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. Author manuscript; available in PMC: 2023 Jul 1.
Published in final edited form as: J Ethn Subst Abuse. 2020 Oct 28;21(3):1141–1164. doi: 10.1080/15332640.2020.1836699

Ethnoracial differences in treatment-seeking veterans with substance use disorders and co-occurring PTSD: Presenting characteristics and response to integrated exposure-based treatment

Delisa G Brown a, Julianne C Flanagan a,b, Amber Jarnecke a, Therese K Killeen a, Sudie E Back a,b
PMCID: PMC8079537  NIHMSID: NIHMS1641939  PMID: 33111647

Abstract

Objective:

Substance use disorders (SUD) and posttraumatic stress disorder (PTSD) frequently co-occur. While previous research has examined ethnoracial differences among individuals with either SUD or PTSD, little research to date has focused on individuals with co-occurring SUD/PTSD. The current study addresses this gap in the literature.

Method:

Participants were 79 military veterans (91% male; 38% African American [AA] and 62% White) with current SUD/PTSD who were randomized to receive Concurrent Treatment of PTSD and Substance Use Disorders using Prolonged Exposure (COPE) or Relapse Prevention (RP). Primary outcomes included substance use and self-reported and clinician-rated PTSD symptoms.

Results:

At baseline, AA participants were significantly older, reported greater substance and alcohol use, and tended to report higher PTSD severity than White participants. AA participants evidenced greater decreases in substance and alcohol use during treatment, but greater increases in substance and alcohol use during follow-up as compared to White participants. All participants decreased alcohol consumption during treatment; however, AA participants in the COPE condition and White participants in the RP condition evidenced the steepest decreases in average number of drinks per drinking day (DDD) during treatment. Additionally, White participants receiving RP reported greater increases in DDD during follow-up compared to AA participants.

Conclusion:

Overall, integrated treatment for co-occurring SUD/PTSD was effective for both AA and White participants; however, some important differences emerged by ethnoracial group. Findings suggest that greater attention to race and ethnicity is warranted to better understand the needs of diverse patients with SUD/PTSD and to optimize treatment outcomes.

Keywords: Substance use disorders, PTSD, health disparities, trauma, ethnoracial, race

Introduction

Extensive research demonstrates a strong association between substance use disorders (SUD) and posttraumatic stress disorder (PTSD) among both civilian and military populations (Mills et al., 2006; Petrakis et al., 2011; Stein et al., 2017; Teeters et al., 2017; Vujanovic & Back, 2019). Using data from the Department of Veterans Affairs (N = 1,001,996), Petrakis and colleagues found that 41.4% of veterans with PTSD also met criteria for a comorbid SUD (Petrakis et al., 2011). Individuals dually-diagnosed with SUD and PTSD have a more severe clinical profile and worse treatment outcomes as compared to those with either disorder alone (Bowe & Rosenheck, 2015; Vujanovic & Back, 2019). Comorbid SUD/PTSD is also associated with increased risk for other psychiatric disorders, such as depression and anxiety disorders, as well as physical health problems, suicide attempts, and violence (McCauley et al., 2012; Rodriquez et al., 2019). Furthermore, veterans with SUD/PTSD tend to have a longer duration of substance use and undergo more episodes of SUD treatment compared those without comorbid PTSD (Stappenbeck et al., 2014; Young et al., 2005). Little research to date has examined ethnoracial differences in individuals with co-occurring SUD and PTSD. Examination of potential ethnoracial variation in presentation of symptoms and response to treatment is critical to increase understanding of unique needs of patients from diverse racial backgrounds and to inform the design of specialty treatment programs or interventions.

While substance use is a significant problem across all race and ethnic identities, individuals who identify as a member of a racial minority group often sustain greater hardship related to SUD due to poorer access to treatment, lack of evidence-based treatment when accessed, and greater environmental, social, and economic risk factors (Emerson et al., 2017; Washington & Brown, 2019). Despite higher rates of substance use among White individuals, ethnoracial minorities, and African-Americans in particular, experience more substance-related problems (Breslau et al., 2006; Chartier & Caetano, 2010). For example, African-Americans (AA) are incarcerated at a dramatically higher rate (5 to 7 times) than Whites for similar or the same substance-related problems (Carson & Sabol, 2012). African-Americans also experience more chronic alcohol-related issues (e.g., financial, physical health, family/social, employment) and more severe symptoms of alcohol use disorder (Zapolski et al., 2014). One study found that AA individuals with low-to-moderate levels of drinking were three times more likely to experience negative social consequences (e.g., arguments or fights, accidents, legal, and physical health problems) and five times more likely to experience symptoms of alcohol use disorder compared to White individuals with similar drinking patterns (Mulia et al., 2009).

Studies examining ethnoracial differences in PTSD often find higher rates of trauma exposure and PTSD diagnosis among members of ethnoracial minority groups. Several community-based studies utilizing nationally representative datasets, as well as investigations among military veterans, report significantly higher rates of PTSD diagnosis and/or PTSD symptom severity among ethnic minority populations (Alcantara et al., 2013; Asnaani et al., 2010; Davis et al., 2008; Hall-Clark et al., 2017; Kulka et al., 1990; Roberts et al., 2011; Werner et al., 2016). Several studies show that AA individuals carry the highest prevalence rates of current PTSD compared to all other ethnicities among both civilian and veteran populations (Alim et al., 2006; Asnaani et al., 2010; Himle et al., 2009; Kulka et al., 1990; Roberts et al., 2011). Additionally, a diagnosis of PTSD among ethnoracial minorities is associated with greater symptom severity, more functional impairment, and poorer overall treatment outcomes (Alcantara et al., 2013; Benıtez et al., 2014; Breslau et al., 2006; Eack & Newhill, 2012; Himle et al., 2009). Differences in treatment outcomes may be due, in part, to pre- and post-trauma factors that tend to be elevated among ethnic minority individuals, such as lower socioeconomic status, greater exposure to violence, limited access to treatment, treatment seeking tendencies, and differences in physiological reactivity (Roberts et al., 2011; Sareen, 2014; Washington & Brown, 2019).

