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. Author manuscript; available in PMC: 2017 Nov 1.
Published in final edited form as: Psychol Addict Behav. 2016 Jun 6;30(7):771–777. doi: 10.1037/adb0000185

A Population Based Study of Help-seeking and Self-medication Among Trauma Exposed Individuals

Christina Sheerin a,c, Erin C Berenz b, Gun Peggy Knudsen d, Ted Reichborn-Kjennerud d,e, Kenneth S Kendler c,f, Steven H Aggen c, Ananda B Amstadter c,f
PMCID: PMC5114150  NIHMSID: NIHMS780565  PMID: 27269293

Abstract

Epidemiologic studies of trauma highlight the imbalance between prevalence of psychiatric diagnoses and help-seeking. We investigated prevalence and correlates of help-seeking and self-medication in Norwegian adults with trauma history with a focus on common post-trauma outcomes of posttraumatic stress disorder (PTSD) and substance use disorders (alcohol or drug). Participants reporting at least one PTSD symptom (n=307) were asked if they consulted with a doctor/another professional (help-seeking) or used drugs/alcohol (self-medication) for trauma-related problems. PTSD, alcohol abuse or dependence (AUD), and drug use or dependence (DUD) were assessed via structured diagnostic interviews. Help-seeking and self-medication were endorsed by 37.4% and 10.4% of the sample, respectively. As compared to the full sample, help-seeking was endorsed at a greater rate in individuals with PTSD (χ2=8.59, p=.005) and at a lower rate in those with AUD (χ2=7.34, p<.004). Self-medication was more likely to be endorsed by individuals with PTSD versus without PTSD (χ2=25.68, p<.001). In regression analyses, PTSD was associated with increased likelihood of self-medication (OR=4.56) and help-seeking (OR=2.29), while AUD was associated with decreased likelihood of help-seeking (OR=.29). When self-medication was included as a predictor, PTSD was no longer associated with help-seeking, although AUD remained inversely associated. PTSD and AUDs have a nuanced relationship with formal help-seeking as well as the use of substances to cope. Trauma-exposed individuals are likely engaging in adaptive and maladaptive coping strategies, the latter of which may be compounding distress.

Keywords: help-seeking, potentially traumatic events, posttraumatic stress disorder, self-medication, alcohol use disorder

Introduction

Epidemiologic studies in the United States (US) suggest a significant imbalance between the prevalence of mental health diagnoses and utilization of mental health services, with approximately 50% seeking help (Wang et al., 2005). Investigation of help-seeking behavior, particularly in populations at increased risk for psychopathology, is needed to inform our understanding of treatment utilization. Trauma-exposed populations may be particularly relevant, given that trauma serves as a generalized risk factor with wide-reaching effects, associated with increased rates of posttraumatic stress disorder (PTSD; Kessler et al., 1995) as well as a wide range of psychiatric disorders and substance use disorders (Goldstein et al., 2013; Schiff, Zweig, Benbenishty, & Hasin, 2007; Vlahov et al., 2004). Although help seeking has been studied in trauma populations, much of the extant studies on trauma-related help-seeking behaviors are conducted with specific populations such as combat veterans (van den Berk-Clark & Wolf, 2015) and victims of crime (McCart, Smith, & Sawyer, 2010), potentially limiting generalizability for understanding these patterns outside of these homogenous trauma samples. Thus, population-based studies of help-seeking are called for.

In the US, studies of the prevalence and correlates of help-seeking among trauma-exposed populations suggest that PTSD is related to increased likelihood of seeking help (Amstadter et al., 2008). Among those with a PTSD diagnosis, older age, being married, greater functional impairment, and comorbid diagnoses are associated with greater likelihood of help-seeking (Koenen et al., 2003). Research in US trauma-exposed samples indicates that greater distress and impairment are related to increased likelihood of both treatment utilization and self-medication. However, as noted above, most of this work is limited to clinical populations with specified trauma histories (e.g., sexual assault, combat) and few studies have examined these factors within a single population-based investigation, with a broad range of trauma exposures, and in a non-US population, to determine cross-cultural patterns.

