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. 2023 Mar 2;33(3):250–257. doi: 10.1016/j.whi.2023.02.001

Rates and Correlates of Alcohol and Substance Use Among Women Veterans During the COVID-19 Pandemic: The Moderating Role of COVID-Specific Anxiety

Katherine A Buckheit a,∗, Carrie Pengelly b, Abigail Ramon c, Wendy Guyker d, Catherine Cook-Cottone d, Paul R King Jr b,d
PMCID: PMC9977618  PMID: 37003919

Abstract

Introduction

Mental health symptoms and substance use increased during the COVID-19 pandemic, and women may be disproportionately affected. Women report substantial mental health consequences, and women veterans may experience additional risks associated with military service. However, rates and correlates of substance use and consequences among women veterans are largely unknown. This study aimed to 1) report rates of substance use and consequences among women veterans; 2) identify correlates of substance use and consequences; and 3) test COVID-specific anxiety as a moderator.

Method

Women veterans (n = 209) enrolled in Veterans Health Administration primary care completed measures of demographics, psychiatric and substance use disorder (SUD) diagnoses, current mental health symptoms, alcohol consumption, drug-related problems, and COVID-specific anxiety. Bivariate correlations evaluated demographics (age, race, employment, relationship status), psychiatric (depression/anxiety/posttraumatic stress disorder) and SUD diagnoses, and current mental health (depression/anxiety) symptoms as correlates of substance use outcomes. For any relationships between correlates and outcomes that were statistically significant, COVID-specific anxiety was tested as a moderator using the PROCESS macro in SPSS version 27. Any statistically significant moderation effects were further investigated using the PROCESS macro to estimate conditional effects. COVID-specific anxiety was mean-centered before analyses. Alpha was set to 0.05 for all statistical tests.

Results

Thirty-six percent screened positive for hazardous (Alcohol Use Disorder Identification Test-Consumption [AUDIT-C] ≥ 3) alcohol consumption and 26% reported drug-related problems (18% low-level, 7% moderate-level, and 2% substantial per Drug Abuse Screening Test [DAST-10] scores). Drug-related problems were positively associated with COVID-specific anxiety, psychiatric diagnosis, SUD diagnosis, and depression symptoms. Alcohol consumption was significantly associated with SUD diagnosis. COVID-specific anxiety significantly moderated relationships between SUD diagnosis and both outcomes.

Discussion

Results help identify women veterans with SUD diagnoses and high COVID-specific anxiety as at risk for increased substance use during COVID-19 and suggest a potential intervention target (COVID-specific anxiety).

The onset of the COVID-19 pandemic and mitigation strategies such as social distancing have been associated with increased mental health symptoms and substance use. Among adults in the United States, 40% endorsed at least one mental health symptom and 13.3% reported initiating or increasing substance use to cope with pandemic-related stress and emotions during April to June 2020 (Czeisler et al., 2020). The self-medication hypothesis, wherein substances are used to alleviate psychological distress (Khantzian, 2003), may help explain patterns of mental health symptoms and substance use during the COVID-19 pandemic.

A recent meta-analysis suggests small but significant adverse effects of lockdowns on anxiety and depressive symptoms (Prati & Mancini, 2021) and, importantly, highlights substantial heterogeneity in effects. Similarly, a narrative review found mixed evidence for the effect of COVID-19 on alcohol consumption (Murthy & Narasimha, 2021). Heterogeneity may be explained by methodological confounds inherent to the study of the effects of COVID-19 (e.g., lack of random assignment and control groups) or, alternatively, may reflect variability in stress response and coping capabilities (Prati & Mancini, 2021). Research examining the effects of COVID-19 on mental health and substance use has not demonstrated homogeneous findings, and this suggests that the effects of COVID-19 likely depend on a range of factors that span the biopsychosocial spectrum. The ability to detect adverse effects experienced by specific groups may be suppressed when mental health and substance use are assessed on a global level. Differential effects of and responses to the COVID-19 pandemic necessitate additional research on the effects of COVID-19 among specific groups.