Research on ethnoracial variations among individuals with comorbid SUD/PTSD or trauma exposure is limited (Emerson et al., 2017; Ruglass et al., 2016; Ruglass & Yali, 2019; Werner et al., 2016; Zandberg et al., 2016) and studies specifically focusing on ethnoracial differences in treatment outcomes among individuals with comorbid SUD/PTSD are even more sparse. To our knowledge, only two studies conducted by Ruglass et al. (2016) and Ruglass and Yali (2019) performed secondary analysis to examine ethnoracial differences in treatment outcomes among individuals with comorbid SUD/PTSD. One study utilized Concurrent Treatment of PTSD and Substance Use Disorders using Prolonged Exposure (COPE; Back et al., 2015) as a treatment condition compared to active monitoring controlled group. The main objective of this study was to examine the effect of race/ethnicity and religious affiliation on treatment outcomes. They reported that AA participants endorsed more PTSD symptoms at baseline and regardless of assigned treatment condition also reported significantly lower PTSD symptoms by the end of the first week of treatment which remained lower over time, but no racial differences in substance use were reported (Ruglass & Yali, 2019). Another study by Ruglass et al. (2016) examined racial differences in treatment adherence and treatment outcomes among individuals with SUD/PTSD and found that AA and White participants receiving Seeking Safety (SS) plus sertraline or SS and placebo were equally adherent; however, AA participants who received SS plus sertraline reported significantly lower PTSD symptoms post treatment and at 6 months compared to AA participants who received SS and placebo. This finding was not observed among White participants. No racial differences in substance use were observed at posttreatment or follow-up (Ruglass et al., 2016). However, these studies focused on civilians and not veterans, who experience SUD and PTSD at higher rates and are less likely to seek treatment (Dworkin et al., 2018; Kulesza et al., 2015).

Continued examination of such differences across subpopulations may better inform our understanding of the etiology of SUD/PTSD across diverse populations, increase awareness of the treatment needs of patients from different ethnoracial backgrounds within different sub-groups, and inform the development of tailored interventions. The current study extends previous research in this area by examining ethnoracial differences in SUD and PTSD symptomatology and outcomes among military veterans enrolled in a clinical trial for comorbid SUD/PTSD who received either COPE, an integrated exposure-based psychosocial treatment, or Relapse Prevention (RP) for SUD only. The main outcome paper comparing the efficacy of COPE vs. RP was recently published and results showed that COPE was superior to RP in reducing PTSD symptoms (Back et al., 2019). While SUD severity decreased in both COPE and RP during treatment, participants who received COPE consumed fewer drinks per drinking day during follow-up. The current paper extends these findings by examining differences in baseline characteristics and treatment outcome by ethnoracial group. Given the lack of empirical studies examining ethnoracial differences among individuals with SUD/PTSD in general and among veterans, in particular, no a priori hypotheses regarding directionality were proposed and the analyses are considered exploratory.

Methods

Participants

The data for this secondary analysis was obtained from a larger randomized clinical trial that examined the efficacy of COPE (Back et al., 2015) versus RP (Kadden et al., 1992) among treatment-seeking military veterans with current SUD/PTSD (Back et al., 2019). Participants were recruited via flyers posted in the local Veterans Affairs (VA) hospital and community hospitals, as well as advertisements in local newspapers and social media. Inclusion criteria were: a) U.S. military veteran, b) 18 to 65 years old, c) met DSM-IV diagnostic criteria for current PTSD and had a score of ≥ 50 on the Clinician-Administered PTSD Scale (Blake et al., 1995); and d) met DSM-IV diagnostic criteria for a current SUD and had used substances in the past 90 days. Exclusion criteria were: a) ongoing enrollment in another treatment for SUD or PTSD, b) suicidal or homicidal ideation with intent, c) psychiatric conditions that would likely require a higher level of care or could interfere with treatment (e.g., psychotic disorder), and d) severe cognitive impairment as measured by the Mini-Mental Status Examination (Folstein et al., 1975). Participants taking psychotropic medication were required to be stabilized on the medication for 4 weeks prior to enrollment. Eighty-one participants were enrolled in the study. Two participants identified as a race other than AA or White and were removed from analysis, leaving a total sample size of n = 79 (30 AA and 49 White) for the current study.

Procedures

Procedures are briefly summarized here; a detailed description of study procedures can be found elsewhere (Back et al., 2019). Following informed consent, participants completed a baseline clinical interview and self-report assessments. Participants were randomized to treatment group using a 2:1 (COPE:RP) ratio. Treatment consisted of 12, individual, 90-minute sessions delivered once per week. The COPE therapy content focused on psycho-education and methods for coping with cravings (Sessions 1–2); in vivo exposure (Sessions 3–12); and imaginal exposure (Sessions 4–11). Relapse prevention techniques were integrated throughout each session. Follow-up assessments were conducted at 3- and 6-months post treatment.

Measures

Substance use

The Mini International Neuropsychiatric Interview (Sheehan et al., 1998) was used to assess current DSM-IV diagnosis of SUD and other psychiatric diagnoses for inclusion/exclusion at baseline. Percent days using any substances (PDU), percent days using alcohol (A-PDU), and average number of drinks per drinking day (DDD) were assessed for 60 days prior to baseline and weekly during treatment using the Timeline Follow-Back (TLFB; Sobell & Sobell, 1992).

PTSD symptoms

The CAPS (Blake et al., 1995) is a semi-structured clinical interview used to obtain PTSD diagnosis consistent with DSM-IV and assess symptom severity at baseline, week 6, and week 12 as well as 3- and 6-month follow-ups. Scores range from 0 to 136 (α at baseline = .85). The CAPS also includes the Life Events Checklist which assesses lifetime exposure (yes/no) to various types of traumatic events. The PTSD Checklist-Military (PCL-M; Weathers et al., 1994) is a 17-item, self-report measure that assesses PTSD symptoms based on DSM-IV criteria (α at baseline = .86). Scores on the PCL-M range from 17 to 85. The PCL-M was administered at baseline, weekly during treatment, and at each follow-up assessment.