Existing studies have indicated that when individuals engage in substance use after exposure to trauma, they are more likely to delay behaviors that are more effortful but can improve long-term outcomes (e.g., help-seeking; MacKillop et al., 2011) and such use can inhibit an individual’s ability to manage emotions or process trauma-related information and thoughts (Kaysen et al., 2011). A recent systematic review found mixed results regarding the direction of association between substance use in the aftermath of trauma exposure and treatment utilization, noting that the association remains poorly understood (i.e., whether and under what circumstances traumatized individuals are choosing substance use over help-seeking or whether substance use motivates help-seeking; van den Berk-Clark & Wolf, 2015). Both trauma exposure itself and PTSD symptoms are related to increased self-medication behavior, such as coping-oriented alcohol use (e.g., Dixon, Leen-Feldner, Ham, Feldner, & Lewis, 2009). Self-medication behaviors more broadly are associated with an increase in the development of alcohol use disorders (AUDs; Cooper, 1994; Dixon et al., 2009) and greater levels of cannabis use (Bonn-Miller, Zvolensky, & Bernstein, 2007). Notably, a study of daily monitoring data indicated that coping-oriented alcohol use moderated a relationship between PTSD symptoms and acute alcohol use (Simpson et al., 2014). Such findings align with the well-documented and common comorbidity of substance use disorders and PTSD; this relationship is associated with increased symptoms and disability, as well as greater rates of treatment utilization in this comorbid population (Blanco et al., 2013).

The present study aimed to add to the existing literature by examining both help-seeking and self-medication behaviors, separately and in combination, as a function of both alcohol use disorder and PTSD in a Norwegian epidemiological sample with a range of trauma exposure histories. Epidemiologic research on help-seeking and self-medication within non-US trauma-exposed populations is limited. Epidemiologic studies have been conducted on rates of trauma exposure, and have indicated lower rates of both trauma exposure and PTSD in Western Europe (to varying degrees depending on the country; e.g. Perkonigg, Kessler, Storz, & Wittchen, 2000). Yet, much less is known about treatment utilization and self-medication following trauma in this region. The primary aim of the present study was to investigate the prevalence and correlates of help-seeking and trauma-related self-medication among Norwegian young adults with a history of trauma exposure as it relates to outcomes of PTSD, AUDs, and drug use disorders (DUDs). It was hypothesized that PTSD would increase the likelihood of help-seeking and self-medication while the presence of a substance use disorder diagnosis (AUD or DUD) would decrease the likelihood of formal help-seeking but increase the likelihood of self-medication. The secondary aim was to examine whether trauma-related self-medication was related to likelihood of help-seeking. It was hypothesized that self-medication, as a marker of avoidance behavior, would be associated with decreased odds of help-seeking behavior.

Methods

As detailed in prior work with this dataset (Amstadter et al., 2013), the sample consists of an epidemiological study of twins recruited from the Norwegian Institute of Public Health Twin Panel (NIPHTP; Harris, Magnus, & Tambs, 2002). Informed consent was collected following description of the study; approval was granted from the Norwegian Data Inspectorate and the Regional Ethical Committee. Data for this report utilized an interview study of this sample (Tambs et al., 2009). Axis I disorders were assessed with a Norwegian computerized version of the Munich-Composite International Diagnostic Interview (M-CIDI, Plomin, DeFries, & Loehlin, 1977), a structured diagnostic interview shown to have good reliability. The interviews, mostly face-to-face, were carried out between 6/99 and 5/04.

The interview study was conducted with 2,794 individuals (44% of those eligible). The derivation of the current study sample from the interview study is depicted in Figure 1. During the PTSD module, participants were queried if they had (a) experienced or witnessed seven types of traumatic events (e.g., combat, natural catastrophe), as well as an “other” option, and (b) if they felt “terrified, helpless, or frightened” during the event. Individuals who endorsed at least one event meeting DSM-IV Criterion A for PTSD (n=737) completed an assessment of DSM-IV PTSD symptoms in reference to their “worst” endorsed event. Trauma exposed participants who endorsed at least one symptom (n=307) were asked two questions about help-seeking: 1) if they told a doctor (a medical doctor; e.g., physician, psychiatrist) about the problems that occurred as a result of the traumatic event; and 2) if they told another professional (e.g., psychologist, social worker) about these difficulties, combined to form the “help-seeking” outcome variable. Participants were also asked if they took medication, or used drugs or alcohol more than once, for problems occurring as a result of the traumatic event (0=no self-medication, 1=self-medication). Thus, the present analyses assess those individuals who endorsed at least one symptom and were then asked follow-up questions regarding help-seeking and self-medication. Diagnoses of PTSD, as well as abuse and dependence on alcohol (AUD) and drugs (DUD) and major depressive disorder (MDD; for use as a covariate) reflect diagnostic criteria as determined by the M-CIDI.