Women have been disproportionately affected by the COVID-19 pandemic. Women have reported greater job loss, reduced hours at work, increased childcare responsibilities (Zamarro & Prados, 2021), and greater depression, anxiety (Ausín et al., 2021), and pandemic-specific trauma symptoms (Currie, 2021; Liu et al., 2020) compared with men. Yet research examining gender differences in substance use has resulted in mixed findings. Two studies found no gender differences in reported substance use patterns following the onset of COVID-19 (Bartoszek et al., 2020; Currie, 2021). Another study observed increased alcohol use across all sociodemographic groups assessed but found that the increase in women who reported drinking above recommended limits was larger than that of men (Barbosa et al., 2021).

Similarly, studies examining gender differences in factors associated with substance use have produced mixed results. One study found greater COVID-specific posttraumatic stress disorder (PTSD) symptomatology was associated with increased substance use across genders (Currie, 2021). Another reported that although pandemic-related psychological distress was associated with more alcohol consumption regardless of gender, greater psychological distress was associated with several specific indicators of hazardous alcohol consumption (greater typical and peak quantity of alcohol) among women only (Rodriguez et al., 2020). Results from investigations of gender differences in substance use during COVID-19 echo those of the population at large: evidence of increased substance use and related factors is reported, but not universally. Continued investigation among populations historically (i.e., pre-pandemic) at risk for substance use and mental health consequences may help clarify relationships and identify those in need of mental health and substance use treatment.

Women veterans may be at risk for adverse effects to mental health and substance use due to increased vulnerability at the onset of the pandemic in several key areas. Although likely subject to similar socio-environmental consequences of the pandemic as civilian women, they also face additional unique risk factors associated with previous military service. Certain aspects of military culture and occupational hazards (i.e., combat exposure, military sexual trauma, skewed alcohol norms) are potential risk factors for substance use among women veterans (Ames & Cunradi, 2004; Cucciare et al., 2013; Goldberg et al., 2019). Research has reported high rates of substance use among women veterans, including heavy episodic drinking (19–23%; Hoggatt, Jamison, et al., 2015; Hoggatt et al., 2017), alcohol misuse (12–37%; Hoggatt, Jamison, et al., 2015), illicit substance use (11%; Hoggatt et al., 2017), and prescription drug misuse (5%; Hoggatt et al., 2017). Women veterans also experience high rates of psychiatric diagnoses including depressive disorders (27.4%; Lehavot et al., 2012), anxiety disorders (19.5%; Lehavot et al., 2012), PTSD (13.4%; Lehavot et al., 2018), and poor current mental health status (Hoglund & Schwartz, 2014). Despite the presence of multiple mental health and substance use risk factors at the onset of COVID-19, to our knowledge, no research has been conducted on the effects of COVID-19 on mental health and substance use among this potentially at-risk population.

This study aims to extend the literature on mental health and substance use during COVID-19 to an understudied population of women veterans by 1) reporting rates of substance use and related problems among a sample of women veterans enrolled in Veterans Health Administration (VHA) primary care during the COVID-19 pandemic; 2) testing correlates of substance use and related problems; and 3) testing COVID-specific anxiety as a moderator.

Due to the lack of research among women veterans and reported heterogeneity in the effects of COVID-19 on mental health and substance use among broader populations, we made no a priori hypotheses regarding specific correlates of substance use and/or the moderating effect of COVID-specific anxiety. Rather, previous research informed our selection of specific factors for investigation in relation to substance use among women veterans. Our review of available literature suggested that age (Czeisler et al., 2020), racial identity (Czeisler et al., 2020; Murthy & Narasimha, 2021), employment status (Czeisler et al., 2020; Murthy & Narasimha, 2021), relationship status (Murthy & Narasimha, 2021), psychiatric (Czeisler et al., 2020) and substance use disorder (SUD) diagnoses (Murthy & Narasimha, 2021), current anxiety and depression symptoms (Murthy & Narasimha, 2021; Prati & Mancini, 2021), and pandemic-specific mental health symptoms (Currie, 2021; Rogers et al., 2020) were the most likely to be associated with substance use among women veterans and were therefore included in this study.

Method

Participants

Women veterans aged 18 to 65 who were enrolled in VHA primary care (at least one primary care appointment in the past year) in a northeastern VHA region including four health care systems composed of 14 medical centers and 57 community-based outpatient clinics were eligible to participate. Eligible participants were identified via electronic medical record review.