Therapeutic alliance

The Helping Alliance Questionnaire (HAQ-II; Luborsky et al., 1996) was used to examine patient alliance with therapists at the end of treatment. Scores range from 19 to 114, with greater scores reflecting better alliance (α = .91).

Associated symptoms

The Beck Depression Inventory-2nd Edition (BDI-II; Beck et al., 1996) is a 21-item, self-report scale that measured depression symptoms. Scores for the BDI-II range from 0 to 63 (α at baseline = .91). The State-Trait Anxiety Inventory (STAI; Spielberger & Gorsuch, 1983) is a 40-item, self-report scale used to measure state (STAI-S; 20-items) and trait (STAI-T; 20 items) anxiety. Scores for each subscale can range from 20 to 80 (STAI-S α at baseline = .92; STAI-T α at baseline = .91).

Data analytic approach

Statistical analyses were conducted using SPSS 25.0 (IBM, 2017). A univariate approach was used to examine differences between ethnoracial groups on baseline clinical and demographic characteristics. Continuous and ordinal characteristics were compared using t-tests while categorical characteristics were compared using Pearson Chi-Square or Fisher’s exact tests, as appropriate. Any demographic variables found to be significantly different between groups were handled as covariates in mixed models to examine ethnoracial differences in PTSD symptoms and substance use as well as depression and anxiety symptoms over the course of treatment and follow-up.

Piecewise linear mixed effects models were used for the present study so that slopes were allowed to differ between the treatment phase and follow-up phase. Timepoints across treatment and follow-up were nested within individuals. Time was scaled in months and the end of treatment was set at 0. Thus, time was coded as −3 (baseline), −1.5 (6 weeks into treatment), 0 (end of treatment), 3 (3-month follow-up), and 6 (6-month follow-up). All models accounted for age (the only demographic variable that was significantly different between ethnoracial groups), treatment condition (RP = −1; COPE = 1), and race (White = −1; AA = 1). The effects of treatment condition and ethnoracial group on change in outcomes during 1) the treatment phase and 2) the follow-up phase were also modeled. Interaction terms of treatment condition and ethnoracial group on each slope variable were included. Further, interaction terms of treatment condition by ethnoracial group by each slope variable was included. Intercepts were allowed to vary. Independent models examined each outcome variable of interest (e.g., CAPS, PCL-M, PDU, DDD). Given the small sample size and exploratory nature of the study, alpha was set at .05.

Results

Baseline demographic and clinical characteristics

As shown in Table 1, the majority of participants were male (91.1%) with an average age of 40.4 years old. The most common military branch represented was the Army (57.0%) and the average number of years of military service was 9.6 years. A greater proportion of White participants were assigned to the COPE treatment condition. AA participants were significantly older than White participants (p = 0.036). No other differences in demographic characteristics by ethnoracial group were revealed.

Table 1.

Baseline demographics and clinical characteristics by ethnoracial group.

Variable African American (n = 30) White (n = 49) Total (N = 79)
% (n)
Treatment Condition, COPE 20.3 (16) 46.8 (37) 67.1 (53)*
Gender, Male 90.0 (27) 91.8 (45) 91.1 (72)
Relationship Status
  Single 30.0 (9) 28.6 (14) 29.1 (23)
  Married 26.7 (8) 24.5 (12) 25.3 (20)
  Separated 10.0 (3) 8.2 (4) 8.9 (7)
  Widowed 0.0 (0) 2.0 (1) 1.3 (1)
  Divorced 33.3 (10) 36.7 (18) 35.4 (28)
Employment Status
  Part-time 10.0 (3) 8.2 (4) 8.9 (7)
  Full-time 33.3 (10) 22.4 (11) 26.6 (21)
  Unemployed 20.0 (6) 46.9 (23) 36.7 (29)
  Retired 6.7 (2) 2.0 (1) 3.8 (2)
  Student 6.7 (2) 2.0 (1) 3.8 (2)
  Disabled 20.0 (6) 18.4 (9) 19.0 (15)
Military Branch
  Army 60.0 (18) 55.1 (27) 57.0 (45)
  Navy 16.7 (5) 6.1 (3) 10.1 (8)
  Marines 13.3 (4) 18.4 (9) 16.5 (13)
  Air Force 6.7 (2) 10.2 (5) 1.3 (1)
  National Guard 3.3 (1) 8.2 (4) 8.9 (7)
  Coast Guard 0.0 (0) 2.0 (1) 6.3 (5)
OEF/OIF Veteran 53.3 (16) 69.4 (34) 63.2 (50)
Cigarette Smoker 53.3 (16) 59.2 (29) 57.0 (45)
Mean (SD)
Age 43.6 (11.04) 38.41 (10.12) 40.38 (10.71)*
Years of education 13.45 (1.70) 14.20 (2.12) 13.92 (2.00)
Years of military service 11.33 (8.72) 8.51 (7.01) 9.60 (7.78)
Number of sessions completed 7.93 (4.88) 8.57 (4.27) 8.33 (4.49)
CAPS Total Score 77.87 (17.50) 81.00 (19.08) 79.81 (18.45)
PCL-M Total Score 65.73 (9.66) 61.16 (10.55) 62.90 (10.40)**
Percent days using any substance (PDU) 57.25 (34.19) 40.50 (33.98) 46.86 (34.82)*
Percent days using alcohol (A-PDU) 54.54 (33.88) 36.39 (31.55) 43.28 (33.44)*
Average drinks per drinking day (ADD) 8.83 (9.28) 9.00 (4.76) 8.93 (6.95)**
BDI-II Total Score 29.37 (10.24) 29.74 (12.01) 29.60 (11.29)
STAI State Score 53.03 (11.10) 54.56 (11.11) 53.99 (11.06)
STAI Trait Score 55.33 (9.54) 57.85 (10.06) 56.88 (9.88)
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*

p<.05.

**

p<.07.

