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. Author manuscript; available in PMC: 2023 Jul 1.
Published in final edited form as: J Affect Disord. 2022 Apr 7;308:10–18. doi: 10.1016/j.jad.2022.04.006

Comparing Psychosocial Functioning, Suicide Risk, and Nonsuicidal Self-Injury between Veterans with Probable Posttraumatic Stress Disorder and Alcohol Use Disorder

Shannon M Blakey 1,2,3,*, Sarah C Griffin 1,2, Jeremy L Grove 4, Samuel C Peter 1, Ryan D Levi 1, Patrick S Calhoun 1,2,4, Eric B Elbogen 2,4,5, Jean C Beckham 1,2,4, Mary J Pugh 6,7, Nathan A Kimbrel 1,2,4
PMCID: PMC9133145  NIHMSID: NIHMS1795474  PMID: 35398395

Abstract

Background:

Posttraumatic stress disorder (PTSD) and alcohol use disorder (AUD) are each common among Unites States (U.S.) military veterans and frequently co-occur (i.e., PTSD+AUD). Although comorbid PTSD+AUD is generally associated with worse outcomes relative to either diagnosis alone, some studies suggest the added burden of comorbid PTSD+AUD is greater relative to AUD-alone than to PTSD-alone. Furthermore, nonsuicidal self-injury (NSSI) is more common among veterans than previously thought but rarely measured as a veteran psychiatric health outcome. This study sought to replicate and extend previous work by comparing psychosocial functioning, suicide risk, and NSSI among veterans screening positive for PTSD, AUD, comorbid PTSD+AUD, and neither disorder.

Methods:

This study analyzed data from a national sample of N = 1,046 U.S. veterans who had served during the Gulf War. Participants self-reported sociodemographic, functioning, and clinical information through a mailed survey.

Results:

Veterans with probable PTSD+AUD reported worse psychosocial functioning across multiple domains compared to veterans with probable AUD, but only worse functioning related to controlling violent behavior when compared to veterans with probable PTSD. Veterans with probable PTSD+AUD reported greater suicidal ideation and NSSI than veterans with probable AUD, but fewer prior suicide attempts than veterans with probable PTSD.

Limitations:

This study was cross-sectional, relied on self-report, did not verify clinical diagnoses, and may not generalize to veterans of other military conflicts.

Conclusions:

Findings underscore the adverse psychiatric and functional outcomes associated with PTSD and comorbid PTSD+AUD, such as NSSI, and highlight the importance of delivering evidence-based treatment to this veteran population.

Keywords: Post Traumatic Stress Disorder, Alcohol Use Disorder, Psychosocial Functioning, Suicidal Ideation, Suicide, Non-Suicidal Self Injury

Posttraumatic stress disorder (PTSD) and alcohol use disorder (AUD) frequently co-occur. Approximately 40% of United States (U.S.) adults with lifetime PTSD also have lifetime AUD (Pietrzak et al., 2011), and a lifetime PTSD diagnosis is associated with up to three times greater risk for lifetime AUD (Grant et al., 2015). Recent epidemiological studies of the general U.S. adult population report lifetime and past-year PTSD prevalence estimates of 6% and 5%, respectively (Goldstein et al., 2016), which are surpassed by lifetime and past-year AUD prevalence estimates of 29% and 14%, respectively (Grant et al., 2015). PTSD and AUD are both more prevalent among U.S. military veterans than civilians (Fuehrlein et al., 2016; Kulka et al., 1990; Seal et al., 2011; Smith et al., 2016; Stecker et al., 2010; Wisco et al., 2014), perhaps due to the types of trauma exposure, “drinking culture” (Meadows et al., 2018), and demographic characteristics associated with military service (e.g., Dworkin et al., 2018). Although PTSD and AUD are each associated with negative health and functioning outcomes, comorbid PTSD and AUD (PTSD+AUD) has been linked to even greater psychiatric severity and comorbidity, physical health problems, psychosocial functioning difficulties, and suicide risk (Blakey et al., 2021a; Blanco et al., 2013; Bowe and Rosenheck, 2015; Norman et al., 2018; Simpson et al., 2019).

Data from national surveys of adult and veteran samples suggest that the increased burden associated with comorbid PTSD+AUD is more pronounced when comparing people with PTSD+AUD to people with AUD-only than when comparing people with PTSD+AUD to people with PTSD-only. For example, a recent analysis of the National Epidemiological Survey on Alcohol and Related Conditions (NESARC-III; Simpson et al., 2019) showed that adults with PTSD+AUD were more likely than adults with AUD but equally likely as adults with PTSD to be unemployed, have a family income below the poverty level, and have received public financial assistance in the previous year. The Australian National Survey of Mental Health and Well-Being (Mills, 2006) similarly found that PTSD+AUD was associated with greater symptom severity and functioning difficulties relative to AUD but not relative to PTSD.