Measures

Demographics (age, racial identity, ethnicity, relationship status, and employment status) were assessed via self-report.

Alcohol consumption was assessed with the Alcohol Use Disorder Identification Test-Consumption (AUDIT-C; Bush et al., 1998). The AUDIT-C contains three items assessing typical drinking frequency, quantity, and frequency of binge drinking (four or more drinks/occasion) over the past year. Scores range from 0 to 12; higher scores represent greater alcohol consumption. Research supports a gender-specific cutoff of 3 for women as an indicator of risky alcohol consumption (Dawson et al., 2005; Hagman, 2015; Reinert & Allen, 2007). Internal consistency in this sample was good (α = .78).

Drug-related problems were assessed with the Drug Abuse Screening Test (DAST-10; Skinner, 1982). Ten items assess past-year drug-related problems on a binary (yes/no) scale; each affirmative response is assigned one point. The sum indicates degree of functional impairment related to use of drugs other than alcohol; higher scores indicate greater functional impairment. A score of 1 to 2 indicates low-level problems, 3 to 5 is suggestive of moderate-level problems, 6 to 8 indicates substantial problems, and 8 to 10 indicates severe problems (Skinner, 1982). Internal consistency in this sample was good (α = .78).

Psychiatric and SUD diagnoses were assessed via self-report. Participants indicated whether they had ever received a psychiatric (depression, anxiety, and/or PTSD) or SUD diagnosis. Presence of Alcohol Use Disorder (AUD) and Drug Use Disorder (DUD) were assessed separately, but drug types were collapsed in the assessment of DUD (i.e., “illegal, street, or prescription drugs”).

Anxiety symptoms were assessed with the General Anxiety Disorder 7-Item Scale (GAD-7; Spitzer et al., 2006). The GAD-7 contains seven items rated on a 4-point Likert scale; higher scores indicate greater distress related to anxiety symptoms. Internal consistency in this sample was excellent (α = 0.94).

Depression symptoms were measured with the Patient Health Questionnaire 8-Item Scale (PHQ-8), which is identical to the PHQ-9, the standard 9-item measure of depression symptoms (Kroenke et al., 2001) except for omission of the suicidal ideation item. Items assess distress and functional impairment related to depression symptoms on a 4-point Likert scale; higher scores indicate greater distress and functional impairment related to depression symptoms. Internal consistency in this sample was good (α = 0.89).

COVID-specific anxiety was assessed with the Coronavirus Anxiety Scale (CAS; Lee, 2020). The CAS contains five items rated on a 5-point Likert scale that represent distress related to COVID-specific anxiety in the past 2 weeks. Higher scores indicate greater COVID-specific anxiety, and scores ≥9 signal maladaptive levels of anxiety. Internal consistency in this sample was excellent (α = 0.92).

Procedure

All study procedures were approved by the Western New York VA Health Care System Institutional Review Board. This study is a secondary analysis of data gathered as part of a larger survey of health beliefs and behaviors among women veterans in primary care. Eligible participants were mailed study packets with a description of the study, self-report measures, return envelope, and study team contact information. Those who did not return the packets after 2 weeks were contacted by study staff. If study staff were unable to contact candidates, they were sent a reminder letter. Participants were compensated $35 for returned surveys. Of the 10,820 who were eligible to participate based on electronic medical record review, 675 women were sent letters to achieve a sample size of n = 211 (31% response rate). The 31% overall response rate was within the range of responses from our previous work (i.e., 27–38%; Buchholz et al., 2018; King et al., 2019). Data were collected Summer-Fall 2020. Responses from two participants who did not identify as women were removed for a final sample size of n = 209.

Analytic Strategy

Independent variables include demographics, psychiatric and SUD diagnoses, and current mental health symptoms. Dependent variables include two operationalizations of substance use: alcohol consumption (AUDIT-C) and drug-related problems (DAST-10). COVID-specific anxiety is the moderator.