At baseline, AA participants reported having significantly more days of overall substance use (57.3% vs. 40.5%; t = −2.12, p = .037) and more days of alcohol use than White participants (54.5% vs. 36.4%; t = −2.41, p = 0.018) (see Table 1). AA participants tended to endorse more severe baseline PTSD symptoms as assessed by the PCL-M relative to White participants (M = 65.7 vs. 61.2; t = −1.93; p = .057).

As shown in Table 2, participants were exposed to a wide range of civilian and military-related traumas. The majority of participants (77.2%) reported exposure to combat or a war-zone and 78.5% identified their index trauma as a military-related event. A significantly greater proportion of White participants, relative to AA participants, reported experiencing exposure to toxic substance (χ2 = 5.29, p = .021), physical assault (χ2 = 6.95, p = .008), and assault with a weapon (χ2 = 6.07, p = .014).

Table 2.

Lifetime traumatic events by ethnoracial group.

Lifetime traumatic events African American (n = 30) White (n = 49) Total (N = 79)
% yes (n)
Natural disaster 76.7 (23) 75.5 (37) 75.9 (60)
Fire or explosion 66.7 (20) 81.6 (40) 75.9 (60)
Transportation accident (e.g., car accident, train wreck) 80.0 (24) 81.6 (40) 81.0 (64)
Serious accident at work, home or during recreation 53.3 (16) 63.3 (31) 59.4 (47)
Exposure to toxic substances 26.7 (8) 53.1 (26) 43.0 (34)*
Physical assault (e.g., being attacked, hit, beaten up) 56.7 (17) 83.7 (41) 73.4 (58)*
Assault with a weapon (e.g., shot, stabbed, threatened with a knife, gun, bomb) 53.3 (16) 79.6 (39) 69.6 (55)*
Sexual assault (e.g., rape, attempted rape, made to perform sexual act through force or threat of harm) 20.0 (6) 38.8 (19) 31.6 (25)
Other unwanted or uncomfortable sexual experience 20.0 (6) 30.6 (15) 26.6 (21)
Combat or war-zone exposure 70.0 (21) 81.6 (40) 77.2 (61)
Captivity (e.g., kidnapped, held hostage, prisoner of war) 13.3 (4) 26.5 (13) 21.5 (17)
Life-threatening illness or injury 53.3 (16) 51.0 (25) 51.9 (41)
Severe human suffering 60.0 (18) 69.4 (34) 65.8 (52)
Sudden violent death of someone close (e.g., suicide, homicide) 83.3 (25) 73.5 (36) 77.2 (61)
Sudden unexpected death of someone close 93.3 (28) 83.7 (41) 87.3 (69)
Serious injury, harm or death you caused to someone 53.3 (16) 49.0 (24) 50.6 (40)
Other very stressful event or experience 33.3 (10) 42.9 (21) 39.2 (31)
Military-related index trauma 76.7 (23) 79.6 (39) 78.5 (62)
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*

p<.05.

Note. Some events/experience included missing values. Percentages reflect the proportion of participants.

Treatment retention and clinical outcomes

Examination of the number of treatment sessions completed revealed that AA participants (M = 7.93, SD = 4.88) and White participants (M = 8.57, SD = 4.27) completed an equivalent number of sessions (t = .61, p = .543). Likewise, AA participants (M = 96.94, SD = 12.41) and White participants (M = 102.50, SD = 9.79) reported similar levels of therapeutic alliance with their therapist at the end of treatment (t = 1.62, p = .113). Further, we examined ethnoracial differences in diagnostic remission for PTSD at the end of treatment, as measured by the CAPS, and found no significant differences between AA and White participants (χ2 = .01, p = .927).

Results from the mixed models examining clinical outcomes are presented in Tables 3–5. We primarily focus on reporting the fixed effects focused on differences by ethnoracial group. As can be seen, results from the models examining PTSD outcomes (i.e., CAPS and PCL-M) revealed significant effects for both the treatment and follow-up slopes (Table 3). There was also a significant effect of treatment condition in both of these models; however, there were no effects of ethnoracial group on changes in PTSD symptoms, as measured by the CAPS and PCL, during treatment or follow-up.

Table 3.

Results from mixed effects models examining PTSD outcomes.

CAPS Total B SE t or Wald Z p-value 95% CI
Lower Upper
Fixed Effects
  Intercept 28.87 10.35 2.79 0.006 8.33 49.42
  Treatment Slope −14.66 2.13 −6.87 0.000 −18.87 −10.45
  Follow-up Slope 18.69 3.05 6.12 0.000 12.67 24.71
  Age −0.02 0.20 −0.10 0.920 −0.42 0.38
  Treatment Condition 21.96 6.54 3.36 0.001 9.06 34.87
  Ethnoracial Group −1.32 6.13 −0.22 0.829 −13.42 10.77
  Treatment Slope × Treatment Condition 3.37 3.00 1.12 0.264 −2.55 9.29
  Follow-up Slope × Treatment Condition −6.13 4.24 −1.45 0.150 −14.50 2.23
  Treatment Slope × Ethnoracial Group −2.00 2.53 −0.79 0.430 −7.00 2.99
  Follow-up Slope × Ethnoracial Group 1.13 3.64 0.31 0.756 −6.04 8.31
  Treatment Slope × Treatment 0.74 3.43 0.22 0.829 −6.02 7.51
    Condition × Ethnoracial Group
  Follow-up Slope × Treatment 0.70 4.74 0.15 0.883 −8.65 10.04
    Condition × Ethnoracial Group
Random Effects
  Intercept Variance 187.79 50.40 3.73 0.000 110.98 317.77
  Residual Variance 284.62 31.97 8.90 0.000 228.37 354.72
PCL-M Total B SE t or Wald Z p-value 95% CI
Lower Upper
Fixed Effects
  Intercept 32.81 6.98 4.70 0.000 18.97 46.65
  Treatment Slope −7.55 1.24 −6.08 0.000 −10.00 −5.10
  Follow-up Slope 8.75 1.76 4.97 0.000 5.27 12.22
  Age 0.21 0.14 1.50 0.138 −0.07 0.48
  Treatment Condition 11.96 4.21 2.84 0.005 3.65 20.27
  Ethnoracial Group −6.02 3.96 −1.52 0.130 −13.83 1.79
  Treatment Slope × Treatment Condition 3.52 1.80 1.96 0.051 −0.02 7.07
  Follow-up Slope × Treatment Condition −4.46 2.55 −1.75 0.082 −9.50 0.57
  Treatment Slope × Ethnoracial Group −0.69 1.48 −0.46 0.644 −3.60 2.23
  Follow-up Slope × Ethnoracial Group 1.40 2.11 0.66 0.509 −2.77 5.56
  Treatment Slope × Treatment −0.43 2.13 −0.20 0.839 −4.62 3.76
    Condition × Ethnoracial Group
  Follow-up Slope × Treatment −1.02 2.98 −0.34 0.732 −6.89 4.85
    Condition × Ethnoracial Group
Random Effects
  Intercept Variance 107.18 23.26 4.61 0.000 70.05 163.99
  Residual Variance 91.07 10.26 8.88 0.000 73.03 113.57
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Table 5.

