An examination of alcohol risk profiles and co-occurring mental health symptoms among OEF/OIF veterans

Highlights

• We examined alcohol risk profiles of OEF/OIF veterans.

• Profiles were associated with different severity of mental health symptoms.

• Interventions could target co-occurring alcohol risk and mental health symptoms.

Abstract

Introduction

Compared to the general population, veterans of the wars in Afghanistan and Iraq (OEF/OIF) are more likely to engage in hazardous alcohol use and meet criteria for mental health disorders including Posttraumatic Stress Disorder (PTSD) and Major Depressive Disorder. Less is known how distinct profiles of alcohol use behavior relate to mental health symptoms.

Method

The current study examined the extent that indicators of alcohol use (i.e., drinks per week, peak blood alcohol concentration, and alcohol-related problems) are categorized into different alcohol risk profiles utilizing a person-centered approach. We also examined how mental health symptoms (i.e., PTSD, depression, and anxiety-related symptoms) were associated with the alcohol risk profiles. Participants were 252 Veterans who reported consuming alcohol within the past month.

Results

Latent profile analysis indicated a four-class solution yielded the best-fitting model, and profiles were named based on their respective levels and patterns of alcohol use. Mental health symptoms were significantly different among the four profiles. Profiles of veterans who endorsed more alcohol-related problems (i.e., the “Severe alcohol behavior” and “Steady drinkers with functional impairment”) also reported comorbid clinical symptoms of PTSD, depression, and anxiety. The “Binge drinkers with no functional impairment” and “Mild alcohol behavior” profiles reported the lowest levels of mental health symptoms.

Discussion

Findings highlight the unique relationship between distinct alcohol risk profiles and mental health outcomes. Targeted interventions and treatment options based on unique alcohol risk profiles may be helpful in tailoring prevention and intervention efforts in detecting co-occurring mental health symptoms among OEF/OIF veterans.

Introduction

Research has indicated that up to 13% of veterans of the wars in Iraq (Operation Iraqi Freedom [OIF]) and Afghanistan (Operation Enduring Freedom [OEF]) meet criteria for an Alcohol Use Disorder (Kehle et al., 2012), compared to 8% of the general US population (Grant et al., 2004). Rates of hazardous drinking among OEF/OIF veterans [defined as binge drinking (using the 4/5 + cut off) and/or scores 8 or higher on the Alcohol Use Disorders Identification Test (AUDIT; Babor, Higgins-Biddle, Saunders, & Monteiro, 2001)], have ranged from 18% to 40% (Calhoun et al., 2008, Eisen et al., 2012, Hoge et al., 2004), and are higher than non-OEF/OIF veterans (Hawkins, Lapham, Kivlahan, & Bradley, 2010) and non-veterans (Wagner et al., 2007). Research examining hazardous alcohol use in OEF/OIF samples typically use brief screeners, such as the AUDIT, which combine questions regarding quantity/frequency of alcohol use, alcohol-related problems, and diagnostic symptoms, into one composite variable (e.g., Burnett-Zeigler et al., 2011, Calhoun et al., 2008, Eisen et al., 2012, Hoge et al., 2004, Jakupcak et al., 2010, McDevitt-Murphy et al., 2010, McDevitt-Murphy et al., 2015, Smith et al., 2014, Wilk et al., 2010). By examining variable-level outcomes that combine multiple alcohol-related indices (e.g., quantity/frequency/problems), these approaches may be limited as they do not identify groups of people who share similarities on specific indices. The dimension of drinking quantity/frequency could be examined separately from alcohol-related problems to further clarify alcohol outcomes.

Previous studies among veterans have addressed the co-occurrence of hazardous alcohol consumption and PTSD (McDevitt-Murphy et al., 2015, Wilk et al., 2010). Other studies have indicated OEF/OIF veterans experience more mental health symptomology compared to the general population (Eisen et al., 2012); 36.9% of OEF/OIF veterans (n = 289.328) entering VA healthcare met criteria for a mental health disorder. Of those, 29% experienced two disorders and 33% met criteria for three or more disorders (Seal et al., 2009). Studies have indicated that 37.3% of OEF/OIF veterans screening positive for mental health disorders also engaged in hazardous drinking (Heltemes, Clouser, MacGregor, Norman, & Galarneau, 2014). In turn, 26.9% of hazardous drinkers screened positive for significant mental health symptoms (Smith et al., 2014). Mental health disorders most commonly associated with hazardous alcohol use include symptoms of Posttraumatic Stress Disorder (PTSD), depression, and other anxiety-related disorders (Burnett-Zeigler et al., 2011, Stecker et al., 2010).