Research with U.S. military veterans has mirrored findings obtained from general adult samples. An analysis of the National Health and Resilience in Veterans Study (NHRVS; Norman et al., 2018) showed that veterans with PTSD+AUD were more likely than veterans with AUD but equally likely as veterans with PTSD to report recent suicidal ideation and an annual household income under $60,000. Additionally, the National Post-Deployment Adjustment Study (PDAS; Blakey, Dillon, et al., 2021) found that post-9/11 veterans with PTSD+AUD1 were at greater risk for lifetime suicidal ideation, lifetime suicide attempts, and difficulties with financial and vocational functioning relative to veterans with AUD, but not relative to veterans with PTSD.

Suicide is a significant veterans health issue, with suicide rates steadily climbing among veterans between 2005–2018 (U.S. Department of Veterans Affairs Office of Mental Health and Suicide Prevention, 2020). As a result, substantial research has sought to better understand risk factors for veteran suicidal behavior, such as suicidal ideation and prior suicide attempts. Another relevant factor is nonsuicidal self-injury (NSSI; Franklin et al., 2017), a form of self-directed violence performed without intention to die as a result. Much of the research on NSSI to date has focused on civilians, especially civilians with borderline personality disorder (Patel et al., 2021). Yet between 4% and 30% of veterans report a history of NSSI (Bryan et al., 2015; Kimbrel et al., 2016), which notably exceeds that of the general population (between 3 and 6%; Klonsky, 2011). Moreover, growing evidence suggests that NSSI occurs more commonly than previously thought among people with conditions other than borderline personality disorder, such as PTSD and AUD. Indeed, one recent study found that 82% of veterans seeking treatment for PTSD also reported a lifetime history of NSSI (Kimbrel et al., 2018). Although limited research has investigated the co-occurrence of AUD and NSSI, this link is plausible considering that problem drinking and NSSI sometimes share similar behavioral functions (e.g., to alleviate distress) and psychological underpinnings (e.g., trait impulsivity and emotion dysregulation; Greene et al., 2020; Hasking & Claes, 2020). Taken together, NSSI is a serious problem with negative individual, societal, and health care consequences. Yet despite the alarming rate of occurrence in veterans, NSSI is grossly understudied in veterans or in samples without borderline personality disorder and thus deserves greater research attention.

With the exception of the PDAS and the NHRVS (Blakey et al., 2021a; Norman et al., 2018), most studies comparing psychosocial functioning and suicide risk between veterans with PTSD, AUD, and comorbid PTSD+AUD used convenience or treatment-seeking samples that were not representative of the overall veteran population. Considering that the majority of the U.S.’s nearly 20 million veterans receive their health care services outside of the Veterans Health Administration (VHA; U.S. Department of Veterans Affairs, 2019), additional research on psychosocial functioning and self-directed violence risk factors among veterans with PTSD and/or AUD could meaningfully inform future veteran health care and policy both within and beyond VHA.

The current study was therefore designed to compare psychosocial functioning, suicide risk, and NSSI between veterans screening positive for: PTSD but not AUD (i.e., PTSD only), AUD but not PTSD (i.e., AUD only), both PTSD and AUD (i.e., PTSD+AUD), and neither disorder. We sought to extend previous research on this topic by (1) recruiting a large, national veteran sample, (2) using sex-specific AUD screening cutoffs recommended for men versus women, and (3) including an NSSI outcome measure. We hypothesized that veterans screening positive for PTSD, AUD, or PTSD+AUD (i.e., the combined group of veterans screening positive for either or both disorders) would collectively report poorer status on all outcomes relative to the group of veterans with neither PTSD nor AUD. Based on previous related research in veteran samples (Blakey et al., 2021a; Norman et al., 2018), we also hypothesized differential findings when comparing veterans with PTSD+AUD to veterans with AUD versus PTSD. Specifically, based on these previous studies, we predicted that veterans screening positive for PTSD+AUD would be significantly worse on all outcomes compared to veterans with probable AUD, but only worse on measures of housing stability and violent behavior when compared to veterans with probable PTSD.

Methods

Participants and Procedure

This study analyzed data collected as part of a larger project, entitled Gulf War Research and Individual Testimony (Project GRIT; Grant 1I01HX001682), that focused on the healthcare needs of Gulf War veterans. The Project GRIT survey was administered to a national cohort of U.S. Gulf War veterans between January 2019 and August 2020. All study procedures were approved by the Institutional Review Boards at the Durham Veterans Affairs (VA) Health Care System and the VA Salt Lake City Health Care System. A summary of study procedures is described below; for more information, see a previous report by Blakey and colleagues (2021b).