For aim 1, descriptive statistics were calculated to characterize the sample in terms of demographics (age, racial identity, employment status, relationship status), psychiatric (PTSD, depression, or anxiety disorder) and SUD diagnoses, current mental health symptoms (depression, anxiety, COVID-specific anxiety), alcohol use (AUDIT-C), and drug-related problems (DAST-10).

For aim 2, bivariate associations (Pearson's r, point biserial) were computed to test associations between correlates (age, racial identity, employment status, relationship status, psychiatric diagnosis, SUD diagnosis), the moderator (COVID-specific anxiety), and outcomes (AUDIT-C, DAST-10) compared with the null hypothesis that variables are not significantly related. Given the rapidly evolving literature on mental health, substance use, and COVID-19, we opted to first conduct bivariate analyses to evaluate and establish that study variables were associated on a bivariate level before conducting analyses to evaluate more specific relationships among study variables. Results from aim 2 analyses directly informed aim 3 analyses (detailed in the following paragraph). Categorical variables (racial identity: White = 0, non-White = 1; employment status: not employed = 0, employed full- or part-time = 1; relationship status: not partnered = 0, partnered = 1) were dichotomized due to low frequencies of some categories. The psychiatric diagnosis variable indicates whether a participant had ever been diagnosed with any of the psychiatric conditions assessed (i.e., no diagnosis = 0, at least one depression, anxiety, or posttraumatic stress disorder diagnosis = 1). The SUD diagnosis variable indicates whether a participant had ever been diagnosed with any SUD, including alcohol, illicit, and prescription substances (i.e., no diagnosis = 0, at least one SUD diagnosis = 1).

For aim 3, correlates significantly associated (p < .05) with either outcome on a bivariate level were entered into linear regression models to test for moderation effects using the PROCESS macro in SPSS version 27. The PROCESS macro uses ordinary least squares regression to estimate coefficients and, in moderation models, test for a statistically significant interaction (p < .05) between the independent variable and the moderator, compared with the null hypothesis that the coefficient for the interaction is zero (Igartua & Hayes, 2021). We probed any statistically significant interactions using the PROCESS macro, which yields estimates of conditional effects of the independent variable on the dependent variable at three levels of the moderator: −1 standard deviation, mean, and +1 standard deviation (Igartua & Hayes, 2021). The moderator (COVID-specific anxiety) was mean-centered before analyses. Alpha was set to 0.05 for all statistical tests.

Results

Participant Characteristics

Participants were on average 49 years old (m = 49.51, SD = 10.82). Participants were primarily White (69%), with 19% identifying as Black/African American, 6% identifying as multicultural/multiracial, 1% identifying as American Indian/Alaska Native, and 1% identifying as Asian. Participants primarily identified as non-Hispanic (85%). Most participants were married (41%), divorced (20%), or single (never married, 15%). Thirty-seven percent of participants were working full-time, 14% were working part-time, and 35% were unemployed. Most (66%) had a psychiatric diagnosis (depressive disorder: 55%; PTSD: 33%; anxiety disorder: 37%). Overall prevalence of at least one SUD diagnosis in this sample was 8%. Five percent reported a DUD diagnosis and 4% reported an AUD diagnosis. On average, participants reported mild symptoms of depression (m = 8.53, SD = 6.1) and anxiety (m = 8.46, SD = 6.36). Most (91%) reported COVID-specific anxiety symptoms below the clinically significant threshold (m = 2.47, SD = 4.18).

Rates of Alcohol Use and Drug-Related Problems

A substantial minority of the sample (36%) screened positive for hazardous alcohol consumption on the AUDIT-C (m = 2.19, SD = 2.31). Most did not endorse drug-related problems (65%), 18% reported low-level problems, 7% reported moderate-level problems, and 2% reported substantial problems on the DAST-10 (m = 0.65; SD = 1.38).

Correlates of Alcohol Use and Drug-Related Problems

Results from bivariate analyses are shown in Table 1 . There were statistically significant bivariate associations between higher DAST-10 scores and higher COVID-specific anxiety (r = 0.20, p = .01), having a psychiatric diagnosis (r = 0.23, p = .002), having a SUD diagnosis (r = 0.41, p < .001), and more current depression symptoms (r = 0.15, p = .04). A higher AUDIT-C score was statistically significantly associated with having an SUD diagnosis (r = 0.14, p = .04). More COVID-specific anxiety was statistically significantly associated with being unemployed (r = −0.28, p < .001), more current depression symptoms (r = 0.52, p < .001), and more current anxiety symptoms (r = 0.50, p < .001). No other associations were statistically significant (all p's > .05).