Results from mixed effects models examining associated symptoms.

BDI-II B SE t or Wald Z p-value 95% CI
Lower Upper
Fixed Effects
  Intercept 15.21 5.78 2.63 0.010 3.74 26.67
  Treatment Slope −4.63 1.01 −4.56 0.000 −6.63 −2.63
  Follow-up Slope 4.78 1.47 3.26 0.001 1.88 7.68
  Age −0.01 0.11 −0.08 0.940 −0.24 0.22
  Treatment Condition 5.38 3.46 1.56 0.122 −1.45 12.22
  Ethnoracial Group −2.06 3.25 −0.63 0.528 −8.49 4.37
  Treatment Slope × Treatment Condition 1.58 1.45 1.09 0.279 −1.29 4.44
  Follow-up Slope × Treatment Condition −1.80 2.06 −0.87 0.386 −5.87 2.28
  Treatment Slope × Ethnoracial Group −0.81 1.21 −0.67 0.505 −3.19 1.58
  Follow-up Slope × Ethnoracial Group 1.44 1.75 0.82 0.412 −2.02 4.90
  Treatment Slope × Treatment −0.22 1.80 −0.12 0.901 −3.76 3.32
    Condition × Ethnoracial Group
  Follow-up Slope × Treatment −0.83 2.50 −0.33 0.740 −5.75 4.10
    Condition × Ethnoracial Group
Random Effects
  Intercept Variance 74.74 16.28 4.59 0.000 48.77 114.54
  Residual Variance 61.18 6.90 8.87 0.000 49.05 76.32
STAI-Trait B SE t or Wald Z p-value 95% CI
Lower Upper
Fixed Effects
  Intercept 45.50 5.84 7.80 0.000 33.93 57.08
  Treatment Slope −3.11 1.13 −2.76 0.006 −5.33 −0.89
  Follow-up Slope 4.52 1.63 2.77 0.006 1.30 7.74
  Age −0.01 0.11 −0.08 0.935 −0.24 0.22
  Treatment Condition 6.02 3.56 1.69 0.093 −1.01 13.05
  Ethnoracial Group −0.49 3.38 −0.15 0.885 −7.17 6.19
  Treatment Slope × Treatment Condition 1.04 1.55 0.67 0.506 −2.03 4.10
  Follow-up Slope × Treatment Condition −1.88 2.22 −0.85 0.398 −6.25 2.49
  Treatment Slope × Ethnoracial Group −1.19 1.32 −0.90 0.370 −3.80 1.42
  Follow-up Slope × Ethnoracial Group 1.14 1.92 0.60 0.552 −2.64 4.92
  Treatment Slope × Treatment 0.82 1.84 0.45 0.655 −2.80 4.45
    Condition × Ethnoracial Group
  Follow-up Slope × Treatment −2.28 2.56 −0.89 0.375 −7.33 2.77
    Condition × Ethnoracial Group
Random Effects
  Intercept Variance 68.62 16.04 4.28 0.000 43.40 108.50
  Residual Variance 70.18 8.00 8.77 0.000 56.13 87.75
STAI-State B SE t or Wald Z p-value 95% CI
Lower Upper
Fixed Effects
  Intercept 45.16 6.39 7.07 0.000 32.48 57.85
  Treatment Slope −3.22 1.17 −2.75 0.007 −5.54 −0.91
  Follow-up Slope 4.27 1.69 2.53 0.012 0.94 7.60
  Age −0.04 0.13 −0.31 0.757 −0.29 0.21
  Treatment Condition 5.47 3.85 1.42 0.158 −2.14 13.07
  Ethnoracial Group −1.35 3.64 −0.37 0.710 −8.54 5.83
  Treatment Slope × Treatment Condition 1.92 1.66 1.16 0.249 −1.35 5.19
  Follow-up Slope × Treatment Condition −2.22 2.35 −0.94 0.346 6.86 2.42
  Treatment Slope × Ethnoracial Group −0.78 1.39 −0.56 0.578 −3.52 1.97
  Follow-up Slope × Ethnoracial Group 0.56 2.01 0.28 0.780 −3.40 4.52
  Treatment Slope × Treatment −0.88 1.99 −0.44 0.661 −4.81 3.06
    Condition × Ethnoracial Group
  Follow-up Slope × Treatment −0.81 2.77 −0.29 0.770 −6.27 4.65
    Condition × Ethnoracial Group
Random Effects
  Intercept Variance 84.96 19.72 4.31 0.000 53.91 133.90
  Residual Variance 79.34 9.21 8.61 0.000 63.20 99.62
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Results from the models examining substance use outcomes are presented in Table 4. When examining PDU and A-PDU, significant effects emerged for the treatment slope, follow-up slope, age, and treatment and follow-up slopes by ethnoracial group. In the model examining PDU as the outcome, the effect of follow-up slope by treatment condition was also significant. Relative to White participants, AA participants experienced significantly greater decreases in PDU (see Figure 1) and A-PDU (see Figure 2) during the treatment phase, and greater increases in PDU and A-PDU during the follow-up phase. When examining A-PDU as the outcome, there were also significant effects of treatment slope and treatment and follow-up slopes by treatment condition and ethnoracial group. As shown in Figure 3, AA participants in the COPE condition and White participants in the RP condition had the steepest decreases in average drinks per drinking day (DDD) during the treatment phase. White participants in the RP condition also had the greatest increase in DDD from the end of treatment across follow-up.