Eligible participants for Project GRIT were initially identified from a VA administrative database of 1,098,991 veterans (12.14% women) who had a history of military service during the Gulf War era. Stratified random sampling from eight U.S. geographic regions was used to ensure that the study identified a sufficiently large group of eligible veterans to support study recruitment efforts. Women veterans were intentionally oversampled (25% women) to ensure adequate representation. A modified Dillman approach (Dillman et al., 2014) involving multiple and multimethod contacts was used to maximize participant response rate. First, pre-notification letters on VA letterhead were mailed to 3,272 of the identified Gulf War veterans informing them of their eligibility for the study. The letter described study purpose and procedures, study compensation (either a $100 or $500 prize based on a lottery drawing), and instructions for how to decline participation. Potential participants were then mailed a duplicate pre-notification letter, a copy of the survey packet, a challenge coin with the study name printed on it as a modest expression of appreciation, and a pre-paid envelope to return the survey to study staff. It was assumed that any veteran who returned the completed survey consented to study participation. After two weeks, any veteran who had not returned the survey was mailed a reminder letter, and one week after that was mailed another copy of the pre-notification letter, a duplicate survey, a complimentary pen, and instructions for how to decline study participation.

A total of 1,153 veterans returned the survey, resulting in a corrected response rate of 42.3%. As intended, the final Project GRIT cohort contained significantly more women veterans than the national cohort from which they were sampled (21.6% vs. 12.1%, p < .001). The Project GRIT cohort’s age (M = 58.8, SD = 7.3) was approximately 0.6 years older that of the national cohort in 2020, which was the year that most participants completed the Project GRIT survey (M = 58.2, SD = 7.7, z = 2.51, p = .006). The Project GRIT sample was reflective of the national cohort among those with non-missing race data in their electronic records (white = 61.3% vs. 63.1%, z = −1.28, p > .05; any other race = 38.7% vs. 36.9%, z = 1.26, p > .05).

A small proportion (n = 107; 9.3%) of the Project GRIT sample was excluded from the current study because these survey respondents’ diagnostic screening group could not be determined due to missing PTSD symptom and alcohol use data. Thus, this study included a final analyzed sample of n = 1,046 Gulf War veterans. Analyses with critical significance thresholds adjusted for multiple comparisons did not detect any significant differences between those with (n = 1,046) and without (n = 107) diagnostic screening group data. See Figure 1 for a recruitment flow diagram.

Figure 1.

Figure 1.

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Participant Recruitment Flow

Measures

Sociodemographic and military service information.

Participants self-reported their age, sex, race, marital status, education level, military service era(s), and service connection status. Participants also self-reported experiences of childhood physical or sexual abuse, military sexual trauma, or military combat using a yes or no response format.

Probable PTSD.

Probable PTSD was assessed with the validated 5-item Primary Care PTSD Screen for DSM-5 (PC-PTSD-5; Prins et al., 2016). Participants self-reported whether they had experienced nightmares or intrusive memories, avoided trauma-related memories or situations, were hypervigilant or on guard, felt numb or detached, and experienced guilt or self-blame related to a previous traumatic event over the past month using a yes (scored as 1) or no (scored as 0) response format. Possible scores range 0 to 5; a score of 3 or higher denotes probable PTSD (Prins et al., 2016). Internal consistency in the Project GRIT sample was good (Cronbach’s α = .85).

Probable AUD.

Probable AUD was assessed with the 3-item Alcohol Use Disorders Identification Test (AUDIT-C; Bush et al., 1998), a validated abbreviated version of the 10-item Alcohol Use Disorders Identification Test (Saunders et al., 1993). Participants self-reported their typical alcohol consumption on a 0 to 4 scale (anchors vary by item). Possible scores range 0 to 12; a score of 3 or higher for women and 4 or higher for men denotes probable AUD (Bradley et al., 2007, 2003; Crawford et al., 2013). Internal consistency in the Project GRIT sample was good (Cronbach’s α = .81).

Probable PTSD/AUD.

Participants were classified as having probable PTSD/AUD if they screened positive for both PTSD and AUD on the PC-PTSD-5 and AUDIT-C, respectively, as described above.

Psychosocial functioning difficulties.

We included five functional outcome measures in this study. Overall psychosocial functioning was assessed with the Brief Inventory of Psychosocial Functioning (BIPF; Kleiman et al., 2020), a 7-item self-report measure of past-30-day psychosocial functioning within interpersonal, vocational, and daily living domains. Items are scored on a scale of 0 (never) to 6 (always). A scoring algorithm excluding items marked as “not applicable” yields a total score ranging 0 to 100, with higher scores indicating poorer psychosocial functioning (Kleiman et al., 2020). Internal consistency in the Project GRIT sample was excellent (Cronbach’s α = .91).