Table 1.

Bivariate Associations Between Demographic and Mental Health Correlates and Substance Use Outcomes

Variable Age Race Employment Status Relationship Status Psychiatric Diagnosis SUD Diagnosis Anxiety Symptoms Depression Symptoms COVID-Specific Anxiety Alcohol Consumption
1. Age -
2. Race 0.05 -
3. Employment status −0.25† −0.13 -
4. Relationship status −0.19† −0.20† 0.06 -
5. Psychiatric diagnosis −0.07 0.04 −0.19† 0.01 -
6. SUD diagnosis 0.11 0.09 −0.14∗ −0.04 0.13 -
7. Anxiety symptoms −0.19† −0.09 −0.11 0.11 0.34‡ 0.03 -
8. Depression symptoms −0.03 −0.09 −0.20† 0.01 0.40‡ 0.11 0.76‡ -
9. COVID-specific anxiety 0.08 0.12 −0.28‡ 0.04 0.22† 0.10 0.50‡ 0.52‡ -
10. Alcohol consumption −0.07 −0.13 0.08 0.09 −0.002 0.14∗ 0.09 −0.004 −0.07 -
11. Drug-related problems 0.05 0.05 −0.11 −0.07 0.23† 0.41† 0.11 0.15∗ 0.20† 0.22†
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Abbreviation: SUD, substance use disorder.

Note: N = 209. Race: White = 0, non-White = 1. Employment status: not employed = 0, employed full- or part-time = 1. Relationship status: not partnered = 0, partnered = 1. Psychiatric diagnosis: no diagnosis = 0, at least one depression, anxiety, or posttraumatic stress disorder diagnosis = 1. SUD diagnosis: no diagnosis = 0, at least one SUD diagnosis = 1. Anxiety symptoms were assessed with the General Anxiety Disorder 7-Item Scale (GAD-7) (Spitzer et al., 2006). Depression symptoms were assessed with the Patient Health Questionnaire 8-Item Scale (PHQ-8) (Kroenke et al., 2001). COVID-specific anxiety was assessed with the Coronavirus Anxiety Scale (CAS) (Lee, 2020). Alcohol use was assessed with the Alcohol Use Disorder Identification Test-Consumption (AUDIT-C) (Bush et al., 1998). Drug-related problems were assessed with the Drug Abuse Screening Test (DAST-10) (Skinner, 1982).

∗

p < .05.

†

p < .01.

‡

p < .001.

Moderation Effect of COVID-Specific Anxiety

We tested COVID-specific anxiety as a moderator of the following significant correlate/outcome relationships in separate models: psychiatric diagnosis/DAST-10, SUD diagnosis/DAST-10, SUD diagnosis/AUDIT-C, current depression symptoms/DAST-10.

Results showed no significant moderation of COVID-specific anxiety on the relationship between psychiatric diagnosis and DAST-10 scores (b = 0.09, p = .19). There was a significant main effect of psychiatric diagnosis on DAST-10 scores (b = 0.64, p = .04). There was no significant moderating effect of COVID-specific anxiety on the relationship between current depression symptoms and the DAST-10 (b < 0.001, p = .99) nor was there a significant main effect.