Of all medical and psychiatric diagnoses, depression and PTSD were the second and third most common, occurring in nearly 13% and 12% of a national OEF/OIF sample, respectively; PTSD was the most common mental health diagnosis (Seal et al., 2009, Stecker et al., 2010). For comparison, 7% of the general US population meets criteria for Major Depressive Disorder and 11% meets criteria for any anxiety disorder (Grant et al., 2004). OEF/OIF veterans endorsing PTSD or depression symptoms are two times more likely to engage in hazardous alcohol use relative to veterans not endorsing symptoms (Jakupcak et al., 2010). Additionally, PTSD symptoms, depression symptoms, and hazardous drinking are highly predictive of one another (Mustillo et al., 2015). Studied less often in OEF/OIF samples is the presence of anxiety symptoms (distinct from PTSD-related symptomology), despite 5% of veterans being diagnosed with a current anxiety-related disorder (Stecker et al., 2010), 16% to 18% reporting anxiety-related symptoms (Hoge et al., 2004), and links between anxiety symptoms and hazardous drinking in OEF/OIF samples (Barry, Whiteman, MacDermid Wadsworth, & Hitt, 2012).

Most studies have focused on PTSD when attempting to explain the link between alcohol use and mental health symptoms in OEF/OIF veterans. Findings have indicated that combat experiences and PTSD onset prior to alcohol use disorders (Kline et al., 2014), and symptom clusters related to avoidance and numbing (Jakupcak et al., 2010, Kehle et al., 2012) predict alcohol use behaviors. Moreover, PTSD symptom severity in OEF/OIF veterans was positively associated with increased coping-related drinking motives (McDevitt-Murphy et al., 2015). Such findings suggest that alcohol consumption may serve as a method of managing mental health symptoms, consistent with theories of self-medication where hazardous drinking is negatively reinforced via reduction in symptom-related experiences (Khantzian, 2003, Stewart, 1996). Although a substantial amount of research has reported on the association between hazardous drinking and mental health symptoms, much less research has examined how mental health symptoms relate to distinct profiles of alcohol risk indices.

Latent Profile Analysis (LPA)/Latent Class Analysis (LCA) are person-centered analyses where individuals are categorized into different groups (known as “profiles”) based on shared characteristics. Profiles can then be examined to understand how groups differ on external criteria (Muthén & Muthén, 2002). LPA approaches are helpful in identifying groups who may be at increased risk and therefore candidates for targeted interventions. To date, there has been little research explicitly examining alcohol use profiles. Previous research that has focused on patterns of alcohol use and mental health symptoms has typically created variable level categories of drinking status (i.e., using cut points for moderate and heavy drinking) based on individuals' quantity/frequency estimates (e.g., Alati et al., 2005, Caldwell et al., 2002, O'Donnell et al., 2006).

Taken together, OEF/OIF veterans engage in elevated rates of hazardous drinking. Most findings, however, rely on brief screeners where alcohol-related behaviors such as quantity/frequency estimates and problems are combined in variable-level analyses as a composite alcohol risk variable. To build on the existing literature, the first aim of the current study was to determine the extent to which OEF/OIF alcohol use indices (i.e., drinks per week, peak blood alcohol concentration (BAC), and alcohol-related problems) may be categorized into different alcohol risk profiles utilizing a person-centered approach. Although we made no hypothesizes on the exact number of profiles, we did predict that individuals with greater alcohol use and problems would form a distinct profiles from those with less use and consequently less problems. While the co-occurrence of mental health symptoms and hazardous drinking has been well-documented in OEF/OIF samples, to our knowledge no studies have examined how mental health symptoms may relate to alcohol use profiles. Accordingly, the second aim of the study was to examine how different mental health symptoms (i.e., PTSD, depression, and anxiety-related symptoms) are associated with alcohol risk profiles. We hypothesized that profiles with greater alcohol use indices would be associated with increased mental health symptoms, and profiles with less alcohol use indices would be associated with less mental health symptoms.