Participants were considered to be experiencing housing instability if they denied currently living in a house/apartment/mobile home/condominium that they owned or rented. Participants were considered to be experiencing financial insecurity if they endorsed “having difficulty paying the bills, no matter what [they] do.” Participants were considered to be unemployed or disabled if they denied working full- or part-time, being a student, or being retired (i.e., if they reported being unemployed, disabled, or “other”). Finally, participants were coded as having difficulty controlling violent behavior if they responded ‘yes’ to the item, “during the past 30 days, have you had trouble controlling violent behavior (e.g., hitting someone)?”

Suicide risk.

Measures of suicidal ideation and suicide attempts were derived from the Suicidal Behaviors Questionnaire-Revised (SBQ-R; Osman et al., 2001). We elected to examine these two SBQ-R items separately, instead of using a single SBQ-R sum score, given the important distinctions between suicide-related ideation and action (Klonsky et al., 2018, 2016). We classified participants as having past-year suicidal ideation if they endorsed thinking about killing themselves at least once in the past year. We classified participants as having a history of suicide attempt if they endorsed ever attempting to kill themselves.

NSSI.

We assessed past-year NSSI with the newly developed Screen for Nonsuicidal Self-Injury (Halverson et al., under review). Participants were presented with a definition of NSSI before being asked to indicate whether they had engaged in 10 forms of NSSI (e.g., cutting, burning, scratching, self-mutilation) using a yes/no response format. Participants were coded as having past-year NSSI if they endorsed engaging in any of these behaviors in the past year.

Data Analytic Plan

All analyses were conducted in August 2021 using SAS version 9.4. After characterizing the study sample, we computed ANOVA (for continuous BIPF scores), Fisher’s exact tests (for housing instability and expected future suicide attempt), and chi-square tests (for all other outcomes) with planned contrasts to test our study hypotheses. Fisher’s exact tests were used instead of chi-square tests when there was an assumption violation due to small cells. Planned contrasts tested for significant differences in each outcome between (1) the three diagnostic groups of veterans with PTSD-only, AUD-only, and PTSD+AUD combined vs. the group screening positive for neither disorder, (2) the PTSD+AUD group versus the AUD-only group, and (3) the PTSD+AUD group versus the PTSD-only group.

Additionally, sensitivity analyses were used to replicate the ANOVA findings due to concerns about violated assumptions of normality and homogeneity of variance (see “Preliminary Analyses,” below). Running the omnibus analysis as a Kruskal-Wallis test and using non-parametric pairwise comparisons did not change study conclusions. We also plotted outcomes by diagnostic screening group to illustrate key findings reported in text.

Results

Preliminary Analyses

Sociodemographic characteristics are presented in Table 1. Our sample had an average age of 58.72 years old (SD = 7.45; see Table 2 for ages by diagnostic screening group). PC-PTSD-5 and AUDIT-C scores for each of the diagnostic screening groups are shown in Table 2. Visual inspection and quantitative analysis (i.e., skewness and kurtosis) of continuous measure data suggested approximately normal score distributions in the full sample and within individual diagnostic screening groups, with the exception of the BIPF (skew = 2.05 and kurtosis = 4.38 in the group of veterans with neither PTSD nor AUD). BIPF analyses reported below were adjusted accordingly (see “Data Analytic Plan,” above).

Table 1.

Frequency Statistics (N = 1,046)

Participant Characteristic Missing Endorsed
n n %
Sex 0
 Male - 821 78.49
 Female - 225 21.51
White 28 684 67.19
At least high school education 0 1039 99.33
Marital status 5
 Living together, married or unmarried - 766 73.58
 Separated or divorced - 193 18.54
 Widowed - 20 1.92
 Single, never married - 62 5.96
Military service era (not mutually exclusive) 14
 Korean War - 2 0.19
 Between Korean and Vietnam wars - 4 0.39
 Vietnam War - 188 18.22
 Post-Vietnam War - 382 37.02
 Operation Enduring Freedom/Operation Iraqi Freedom - 391 37.89
 Other military conflict - 82 7.95
Experienced childhood abuse 19 197 19.18
Experienced military sexual trauma 8 122 11.75
Experienced military combat 65 488 49.75
VA service-connected for any condition 45 814 81.32
Diagnostic screening group
 Neither PTSD nor AUD - 521 49.81
 Probable AUD only - 223 21.32
 Probable PTSD only - 187 17.88
 Probable PTSD+AUD - 115 10.99
Psychosocial functioning
 Unemployed or disabled 3 101 9.68
 Financial insecurity 13 38 3.68
 Housing instability 15 24 2.33
 Past-30-day difficulty controlling violent behavior 4 36 3.45
Suicide risk
 Past-year suicidal ideation 3 197 18.89
 History of suicide attempt 18 50 4.82
Any past-year NSSI 4 82 7.87
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Note. VA = Department of Veterans Affairs; PTSD = posttraumatic stress disorder; AUD = alcohol use disorder; PTSD+AUD = comorbid PTSD and AUD; NSSI = nonsuicidal self-injury; percentages reflect proportion of sample with valid (non-missing) responses.