Results showed a statistically significant moderation effect of COVID-specific anxiety on the relationship between SUD diagnosis and DAST-10 scores (b = 0.28, p < .001). Further examination of the interaction revealed statistically significant differences in the magnitude of the effect at low (−1 SD; b = 0.04, p = .02), average (b = 1.63, p < .001), and high (+1 SD; b = 2.78, p < .001) levels of COVID-specific anxiety. Specifically, there was a stronger positive relationship between SUD diagnosis and DAST-10 scores among those with high COVID-specific anxiety compared with weaker positive relationships among those with average or low COVID-specific anxiety. Results also showed a statistically significant moderation effect on the relationship between SUD diagnosis and AUDIT-C scores (b = 0.60, p < .001). Further examination of the interaction revealed statistically significant differences in the magnitude of the effect at low (−1 SD; b = −0.96, p = .18), average (b = 0.55 p = .35), and high (+1 SD; b = 3.08 p < .001) levels of COVID-specific anxiety. Specifically, there was a stronger positive relationship between SUD diagnosis and AUDIT-C scores among those with high COVID-specific anxiety compared with nonsignificant relationships between SUD diagnosis and AUDIT-C scores among those with average or low COVID-specific anxiety. Figures 1 and 2 depict the conditional effects of SUD diagnosis on drug-related problems and alcohol consumption, respectively, at low, average, and high levels of COVID-specific anxiety.

Figure 1.

Figure 1

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Conditional effect of SUD diagnosis on drug-related problems at low (−1 SD), average, and high (+1 SD) levels of COVID-specific anxiety. Drug-related problems were assessed with the DAST-10 (Skinner, 1982), COVID-specific anxiety was assessed with the Coronavirus Anxiety Scale (CAS) (Lee, 2020). Figure depicts mean differences in DAST-10 scores between those with and without SUD diagnoses at different levels of the moderator; lines are to aid visual interpretation.

Figure 2.

Figure 2

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Conditional effect of substance use disorder (SUD) diagnosis on alcohol use at low (−1 SD), average, and high (+1 SD) levels of COVID-specific anxiety. Alcohol use was assessed with the Alcohol Use Disorder Identification Test-Consumption (AUDIT-C) (Bush et al., 1998), COVID-specific anxiety was assessed with the Coronavirus Anxiety Scale (CAS) (Lee, 2020). Figure depicts mean differences in AUDIT-C scores between those with and without SUD diagnoses at different levels of the moderator; lines are to aid visual interpretation.

Discussion

The aims of this study were to describe rates of substance use and related problems among a sample of women veterans during the COVID-19 pandemic, test demographic and mental health correlates of substance use and related problems, and test COVID-specific anxiety as a moderator. Results extend previous research to a novel and understudied group. Rates of hazardous alcohol use in this study are similar to pre-pandemic estimates (i.e., Hoggatt, Williams, et al., 2015), as is the prevalence of SUD (Hoggatt, Jamison, et al., 2015). As for drug-related problems (i.e., DAST-10 scores), one study among women veterans reported that 6% of the sample screened positive (i.e., at least moderate-level problems) on the DAST-10 (Nunnink et al., 2010), and a comparable study reported similar DAST-10 scores (m = 0.47) among women veterans (Eisen et al., 2012). Future research focused on comprehensive assessment of indicators of alcohol and drug involvement among women veterans is crucial to inform efforts to address health care needs of a rapidly expanding population.

Results demonstrate some concordance with previous research during COVID-19 regarding connections between mental health (e.g., psychiatric diagnosis, current depression symptoms) and substance use (Chen et al., 2022; Currie, 2021; Roberto et al., 2020; Rogers et al., 2020; Wang et al., 2020). Statistically significant bivariate, but not moderation, analyses from this study in combination with previous research suggest that for some individuals, mental health is related to substance use regardless of whether the psychological distress/symptoms are specific to COVID-19. Notably, this study only assessed COVID-specific anxiety rather than the range of possible COVID-specific mental health symptoms (i.e., grief, trauma, or depression symptoms; Currie et al., 2021; Hahm et al., 2023). More research is needed to examine a range of possible COVID-specific concerns and symptoms as the nature of COVID-specific mental health symptoms and concerns likely differs between populations.

A different pattern of results emerged from analyses of relationships among SUD diagnosis, COVID-specific anxiety, and substance use. SUD diagnosis was statistically significantly associated with both alcohol consumption and drug-related problems, and both relationships were statistically significantly moderated by COVID-specific anxiety. Statistically significant moderation effects for SUD, but not other psychiatric diagnoses or mental health symptoms, suggest that COVID-specific anxiety is a particularly important stressor among those with SUD diagnoses. Individuals with SUD are more likely to have comorbid physical health complications and compromised immune functioning that places them at higher risk for serious COVID-19 illness and complications, and COVID-19 mitigation efforts compromise access to treatment and social support for individuals with SUD (Mallet et al., 2021; Wang et al., 2021). Our results may reflect these particular COVID-specific difficulties, and associated anxiety, experienced by individuals with SUD.