Table 4.

Results from mixed effects models examining substance use outcomes.

Percent Days Using any Substance B SE t or Wald Z p-value 95% CI
Lower Upper
Fixed Effects
  Intercept 54.04 15.16 3.56 0.001 23.91 84.17
  Treatment Slope −14.48 2.75 −5.26 0.000 −19.91 −9.05
  Follow-up Slope 19.07 3.93 4.86 0.000 11.32 26.83
  Age −0.89 0.30 −3.00 0.004 −1.49 −0.30
  Treatment Condition 11.14 9.14 1.22 0.224 −6.90 29.18
  Ethnoracial Group −0.64 8.62 −0.07 0.941 −17.66 16.39
  Treatment Slope × Treatment Condition 7.36 3.92 1.88 0.062 −0.38 15.09
  Follow-up Slope × Treatment Condition −11.23 5.54 −2.03 0.044 −22.15 −0.30
  Treatment Slope × Ethnoracial Group 8.80 3.28 2.68 0.008 2.32 15.28
  Follow-up Slope × Ethnoracial Group −11.93 4.73 −2.53 0.012 −21.26 −2.61
  Treatment Slope × Treatment −6.83 4.68 −1.46 0.146 −16.05 2.39
    Condition × Ethnoracial Group
  Follow-up Slope × Treatment 9.04 6.52 1.39 0.167 −3.82 21.89
    Condition × Ethnoracial Group
Random Effects
Intercept Variance 492.93 121.37 4.06 0.000 304.23 798.69
Residual Variance 457.59 53.33 8.58 0.000 364.14 575.03
Percent Days Using Alcohol B SE t or Wald Z p-value 95% CI
Lower Upper
Fixed Effects
  Intercept 52.00 16.27 3.20 0.002 19.72 84.28
  Treatment Slope −13.86 3.59 −3.86 0.000 −20.94 −6.78
  Follow-up Slope 19.29 5.22 3.70 0.000 8.99 29.59
  Age −0.84 0.31 −2.72 0.008 −1.45 −0.22
  Treatment Condition 9.36 10.57 0.89 0.377 −11.49 30.21
  Ethnoracial Group −0.31 9.87 −0.03 0.975 −19.80 19.18
  Treatment Slope × Treatment Condition 7.58 5.01 1.51 0.132 −2.29 17.46
  Follow-up Slope × Treatment Condition −11.95 7.13 −1.68 0.095 −26.01 2.11
  Treatment Slope × Ethnoracial Group 9.84 4.26 2.31 0.022 1.45 18.24
  Follow-up Slope × Ethnoracial Group −12.51 6.19 −2.02 0.045 −24.73 −0.30
  Treatment Slope × Treatment −8.17 5.57 −1.47 0.144 −19.15 2.82
    Condition × Ethnoracial Group
  Follow-up Slope × Treatment 9.50 7.70 1.23 0.219 −5.70 24.70
    Condition × Ethnoracial Group
Random Effects
Intercept Variance 393.58 120.36 3.27 0.001 216.13 716.70
Residual Variance 814.30 93.83 8.68 0.000 649.68 1020.62
Drinks per Drinking Day B SE t or Wald Z p-value 95% CI
Lower Upper
Fixed Effects
  Intercept 1.94 3.22 0.60 0.548 −4.46 8.34
  Treatment Slope −1.41 0.57 −2.49 0.014 −2.54 −0.29
  Follow-up Slope 1.39 0.83 1.67 0.099 −0.26 3.04
  Age 0.08 0.06 1.30 0.197 −0.04 0.21
  Treatment Condition −2.04 2.04 −1.00 0.320 −6.07 2.00
  Ethnoracial Group −1.75 1.95 −0.90 0.372 −5.61 2.11
  Treatment Slope × Treatment Condition 0.04 0.73 0.06 0.952 −1.40 1.48
  Follow-up Slope × Treatment Condition 0.21 1.05 0.20 0.840 −1.87 2.29
  Treatment Slope × Ethnoracial Group 0.06 0.67 0.09 0.928 −1.26 1.38
  Follow-up Slope × Ethnoracial Group 0.17 0.97 0.17 0.863 −1.75 2.08
  Treatment Slope × Treatment −2.37 0.91 −2.61 0.010 −4.17 −0.57
    Condition × Ethnoracial Group
  Follow-up Slope × Treatment 3.06 1.30 2.35 0.020 0.49 5.63
    Condition × Ethnoracial Group
Random Effects
  Intercept Variance 23.86 5.75 4.15 0.000 14.87 38.26
  Residual Variance 9.82 1.54 6.38 0.000 7.22 13.35
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Figure 1.

Figure 1.

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Estimated change in percent days using (PDU) any substances during treatment and follow-up by ethnoracial group.

Figure 2.

Figure 2.

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Estimated change in percent days using alcohol (A-PDU) during treatment and follow-up by ethnoracial group.

Figure 3.

Figure 3.

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Estimated change in average drinks per drinking day (DDD) during treatment and follow-up by treatment condition and ethnoracial group.

Finally, we examined the impact of treatment condition and ethnoracial group on associated symptoms, including depressive symptoms, trait anxiety, and state anxiety (see Table 5). Results from these models found that while accounting for all other variables in the model, there were significant effects for the treatment and follow-up slopes. No other significant fixed effects, including by ethnoracial group, emerged for these models. We also examined percent change from baseline during treatment for BDI-II and STAI total scores by ethnoracial group. While there were no ethnoracial differences in BDI-II or STAI scores at baseline (see Table 1), at the end of treatment, AA participants reported slightly higher depression (16.44 vs. 13.28) and anxiety than White participants (M = 92.75 vs. 88.63). AA participants reported a 44.0% decrease in depression and a 14.5% decrease in anxiety symptom severity, whereas White participants reported a 55.4% decrease in depression and a 21.2% decrease in anxiety symptom severity.