Table 2.

Age and Clinical Characteristics by Diagnostic Screening Group

Participant Characteristic Full Sample
(N = 1,046)		 Neither
(n = 521)		 Probable AUD only
(n = 223)		 Probable PTSD only
(n = 187)		 Probable PTSD+AUD
(n = 115)
M SD M SD M SD M SD M SD
Age in years 58.72 7.45 59.76 7.50 59.80 8.36 56.98 5.83 54.57 5.55
PC-PTSD-5 1.45 1.89 0.32 0.64 0.36 0.69 4.11 0.84 4.31 0.80
AUDIT-C 2.53 2.56 1.07 0.99 5.28 1.94 1.10 0.98 6.10 2.45
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Note. PC-PTSD-5 = Primary Care PTSD Screen for DSM-5; AUDIT-C = Abbreviated Alcohol Use Disorders Identification Test.

Psychosocial Functioning Difficulties

Shown in Table 3, all omnibus tests examining group differences on psychosocial functioning were significant, with the exception of analyses focused on housing instability. A Fisher’s Exact test did not detect significant associations between diagnostic screening group and housing instability (p = .575), nor did Fisher’s Exact tests detect any significant differences between groups following planned contrasts (ps ranged .237 to 1.00).

Table 3.

Psychosocial Functioning Difficulties by Diagnostic Screening Group

Outcome Frequency Endorsed
n (%)		 Test of Independence Group Comparisons
Neither Probable
AUD Only		 Probable
PTSD Only		 Probable
PTSD+AUD
Unemployed or disabled 36 (6.94) 10 (4.50) 39 (20.86) 16 (13.91) χ2(3) = 40.33, φ = .20, p < .001 Any disorder > Neither
 PTSD+AUD > AUD
 PTSD+AUD = PTSD
Financial insecurity 14 (2.71) 1 (0.46) 12 (6.52) 11 (9.65) χ2(3) = 23.44, φ = .15, p < .001 Any disorder = Neither
 PTSD+AUD > AUD
 PTSD+AUD = PTSD
Housing instability 12 (2.32) 3 (1.38) 5 (2.72) 4 (3.54) Fisher’s Exact test p = .575 Any disorder = Neither
 PTSD+AUD = AUD
 PTSD+AUD = PTSD
Difficulty controlling violent behavior 7 (1.35) 4 (1.80) 8 (4.30) 17 (14.91) χ2(3) = 54.02, φ = .23, p < .001 Any disorder > Neither
 PTSD+AUD > AUD
 PTSD+AUD > PTSD
Outcome M (SD) and Observed Minimum - Maximum Welch’s Test and
Kruskal-Wallis Test		 Group Comparisons3
Neither Probable
AUD Only		 Probable
PTSD Only		 Probable
PTSD+AUD
BIPF scores (Overall psychosocial functioning) 13.14 (19.04)
0 – 100		 14.33 (19.06)
0 – 100		 44.96 (26.19)
0 – 100		 49.58 (26.42)
0 – 100		 F(3, 333.9) = 131.28, p < .0011
F(3, 1030) = 131.80, p < .0012 		Any disorder > Neither
 PTSD+AUD > AUD
 PTSD+AUD = PTSD
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Note. BIPF = Brief Inventory of Psychosocial Functioning; “<” and “>” indicate a statistically significant difference (p < .05), whereas “=” indicates analyses failed to detect a statistically significant difference (p ≥ .05);

1

Welch’s test was conducted as a sensitivity analysis due to heterogeneity of variance in BIPF scores across groups;

2

Kruskal-Wallis test was conducted due to violation of normal distribution of BIPF scores;

3

Planned comparisons yielded the identical pattern of findings in main and sensitivity analyses.

Veterans screening positive for any diagnosis (i.e., the combined group of veterans with probable PTSD, probable AUD, and probable PTSD+AUD; n = 525) were at greater risk, compared to veterans screening positive for neither disorder, of being unemployed or disabled (χ2 = 8.91, p = .003), having difficulty controlling violent behavior in the past 30 days (χ2 = 13.84, p < .001), and reporting overall functional impairment (F = 291.59, p < .001). Contrary to hypotheses, a positive screening status for any disorder (vs. neither disorder) was not associated with financial insecurity (χ2 = 2.71, p = .100).

