01. p .001. 767 PAIN, PTSD, AND SUBSTANCE USE Bucholz, & Harrington, 2014). More specifically, previous re- search shows that although adaptive social support is consistently associated with successful substance use treatment outcomes, some studies have reported no significant relation between alcohol use severity and social support (Ren et al., 1999;Sacco et al., 2014) and others reporting a small negative relation between the two (Boscarino, 1995). The present findings suggest that increased social support was associated with increased alcohol use. Although the findings are contrary to the literature, there are a few possible hypotheses for these findings that may inform future investigation.
First, the present study was completed on a much younger sample of veterans from recent combat theaters (e.g., OEF/OIF/OND), suggesting possible differences in veterans from varying eras of service. In addition, previous research has demonstrated robust positive associations between younger age and greater alcohol use in adult samples (Centers for Disease Control and Prevention, 2012) and that younger adults are more likely to drink in social settings to enhance social enjoyment (Gruenewald, Remer, & LaScala, 2014;O’Hara, Armeli, & Tennen, 2015). One recent study of heavy-drinking OEF/OIF veterans indicated that those with comorbid PTSD were more likely to attribute their alcohol misuse to symptom self-medication whereas those without PTSD were more likely to drink to enhance social experiences (McDevitt-Murphy, Fields, Monahan, & Bracken, 2015). Perhaps the younger veterans enrolled in our study were engaged in more socially rewarding drinking activities or had less opportunity to experience the negative consequences of prolonged heavy drink- ing, which may account for the perceived association between social support and alcohol use observed here. Finally, the literature examining associations between SUD and social support among veterans is limited, suggesting that differences in drinking patterns and associations with social support may have transitioned over time and with important contextual changes such as prolonged U.S. engagement in the conflicts in Iraq and Afghanistan. A further complicating factor is that social support is conceptualized and measured in widely varying ways across the literature. Additional research on similar samples attending to the nuances of social support source and type is needed to replicate the present findings and investigate these hypotheses among more current and repre- sentative veteran samples.
Despite the interaction of PTSD and alcohol use symptoms, the overall level of social support was low in the present study and particularly when compared with other similar studies of veterans and with the same social support measure (Pietrzak et al., 2010; Polusny et al., 2011). This finding may suggest that the relation between more severe PTSD symptoms and decreased social sup- port may be much stronger than the relation between increased alcohol use and increased social support, resulting in overall lower social support.
Because social support has been found to be protective against the development of PTSD and important in the related treatment outcome in veterans with PTSD, treatments for PTSD and associated comor- bidities should incorporate a social support building component to improve symptoms and potentially reduce future relapse. One exam- ple is the use of Concurrent Treatment of PTSD and Substance Use Disorders Using Prolonged Exposure (COPE;Back et al., 2015), which contains instruction to complete “healthy activities that you have lost interest” in as part of the “in vivo” exposure exercises.
Additional examples include dyadic interventions targeting co-occurring PTSD and SUD such as Significant-Other Enhanced Cognitive–Behavioral Therapy (McDevitt-Murphy, 2011) and Cou- ple Treatment for AUD and PTSD (Schumm, Monson, O’Farrell, Gustin, & Chard, 2015). Both treatments aim to enhance social support gained from partners to simultaneously reduce symptomatol- ogy and improve dyadic functioning. Although additional research is needed, the use of treatments that encourage improvements in social support could have added benefits in PTSD psychotherapeutic out- comes.
The present study contains several limitations. First, only single measures for social support and alcohol use were used, limiting their reliability and comparison across self-report and clinician- rated assessments. In addition, the sample contained an insufficient number of participants endorsing use of other substances of abuse; therefore, the findings cannot generalize to use of other substances.
Although most veterans were deployed to OEF/OIF/OND, a mi- nority of participants were veterans from other conflicts. Finally, the study was limited to a cross-sectional investigation and cannot inform treatment or changes over time. Each of these limitations should be addressed in future research on this topic.
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