Figure 1.

Figure 1

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Breakdown of original study and derivation of present sample

Analyses of the present sample (n=307) were conducted using SPSS version 20. Chi square analyses were conducted to determine differences in prevalence rates as a function of PTSD and AUD diagnostic status1. To address the primary aim, two generalized estimating equation (GEE) regression models were run to account for the non-independence of the twin clustering in the prediction of 1) formal help-seeking and 2) self-medication. Predictor variables included demographic variables (e.g., age, education, sex), trauma characteristics (e.g., number of interpersonal and accidental traumatic event categories endorsed), PTSD status and AUD status. While self-medication was of interest as an outcome, we were also interested in whether trauma-related self-medication was related to formal help seeking. To address this secondary aim, another GEE logistic regression model predicting help-seeking was conducted with the inclusion of self-medication as a predictor variable to examine whether self-medication accounted for unique variance in formal help-seeking, beyond the other variables.

Results

In this subsample, the most common “worst” events endorsed included physical threat (n=81), childhood sexual abuse (n=51), and rape (n=50). Among the 307 participants who endorsed at least one posttraumatic stress symptom (56% female; Mage=28.31, SD=3.98, range=19–36), 23.5% reported telling a doctor and 17.9% reported telling another professional about problems that occurred as a result of the traumatic event, with 37.4% (n=114) endorsing at least one form of help-seeking. A PTSD diagnosis was met by 23% of the sample (n=71), with a mean of 11.93 (SD=2.36, range 7–17) total symptoms in those with a diagnosis as compared to a mean of 6.97 (SD=3.68, range 2–17) in the larger, trauma-exposed sub-sample. Among those with a PTSD diagnosis, 52.1% (n=37) reported formal help-seeking (32.4% told a doctor, 28.6% another professional), a rate greater than those without PTSD (χ2=8.59, p=.005). As compared to PTSD, the prevalence of AUDs and DUDs was lower in this sample, with 15% (n=46) meeting criteria for AUD and 4.6% (n=14) meeting criteria for DUD. The rates of comorbidity with PTSD were 4.9% for AUD, and 2.3% for DUD. Among those with a substance use disorder diagnosis, 19.6% of those with AUD and 35.7% of those with DUD diagnoses reported any formal help-seeking, reflecting rates that were significantly lower than the full sample in those with AUD (χ2=7.34, p<.004). Trauma-related self-medication was endorsed by 10.4% (n=32) of participants, consisting of 26.4% (n=19) of those with PTSD, 15.2% (n=7) of those with AUD, and 28.6% (n=4) of those with a DUD diagnosis. These rates of self-medication were significantly higher in those with PTSD as compared to those without (χ2=25.68, p<.001) and were higher, but did not reach significance, in those with AUD (χ2=1.33, p=.29).

As shown in Table 1, older age (OR=1.08, 95% C.I.=1.01–1.15, p=.03) and PTSD diagnostic status (OR=2.29, 95% C.I.=1.26–4.16, p=.007), were the only variables associated with increased likelihood of help-seeking, while AUD was associated with a decreased likelihood of help-seeking (OR=.29, 95% C.I.=.14–.62, p=.001). In the analysis examining trauma-related self-medication2 PTSD status was the only variable significantly associated, resulting in a greater likelihood of trauma-related self-medication (OR=4.58, 95% C.I.=1.94–10.82, p=.001). These findings remained in follow-up analyses covarying for major depressive disorder (MDD) status, given its high comorbidity with PTSD. In this sample, MDD was not independently associated with either help seeking (p=.70) or self-medication (p=.61).

Table 1.

Logistic regression analyses of the primary models of formal help-seeking and self-medication of 307 individuals from the Norwegian Institute of Public Health Twin Panel exposed to a traumatic event who reported symptoms of distress following the event.