Discussion

The current study is among the first to examine ethnoracial differences among veterans receiving integrated, exposure-based treatment for co-occurring SUD and PTSD (COPE) or RP for SUD only. We examined ethnoracial differences in baseline characteristics and demographics, retention, and treatment outcomes. The findings revealed that AA participants presenting for treatment were significantly older (approximately 5 years older), consumed alcohol more frequently and tended to have higher PTSD symptoms. On average, AA and White participants attended 8 out of 12 therapy sessions with no significant differences in treatment retention. This finding is similar to the findings of Ruglass et al. (2016) that showed equivalent number of sessions completed (average of 6 out of 12 sessions) by AA and Caucasian participants in a study of non-trauma focused integrated treatment (Seeking Safety). Examination of ethnoracial differences in response to treatment revealed that, during the treatment phase, AA participants evidenced significantly greater decreases in percent days using any substances and alcohol as compared to White participants. However, during the follow-up phase, AA participants demonstrated significantly increased percent days using any substances and alcohol than White participants. Moreover, AA participants in the COPE condition and White participants in the RP condition evidenced greater decreases in average drinks per drinking day (DDD) during treatment. However, White participants in the RP condition evidenced increased DDD during follow-up. Examination of changes in depression and anxiety revealed comparable reductions among both ethnoracial groups.

Examination of baseline differences in frequency of any substance use and alcohol use revealed that AA participants reported more overall days of substance and alcohol use than White participants. This finding is inconsistent with findings from other studies that report more frequent alcohol consumption among non-Hispanic White participants (Mukku et al., 2012; Mulia et al., 2009; Zapolski et al., 2014; Zemore et al., 2016). However, Dawson (1998) reported, using a nationally representative sample, that although White individuals were more likely to drink alcohol, AA individuals had the hightest volume of intake and frequency of heavy drinking. Moreover, the findings are consistent with the mutual maintenance model of addiction (Smith & Book, 2008). Hence, baseline PTSD trauma severity at baseline may help explain the increased substance and alcohol use observed in AA participants. AA participants reported more PTSD symptoms at baseline, although it was not statistically significant. PTSD severity has been linked to linked to substance use. Tripp et al. (2020) conducted a study examining PTSD symptom severity and alcohol use and reported that greater PTSD symptom severity was associated with greater future alcohol use, and greater alcohol use was associated with greater future PTSD symptom severity. This finding may also speak to aftercare resources and posttreatment support experiences. At the end of the treatment phase, participants were provided with additional treatment resources, and veterans have access to mental health treatment at the VA including substance use and PTSD treatment clinics. Access to care among veterans does not vary by race, however once connected to treatment, AA veterans are less likely to remain in mental health treatment or report positive experiences (Harpaz-Rotem & Rosenheck, 2011; Spoont et al., 2015). Future studies should assess ethnoracial differences in participants’ experience of perceived support posttreatment and its’ effect on continued symptom decrease or increases.

Though AA participants reported more substance and alcohol use at baseline, they also reported greater decreases in substance use during the course of treatment regardless of treatment condition. Greater decreases in substance and alcohol use during treatment among AA participants may be explained, in part, by the alliance AA participants had with their therapist. An examination of therapeutic alliance in this study revealed no significant differences between AA and White participants, however, and both groups reported high levels of therapeutic alliance. Research demonstrates that alliance is a consistent predictor of engagement, early improvement, and positive treatment outcomes (Meier et al., 2005). Barriers that typically impede treatment engagement among African-Americans and other minority populations include distrust of the mental health profession, diagnostic practices, and equitable treatment (Leong & Kalibatseva, 2011).

Ethnoracial differences during the follow-up phase were also observed. AA participants evidenced a greater rate of increase in substance and alcohol use from the end-of-treatment through follow-up. While African-Americans typically drink less often, regardless of the amount consumed, this population also reports more recurrent and persistent alcohol use problems once diagnosed, including social consequences, medical illness, incarceration, and mortality (Mukku et al., 2012; Mulia et al., 2009; Zapolski et al., 2014; Zemore et al., 2016). Traumatic events are a risk factor for problem-related drinking among African-Americans (Martin et al., 2004) and may explain the more frequent alcohol consumption observed at baseline in this study. Nonetheless, it is true that trauma exposure is a risk factor for more frequent alcohol consumption, alcohol use disorder and related problems across racial and ethnic groups (Kilpatrick et al., 2000). Exposure to specific traumatic events, however, might better explain increased drinking among AA participants in this sample at baseline and during follow-up. Differences in trauma exposure measured by the Life Events Checklist did not account for the increase in days of use at treatment follow-up, however this list is not exhaustive. Racial discrimination and other experiences of race-based traumas can be conceptualized as stressful life events that can impact mental health including substance use and alcohol consumption (Carliner et al., 2016; Garrett et al., 2017; Gerrard et al., 2012; Sanders-Phillips et al., 2014; Skewes & Blume, 2019). Although exposure to discrimination was not measured in this sample, AA individuals are disproportionately impacted by experiences of racism on a daily basis and this experience may have contributed to increased drinking and substance use frequency at baseline and during follow-up.

Examination of the impact of treatment condition by ethnoracial group on depression and anxiety revealed no significant differences. These findings are consistent with previous studies that investigated improvement of associated symptoms such as depression and anxiety among individuals with comorbid SUD/PTSD (Brady et al., 2001; McCauley et al., 2012; Najavits, 2014). However, some studies have shown that more severe substance use, in particular alcohol use, can negatively impact depression and anxiety outcomes over the course of treatment when presenting alone or as an associated symptom of comorbid SUD/PTSD (Sullivan et al., 2005; Wolitzky-Taylor et al., 2015). One study by Norman et al. (2010) examined the impact of PTSD on treatment outcomes of 178 veterans treated for depression, SUD, or both, and found that SUD patients with PTSD and depression had poorer treatment outcomes when compared to individuals with only SUD or depression.