Psychosocial functioning status by diagnostic screening group is illustrated in Figure 2. As predicted, veterans with probable PTSD+AUD were more likely than veterans with probable AUD to be unemployed or disabled (χ2 = 9.42, p = .002), report financial insecurity (Fisher’s Exact test p < .001), have difficulty controlling past-30-day violent behavior (χ2 = 22.10, p < .001), and experience overall functional impairment (F = 204.58, p < .001). Veterans with probable PTSD+AUD and probable PTSD did not significantly differ with regard to employment/disability status (χ2 = 2.30, p = .129), financial insecurity (χ2 = 0.967, p = .326), or overall impairment outcomes (F = 3.30, p = .070); however, veterans with probable PTSD+AUD were more likely than veterans with probable PTSD to have difficulty controlling violent behavior in the past 30 days (χ2 = 10.42, p = .001).

Figure 2.

Figure 2.

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Current Psychosocial Functioning by Diagnostic Screening Group

Note. Asterisks denote statistically significant differences detected in planned contrast analyses.

Self-Directed Violence

Shown in Table 4, omnibus tests identified significant associations between diagnostic screening group and all self-directed violence outcomes. As predicted, the combined group of veterans screening positive for any disorder, relative to neither disorder, were at greater risk of past-year suicidal ideation (χ2 = 60.64, p < .001), prior suicide attempt (χ2 = 12.20, p < .001), and past-year NSSI (χ2 = 27.63, p < .001).

Table 4.

Suicide Risk and Past-Year NSSI by Diagnostic Screening Group

Outcome Frequency Endorsed
n (%)		 Test of Independence Group Comparisons
Neither Probable
AUD Only		 Probable
PTSD Only		 Probable
PTSD+AUD
Past-year suicidal ideation 49 (9.42) 39 (17.57) 63 (33.69) 46 (40.35) χ2(3) = 91.68, φ = .30, p < .001 Any disorder > Neither
 PTSD+AUD > AUD
 PTSD+AUD = PTSD
History of suicide attempt 13 (2.50) 9 (4.04) 23 (12.43) 5 (4.55) χ2(3) = 29.80, φ = .17, p < .001 Any disorder > Neither
 PTSD+AUD = AUD
 PTSD+AUD < PTSD
Past-year NSSI 18 (3.47) 10 (4.50) 33 (17.65) 21 (18.42) χ2(3) = 59.50, φ = .24, p < .001 Any disorder > Neither
 PTSD+AUD > AUD
 PTSD+AUD = PTSD
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Note. “<” and “>” indicate a statistically significant difference (p < .05), whereas “=” indicates analyses failed to detect a statistically significant difference (p ≥ .05).

As hypothesized, veterans with probable PTSD+AUD were more likely than veterans with probable AUD but equally likely as veterans with probable PTSD to report past-year suicidal ideation (PTSD+AUD vs. AUD: χ2 = 20.69, p < .001; PTSD+AUD vs. PTSD: χ2 = 1.36, p = .244) and NSSI (PTSD+AUD vs. AUD: χ2 = 17.42, p < .001; PTSD+AUD vs. PTSD: χ2 = 0.03, p = .865). Contrary to expectations, veterans with probable PTSD+AUD were equally likely as veterans with probable AUD but less likely than veterans with probable PTSD to report a prior suicide attempt (PTSD+AUD vs. AUD: Fisher’s Exact test p = .780; PTSD+AUD vs. PTSD: χ2 = 5.00, p = .025). Rates of suicidal ideation, prior suicide attempts, and NSSI by diagnostic screening group are illustrated in Figure 3.

Figure 3.

Figure 3.

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Suicide Risk and Past-Year Nonsuicidal Self-Injury (NSSI) by Diagnostic Screening Group

Note. Asterisks denote statistically significant differences detected in planned contrast analyses.

Discussion

PTSD and AUD are two of the most common psychiatric diagnoses among U.S. military veterans (Stecker et al., 2010; Toomey et al., 2007) and frequently co-occur (Dworkin et al., 2018). Moreover, PTSD and AUD are associated with a wide array of veteran psychosocial functioning difficulties (Sayer et al., 2010) as well as veteran suicide (Rozanov and Carli, 2012). Less is known about experiences of NSSI among veterans with PTSD and/or AUD, however, and burgeoning research suggests that the burden associated with comorbid PTSD+AUD is greater when compared to AUD-only than to PTSD-only (Blakey et al., 2021a; Mills, 2006; Norman et al., 2018; Simpson et al., 2019). The current study therefore built upon existing work to compare psychosocial functioning, suicidal ideation, suicidal behavior, and NSSI between veterans screening positive for PTSD, AUD, comorbid PTSD+AUD, and neither disorder.