Aim 1
Formal help-seeking Self-medication
Predictor OR 95% C.I. p OR 95% C.I. p
Demographic characteristics
 Age 1.08 1.01–1.15 .02* 1.06 0.96–1.17 .25
 Gender 1.14 0.64–2.03 .65 2.28 0.81–6.42 .12
 Education 0.99 0.90–1.00 .94 1.04 0.87–1.25 .66
Trauma type
 Accidental trauma 1.04 0.62–1.75 .88 1.25 0.55–2.80 .60
 Interpersonal trauma 0.80 0.53–1.21 .29 0.61 0.33–1.13 .12
Posttraumatic Stress Disorder 2.29 1.26–4.16 .01* 4.58 1.94–10.82 .001*
Alcohol Abuse/Dependence 0.29 0.14–0.62 .001* 1.70 0.65–4.40 .28
Aim 2
Demographic characteristics
 Age 1.08 1.01–1.15 .03*
 Gender 1.04 0.58–1.89 .89
 Education 0.99 0.89–1.10 .87
Trauma type
 Accidental trauma 1.03 0.61–1.74 .92
 Interpersonal trauma 0.85 0.56–1.30 .85
Self-Medication 4.38 1.81–10.60 .001*
Posttraumatic Stress Disorder 1.81 0.97–3.39 .06
Alcohol Abuse/Dependence 0.25 0.11–0.60 .002*
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Regarding our secondary aim, to examine the impact of trauma-related self-medication as it relates to help-seeking, the GEE model was run with the inclusion of self-medication as a covariate (see Table 1). In this analysis, older age (OR=1.08, 95% C.I.=1.01–1.45, p=.03) and self-medication (OR=4.38, 95% C.I.=1.81–10.60, p=.001) were significantly associated with increased odds of help-seeking. AUD remained associated with a decreased likelihood of help-seeking (OR=.25, 95% C.I.=.11–.60, p=.002). However, when accounting for self-medication, PTSD was no longer significantly associated (OR=1.81, 95% CI=.97–3.39, p=.06).

Discussion

The primary aim of the study was to document rates and correlates of formal help-seeking and trauma-related self-medication among a Norwegian sample of trauma-exposed adults who reported at least one posttraumatic stress symptom. Approximately one-third of the sample reported trauma-related concerns to a doctor or other professional, as compared to approximately half of those with a PTSD diagnosis and less than a quarter of those with an alcohol or drug abuse/dependence diagnosis, reflective of significantly different prevalence rates as a function of PTSD and AUD. Individuals with PTSD or substance use histories endorsed self-medicating to cope with symptoms to a greater degree than those without either disorder. From a clinical standpoint, this is concerning given that about 50% of individuals with a PTSD history have not sought professional services for their symptoms and a significant portion are using substances in an attempt to manage symptoms (Waldrop, Back, Verduin, & Brady, 2007).

Consistent with prior research, our analyses found that older age and PTSD history were significantly related to greater likelihood of help-seeking (Amstadter et al., 2008; 2010). It is possible that older adults had been experiencing trauma-related distress for a longer period of time. Greater affective distress experienced by those with PTSD may be prompting them to seek relief from these symptoms more actively. Also consistent with existing research, AUD was significantly related to a decreased likelihood of help-seeking (Wang et al., 2005). Extant research has attributed this decreased treatment seeking in this population to factors such as lack of perceived need for treatment or tendencies to delay treatment until the severity of the disorder has become debilitating (Mojtabai, Olfson, & Mechanic, 2002). This has potential implications for individuals who initiate substance use as a means of self-medication and may be less likely to recognize when this behavior becomes problematic. While AUD was not significantly associated with self-medication in the initial model, this may be accounted for by the strong relationship between PTSD and self-medication or the presence of comorbidity of PTSD and AUD.

Contrary to our secondary hypothesis, self-medication, above and beyond the other predictors, was significantly associated with greater likelihood of formal help-seeking. The increased rates of help-seeking in those who self-medicate as compared to decreased rates of help-seeking in those whose substance use has reached the level of alcohol abuse/dependence suggests a complicated picture when examining individuals with AUDs following a trauma as compared to those who identified substance use as a specific means to cope following a trauma. Of note, while PTSD was no longer statistically significant in the model when self-medication was included, given the trend-level significance value and size of the odds ratio (with β=.60), this finding may be more attributable to low power as opposed to a truly nonsignficant effect. However, this should still be interpreted with caution given the confidence interval range.

Although PTSD and substance use disorder comorbidity was lower in our study than is sometimes found (Jacobson, Southwick, & Kosten, 2001; Kessler et al., 1995), precluding further analyses focused on comorbidity, it is clear that examination of these post-trauma outcomes remains important. An examination of the impact of particular traumatic events on both PTSD and AUDs found that the presence of an alcohol use disorder was associated with a broader range of trauma types in those without concurrent PTSD (Fetzner et al., 2011). While the broad trauma type categories in our study were not associated with help-seeking, such categories appear to be important to consider regarding risk of negative post-trauma outcomes.