As previously noted, no significant differences by racial group related to depression and anxiety were observed over the course of treatment. However, White participants experienced a greater reduction in depression (54% decrease) and anxiety (22% decrease) compared to African-American participants (45% and 14%, respectively). While the lower improvements observed among AA participants could be related to more severe alcohol consumption at baseline; it may also be explained, in part, by experiential differences of depressive and anxiety symptoms among minority groups. Williams et al. (2007) estimated the prevalence, persistence, and disability of depression in African Americans, Caribbean Blacks, and non-Hispanic Whites using the National Survey of American Life. When AA participants endorsed depressive symptoms, they tended to experience more severe and more disabling depression compared to White participants. While results from this study may not provide a clear answer for these differences, it will be helpful for future studies to investigate factors that contribute to ethnic minorities’ vulnerability to heavy drinking and co-morbid depression.

As reported in the primary outcome paper, PTSD symptoms decreased for all participants irrespective of treatment condition but those individuals receiving COPE as opposed to RP demonstrated greater improvement as evidenced by significantly lower CAPS and PCL scores (Back et al., 2019). Interestingly, while both AA and White participants experienced a decrease in DDD during treatment, AA participants in COPE decreased their amount of alcohol consumption (DDD) at a greater rate compared to White participants, and White participants in RP decreased their amount of alcohol consumption (DDD) at a greater rate compared to AA participants. Given the results of the current study it would be beneficial for clinicians to focus on substance use patterns among ethnic minorities so that integrated treatments are adapted to specifically address these issues as they relate to PTSD symptom severity. It may also be helpful for future studies to focus on exploring the functional use of alcohol for African Americans. Relapse prevention that can be adapted more effectively to target factors that promote drinking may help to further reduce alcohol use among this group. Furthermore, integrated substance use treatments, such as COPE, can be culturally adapted to include the experiences, behavioral pattern, and norms of ethnic minorities, as previous studies show larger symptom reduction among ethnic minority patients with SUD who received culturally-sensitive substance use treatment (Resnicow et al., 2000; Steinka-Fry et al., 2017).

The current study extends previous research examining ethnoracial differences in symptom presentation and treatment outcomes among individuals with PTSD alone or comorbid SUD/PTSD. Hall-Clark et al. (2017) reported on ethnoracial differences in trauma cognitions among services members with PTSD and found that AA participants reported more reexperiencing symptoms, fear, guilt and numbing than White participants. Substance use, however, was not examined in the study. In a recent report on patterns and correlates of ethnoracial disparities among veterans with PTSD recently separated from the military, McClendon et al. (2019) found significantly elevated rates of PTSD diagnosis among AA, multiracial, and Latinx veterans compared to White veterans, but also did not examine substance use. Specific to ethnoracial differences in treatment outcomes among individuals with comorbid SUD/PTSD, Ruglass et al. (2016) examined racial differences in response to non-trauma focused integrated treatment (Seeking Safety) plus sertraline or placebo among individuals with SUD and full or subthreshold PTSD. The findings revealed that AA individuals who received Seeking Safety plus sertraline evidenced lower PTSD symptom severity post-treatment than AA individuals who received Seeking Safety plus placebo. Moreover, among AA participants, but not White participants, a diagnosis of current major depressive disorder (MDD) at baseline was associated with higher PTSD symptom severity at post-treatment, suggesting that assessment and treatment of comorbid MDD may help improve treatment outcomes among AA individuals (Ruglass et al., 2016). These limited studies have focused on ethnoracial differences in clinical characteristics and treatment outcomes among individuals with PTSD or SUD/PTSD; the current study adds to this literature by examining ethnoracial differences in response to a trauma-focused, integrated, exposure-based treatment for SUD and PTSD among veterans.

Several study limitations should be considered. The current sample size is small and consisted primarily of male veterans, which limits the generalizability of the results. Self-report measures were utilized, which may be affected by responder biases. Ethnic minority disparities in mental health may vary by gender, and little is known about the experiences of female veterans who are members of ethnic minority groups. This study also did not examine ethnoracial differences in PTSD symptom clusters among individuals with SUD/PTSD. Previous literature documents that AA individuals with PTSD tend to experience high levels of reexperiencing and dissociative symptoms (Alegría et al., 2013; Hall-Clark et al., 2017). Najavits and Walsh (2012) reported that among a group of women with PTSD those who experienced more dissociation also reported a stronger expectation that substance use could help manage their PTSD symptoms. Differences in substance use at the beginning of the study and the increase in use during follow-up may be impacted by severity of PTSD symptom clusters. Future research should examine differences in PTSD symptom clusters and impact on outcomes. Finally, defining groups of people using race as an explanatory construct is inherently biased and assumes meaning that may or may not be consistent with the individuals’ ethnic identity and culture; it also carries the risk of perpetuating racial stereotypes and associated problems in society (Helms et al., 2005). When investigating ethnoracial differences, future studies should consider alternative concepts of ethnicity for racial groups that specify factors such as values, customs, or traditions that may be more indicative of culture and social factors.

Despite these limitations, the current study adds to the literature as one of the first to examine ethnoracial differences in treatment outcomes among veterans who received integrated, exposure-based treatment for comorbid SUD/PTSD. Baseline differences were revealed, with AA participants presenting with a more severe clinical profile as evidenced by more frequent alcohol use and higher PTSD symptoms. Overall, COPE and RP effectively reduced symptoms of SUD and PTSD among AA and White participants; however, AA participants experienced greater substance use during follow up. This work highlights the need to attend to ethnoracial differences among individuals with SUD/PTSD and examine cultural adaptations of integrated treatment to better fit the needs of African Americans and African-American veterans to enhance treatment outcomes.

Acknowledgments

Funding

This manuscript is the result of work supported, in part, by grants from the National Institute on Drug Abuse (R01 DA030143, R25 DA020537, K02 039229, P50 DA016511) and the National Institute on Alcohol Abuse and Alcoholism (R01 AA025086, R01 AA025086-03S1, K23 AA023845).

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