Based on published BIPF severity cutoff scores (Kleiman et al., 2020), veterans in our sample screening positive for AUD-only or neither disorder reported mild overall functioning difficulties, while veterans screening positive for PTSD-only or PTSD+AUD reported moderate overall functioning difficulties. Results from group comparison tests supported our study hypotheses, as the combined set of veterans screening positive for any diagnosis reported poorer functioning than veterans with neither disorder, and veterans with probable PTSD+AUD reported poorer functioning compared to veterans with probable AUD-only but not compared to veterans with probable PTSD-only. Thus, our findings align with previous studies showing that psychosocial difficulties associated with comorbid PTSD+AUD may be largely attributable to problems experienced by those with a diagnosis of PTSD, with or without additional AUD (Mills, 2006; Norman et al., 2018; Simpson et al., 2019). One clinical implication of our findings, therefore, is that veterans with PTSD could still experience meaningful improvements in psychosocial functioning during empirically supported PTSD treatment, even if they are not ready to reduce their alcohol consumption. This implication is also consistent with the most recent VA/Department of Defense joint clinical practice guidelines, which recommended that comorbid alcohol/drug use disorders not preclude patients from receiving empirically supported PTSD psychotherapies (U.S. Department of Veterans Affairs and Defense, 2017).

Analyses comparing specific aspects of functioning between diagnostic screening groups yielded mixed support for study hypotheses. Like with overall psychosocial functioning, the combined group of veterans screening positive for any disorder had higher rates of unemployment/disability, financial insecurity, and difficulty controlling violent behavior relative to veterans with neither disorder. Also as expected, veterans with probable PTSD+AUD reported worse status on these outcomes compared to veterans with probable AUD-only but not probable PTSD-only. Contrary to our hypotheses, analyses failed to detect any significant group differences in current housing stability. Although the simple explanation is that diagnostic screening status was not related to housing stability in our sample, another possible explanation for our unexpected findings relates to our study’s recruitment methods. Specifically, Project GRIT surveys were distributed to eligible veterans by mail; therefore, veterans who did not have an address (or who no longer lived at their recorded address for whatever reason, such as recent homelessness) would not have been included. Future studies using administrative data (e.g., medical record data including homelessness or housing services codes) or else offering opportunities to participate electronically (e.g., via web-based survey) may provide better insight into housing outcomes among veterans with mental health conditions such as PTSD and AUD (see Tsai & Rosenheck, 2015).

Analyses comparing suicide risk and NSSI also yielded mixed support for our study hypotheses. As expected, the combined group of veterans with probable PTSD, probable AUD and probable PTSD+AUD collectively reported higher rates of all self-directed violence outcomes compared to veterans with neither disorder. Consistent with our hypotheses, veterans with probable PTSD+AUD reported higher rates of past-year suicidal ideation compared to veterans with probable AUD-only, but not compared to veterans with probable PTSD-only. These findings align with previous related work in veteran samples (Blakey et al., 2021a; Norman et al., 2018) and underscore the importance of assessing for suicidal ideation among trauma-exposed veterans and targeting suicidal ideation during PTSD treatment as indicated (Bryan et al., 2016a; Cox et al., 2016; Norr et al., 2018; Roberge et al., 2021).

Surprisingly, veterans with probable PTSD+AUD were less likely than veterans screening positive for PTSD-only but equally likely as veterans screening positive for AUD-only to report a lifetime history of suicide attempts. This finding contrasts with previous national veteran survey studies, which showed that dually diagnosed veterans were more likely than veterans with AUD-only but not PTSD-only to have made a prior suicide attempt (Blakey et al., 2021a) or else were more likely than both single-disorder groups to have previously attempted suicide (Norman et al., 2018). The reason for these mixed findings is unclear. One potential explanation is that Project GRIT recruited veterans from a VHA database, unlike other national surveys that recruited from the broader veteran population. Additionally, although the Project GRIT sample was on average older than the PDAS sample (59 years old vs. 36 years old, respectively; Elbogen et al., 2013), it was closer in age to the NHRVS subsample analyzed by Norman and colleagues (2018; AUD, PTSD, and PTSD+AUD subgroup’s mean ages were 58, 54, and 47 years old, respectively). Thus, age difference is a possible but unlikely explanation. National rates of veteran suicide did increase between the NHRVS and Project GRIT (U.S. Department of Veterans Affairs Office of Mental Health and Suicide Prevention, 2020), meaning our sample’s suicide attempt history may have reflected national changes in suicide trends at the time of data collection. This question is further complicated by some previous research suggesting that alcohol consumption is associated with greater suicide-related impulsivity, but not lethality of attempt among active duty soldiers (Bryan et al., 2016b). Considering the gravity of veteran suicide—as well as the strong link between suicide attempt and later death by suicide (Franklin et al., 2017)—additional research aimed at identifying and ameliorating veteran suicide risk factors will be essential.