This study is not without limitations. First, although present study was a twin sample, controlled for in analyses, the study was also epidemiologic in nature and assessed a very large number of individuals, which helps temper the limits to generalizability inherent in twin studies. Self-medication and formal help seeking were assessed in a limited manner in this study. While the questions specifically prompted individuals to respond to the items as related to the traumatic experience, which attempts to address coping-related use, the items did not specifically inquire into coping-specific motives. The item also had a low limit for a positive response (e.g., use of “more than once” to meet criteria). As such, conclusions cannot speak to the level and degree of self-medication behavior, nor the function of this behavior. A recent systematic review of the literature noted a general limitation in the literature regarding wide variability of measurement of substance use following trauma (van den Berk & Wolf, 2015). Future studies that explicitly examine coping motives and frequency of use, as well as number of times treatment was sought and prior treatment history will be useful for better understanding this relationship. Furthermore, examination of potential differences in help-seeking or self-medication as a function of trauma history (i.e., single event as compared to chronic trauma history) will be informative.

As the outcome variables assessed were contingent upon endorsement of at least one PTSD symptom, our analyses focused on PTSD diagnostic status as well as AUD and DUD diagnoses. However, given the high rate of comorbidity in this sample (e.g., 86% of the PTSD positive individuals also carried at least one additional Axis 1 condition), we cannot rule out the impact of severity or other psychiatric comorbidity on the associations found. Moreover, MDD was not independently associated with outcomes in follow-up analyses; this may be due to specific study sampling or the impact of comorbidity, wherein PTSD status is more strongly driving the relationship. Examining the interaction of self-medication behavior with diagnoses such as PTSD and AUDs, although not feasible in the present sample given low prevalence rates, is an important consideration of future studies. As DSM-IV was used at the time of the study, it cannot be determined if results would differ substantially using this criteria. Finally, we are unable to determine causal relationships among the variables studied.

The present findings suggest that as opposed to marking avoidance behavior, it may be that individuals who self-medicate are experiencing greater distress, using substances as additional attempts to manage symptoms. This use, however, is likely further compounding existing difficulties in emotion regulation and functional impairment. Thus, these individuals may be experiencing more wide-ranging negative consequences as a result of both PTSD symptoms and problematic substance use. Future, particularly longitudinal, studies geared towards understanding the intricacies of these relationships are needed. Victims of trauma are also often more likely to use informal sources of help, such as family and friends (McCart, Smith, & Sawyer, 2010); examining how this type of help seeking interacts with both formal help-seeking and self-medication will be informative for prevention and treatment efforts. Identifying individuals with PTSD who are prone to cope through self-medication is important, as higher rates of dysthymia and greater odds of suicide attempts have been documented, even when controlling for other diagnostic comorbidity (Leeies et al., 2010). Thus, healthcare providers who are seeing individuals with a trauma history for PTSD symptoms would benefit from early assessments of self-medication and continued monitoring if warranted, to prevent the development of a substance use disorder. Alternatively, providers addressing substance use concerns should be aware of the potential function of such substance as a treatment target.

Acknowledgments

Role of Funding Sources. The original research from which this study sampled was supported by grants from The National Institute of Mental Health (MH-068643), National Institute of Health, and funding in support of the twin program of research at the Norwegian Institute of Public Health including grants from the Norwegian Research Council, the Norwegian Foundation for Health and Rehabilitation, and the European Commission under the program ‘Quality of Life and Management of the Living Resources’ of the 5th Framework Program (no. QLG2-CT-2002-01254). Dr. Sheerin’s time is supported by T32 MH020030. Dr. Amstadter’s time is supported by K02 AA0023239.

Footnotes

1

The prevalence of DUDs was not sufficient to use as a predictor in models.

2

To ensure that individuals who responded positively to the self-medication items were not those who were using psychotropic medication as prescribed by a doctor, individuals who responded positively to the first help-seeking item referring to seeing a Doctor were removed and analyses were re-run. The results of this model remained consistent with findings reported (OR=4.62, 95% C.I.=1.39–15.41, p=.013).

Disclosures: The authors have no financial relationships or conflicts of interest to disclose

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