Results from this study contradict previous reports regarding employment status (i.e., Czeisler et al., 2020), as there was no evidence of statistically significant relationships between employment status and either substance use outcome. This may reflect unique characteristics of a veteran population whose patterns of employment may differ from civilian populations (Collins et al., 2014) overall, or possibly even uniquely during the COVID-19 pandemic. Alternatively, nonsignificant findings could reflect insufficient granularity in the assessment of employment status in this study versus previous findings. We did not assess type of employment (i.e., essential vs. nonessential) as the methodology for this study was designed before the onset of COVID-19. Similarly, nonsignificant findings regarding many of the relationships between correlates and alcohol use may also be due to insufficient granularity. The AUDIT-C is a well-validated measure of alcohol consumption that is predictive of problematic alcohol use (Bush et al., 1998); however, we did not assess alcohol-related problems—such as failure to fulfill role obligations, craving, and use of alcohol in hazardous situations—directly. Future research should include increased granularity in assessment of employment status and alcohol use to best capture their relationship to mental health symptoms.

Results from this study should be considered along with its limitations. As previously noted, the assessment of employment status and alcohol consumption are limited. An additional limitation related to the assessment of alcohol consumption concerns the methods used to gender-tailor this measure. In our study, two methods of gender-tailoring were used: a gender-specific cutoff score of AUDIT-C greater than or equal to 3 and a tailored binge drinking item (four or more drinks/occasion). Research has not yet demonstrated a consensus on the most appropriate method of gender-tailoring of the AUDIT-C to maximize detection of hazardous use without causing undue burden to providers and patients. Some have suggested the combination of both gender-tailoring methods as in this study may be overly inclusive in identifying hazardous alcohol use (Hoggatt et al., 2018). In addition, as this study was not primarily designed to report rates of substance use, we are unable to report rates of consumption for substances other than alcohol, only related problems. Similarly, this study is limited as a secondary data analysis in its variable selection procedures; future research should specify relevant variables a priori rather than via post hoc selection. This study is cross-sectional in design and thus does not allow for assessment of causality. Given the method of assessment of psychiatric and SUD diagnoses (i.e., self-report, with a “lifetime” time frame), we were not able to differentiate between individuals who currently meet diagnostic criteria from those who met diagnostic criteria in the past but not currently. Finally, the sample size was not sufficiently large to conduct further comparisons that are likely important to understanding the nuanced impacts of COVID-19. For example, collapsing racial categories into a dichotomous White/non-White variable does not allow for examination of effects among those of different racially minoritized identities. Limitations notwithstanding, results offer important implications for informing future research, practice, and policy focused on addressing treatment needs among a rapidly expanding population of women veterans.

Implications for Practice and Policy

The growing body of research examining the effects of COVID-19 on mental health and substance use, including results from this study, are important given the disruptions to mental health and substance use treatment stemming from necessary COVID-19 mitigation strategies (Moreno et al., 2020). In immediate clinical practice, our results suggest COVID-specific anxiety may be a risk factor and is also a specific, modifiable psychological factor that could be targeted in interventions. Efforts to adapt evidence-based interventions to address COVID-specific mental health symptoms are under way (i.e., Wahlund et al., 2021), and techniques to address COVID-specific symptoms could be incorporated into substance use interventions (i.e., Cognitive Behavioral Therapy for Substance Use Disorder, DeMarce et al., 2014; Mindfulness Based Relapse Prevention, Witkiewitz et al., 2005). In addition, providers working with women veterans should be mindful to monitor their patients’ substance use, particularly alcohol use, due to high prevalence rates.

Adapting evidence-based interventions to address COVID-specific anxiety may not only help ameliorate the adverse impacts to mental health of the COVID-19 pandemic specifically but may also serve as a model for addressing the mental health impact of potential future stressors (i.e., natural disasters, pandemics). Identifying at-risk populations, as well as possible intervention targets and strategies, may help inform preventive and early intervention efforts in response to future stressors.