Finally, we found that veterans screening positive for PTSD+AUD were more likely to report past-year NSSI than veterans screening positive for AUD-only, but not when compared to veterans screening positive for PTSD-only. This finding is consistent with a growing body of research linking PTSD to NSSI (e.g., Kimbrel et al., 2016) and highlights the importance of continued research in this area. In particular, additional research should clarify the role of concurrent AUD in the relationship between PTSD and NSSI. Given the deleterious effects that alcohol consumption has on domains of functioning also negatively affected by PTSD (e.g., emotion regulation; Ehring & Quack, 2010), one might expect that concurrent PTSD and AUD would heighten risk for NSSI. At the same time, whereas alcohol use and NSSI can each function as maladaptive posttraumatic stress coping strategies (Lane et al., 2019; Smith et al., 2013), research suggests that alcohol use may blunt the very PTSD symptoms most strongly associated with NSSI; particularly, PTSD hyperarousal symptoms (Alharbi et al., 2020; Sami and Hallaq, 2018). Indeed, reduction of regular alcohol use has been associated with increased hyperarousal symptom severity in veterans and disaster responders with PTSD symptoms (Livingston et al., 2020; Simons et al., 2005). Hence, it is possible that veterans with PTSD+AUD are less likely to engage in NSSI because the PTSD symptoms most likely to motivate NSSI behavior are already “successfully” alleviated by alcohol use. Additional research disentangling these clinical phenomena will be necessary to improving the field’s understanding of these complex and understudied relationships.

Limitations and Conclusions

Our findings should be contextualized within several study limitations. For example, our cross-sectional design prevents drawing conclusions about causality or directionality of study variables. Additionally, our outcomes included both lifetime (e.g., prior suicide attempts) and recent experiences (past-year suicidal ideation), either of which may have onset prior to PTSD and/or AUD symptoms. Study findings may also have been confounded by treatment history, such that veterans with previous PTSD and/or AUD diagnoses may have been successfully treated prior to study participation and therefore classified as having “neither disorder” in our analyses, yet have endorsed lifetime suicide attempts that occurred when they did meet full criteria for PTSD and/or AUD. Our reliance on self-report data means we cannot rule out recall error, and our use of self-report screening measures (though validated and often used in veteran samples to ascertain probable diagnoses) precludes us from confirming clinical diagnoses of PTSD or AUD. Future studies incorporating a longitudinal design and supplementing self-report assessment with clinical interview would be helpful. Although Project GRIT recruited a national veteran sample representative of VHA enrollees at the time of data collection (with the exception of intentionally oversampling women veterans), our sample included mostly white, married men with at least high school education who served during the Gulf War. Therefore, our findings may not replicate in samples of veterans who served in different military conflicts or who represent different sociodemographic groups.

At the same time, this study benefitted from several strengths, such as the use of a large, national sample that oversampled for women veterans to ensure adequate representation in study analyses. Additionally, we used sex-specific alcohol consumption screening cutoff scores for men and women participants, thereby improving the accuracy of AUD assessment among women veterans in this study. Our study is also the first to examine NSSI as a critical yet understudied outcome among veterans screening positive for PTSD, AUD, comorbid PTSD+AUD, and neither disorder. Our findings will hopefully inform future studies of the prevalence and course of psychosocial functioning and self-directed violence among veterans with common mental health conditions such as PTSD and AUD.

Highlights.

  • Posttraumatic stress disorder (PTSD) and alcohol use disorder (AUD) often co-occur

  • Veterans with comorbid PTSD+AUD have poorer psychiatric and functional outcomes

  • Veteran nonsuicidal self-injury (NSSI) is a critical but understudied health outcome

  • Gulf War veterans with PTSD+AUD fared worse on most outcomes compared to AUD-only

  • PTSD (with or without AUD) was linked to poorer functioning, suicide risk, and NSSI

Acknowledgements

The views expressed in this article are those of the authors and do not necessarily reflect the position or policy of the United States Government or Department of Veterans Affairs (VA). This work was supported by grant I01HX001682 from the Health Services Research and Development Service from the VA Office of Research and Development, which was awarded to Drs. Kimbrel and Pugh. Drs. Blakey and Griffin were each supported by a VA Office of Academic Affiliations Advanced Fellowship in Mental Illness Research and Treatment. Dr. Beckham was supported by a Senior Research Career Scientist award from VA Clinical Sciences Research and Development (IK6BX00377). Dr. Pugh was funded by a Research Career Scientist Award from VA Health Services Research and Development (IK6HX002608). These sponsors had no role in study design; in the collection, analysis and interpretation of data; in the writing of the report; or in the decision to submit the article for publication.

Footnotes

Declarations of Interest: None.

1

Blakey, Dillon, and colleagues (2021) recruited veterans with PTSD and substance use disorders, which were defined as having either AUD or a drug use disorder, but reported obtaining an identical pattern of findings when restricting analyses to veterans with PTSD-only, AUD-only, PTSD+AUD, and neither disorder (i.e., when veterans with drug use disorders but not AUD were excluded from analyses).

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