Numerous commentaries have identified individuals with SUD diagnoses as potentially at risk for a range of adverse outcomes related to COVID-19 and its associated mitigation strategies (Becker & Fiellin, 2020; Davis & Samuels, 2020). Findings from this study add to the growing body of empirical evidence (Mallet et al., 2021; Wang et al., 2021) that may be used to inform policy governing substance use treatment during, and as some have suggested, following the COVID-19 pandemic (López-Pelayo et al., 2020). Early reports of policy changes to substance use treatment delivery during COVID-19 suggest common adaptations (e.g., telehealth) may not universally increase access, and highlight the importance of social determinants of health (e.g., housing status) to substance use treatment delivery (Harris et al., 2022). In addition, policymakers may consider unique barriers and disruptions to treatment faced by women veterans with problematic substance use during the pandemic, and take steps to ensure that recent policy changes to increase access to substance use treatment (i.e., telemedicine, person-centered care; López-Pelayo et al., 2020) are extended to women veterans. Ongoing evaluation of changes to treatment structures and delivery is key, and will help guide policymakers in determining which changes may be beneficial to retain even after the immediate threat of COVID-19 has subsided to help ensure that systems of substance use treatment delivery are effective and equitable in their accessibility (López-Pelayo et al., 2020).

Conclusions

Our findings add to the literature by reporting rates and correlates of substance use during COVID-19 among women veterans. Rates of alcohol use and drug-related consequences were prevalent and comparable to pre-pandemic estimates among women veterans. Psychiatric and SUD diagnoses, higher COVID-specific anxiety, and more depression symptoms were related to more substance use. Results add to the growing body of research demonstrating that individuals with SUD diagnoses may be at increased risk during COVID-19 and extend previous research to women veterans. Results carry implications for immediate clinical practice by suggesting that providers working with women veterans should consider monitoring substance use because of high prevalence rates, and by identifying COVID-specific anxiety as a possible intervention target among women veterans, particularly those with SUD diagnoses. Results may also serve as a model to inform response to future similar stressors and to ensure equitable access to mental health and substance use treatment .

Biographies

Katherine Buckheit, PhD, is a postdoctoral fellow at the Center for Integrated Healthcare (CIH) at the Syracuse VA. Her research interests include integrating evidence-based substance use interventions into primary care settings and increasing access to substance use treatment for underserved populations.

Carrie Pengelly, MS, is an experienced CIH study coordinator with expertise in patient recruitment and retention in clinical research.

Abigail E. Ramon, PhD, is a Psychologist at the St. Louis VA Medical Center with research interests in integrative medicine applications for health and wellness in integrated PC settings and in patient-centeredness. She is currently developing a brief self-compassion intervention for PC veterans with chronic pain.

Wendy Guyker, PhD, is a Clinical Associate Professor in the University at Buffalo’s Counseling, School, and Educational Psychology (CSEP) Department. Her research interests include mental health and mindful self-care, including yoga-based interventions with diverse populations (e.g., medical residents, aide workers).

Catherine Cook-Cottone, PhD, is a Professor at the University at Buffalo. Her research focuses on embodied self-regulation, eating disorders, and trauma. She is also a registered yoga teacher, and the founder of Yogis in Service, a nonprofit organization that creates access to yoga.

Paul R. King, PhD, is a Clinical Research Psychologist at CIH and Adjunct Assistant Professor in the University at Buffalo’s Counseling, School, and Educational Psychology Department. His professional interests include post-deployment health care, particularly primary care-based management of concussion and mental health conditions.

Footnotes

Funding Statement: This study was supported by funding from the VA Center for Integrated Healthcare Pilot Program, as well as with the use of facilities and resources at the VA Center for Integrated Healthcare, the VA Western New York Healthcare System, the Syracuse VA Medical Center, and the University at Buffalo. Dr. Buckheit is supported by the Department of Veterans Affairs, Office of Academic Affiliations, Advanced Fellowship Program in Mental Illness Research and Treatment, and the Center for Integrated Healthcare, Syracuse VA Medical Center.

Disclaimer: The views expressed in this article are those of the authors and do not necessarily reflect the position or policy of the Department of Veterans Affairs or the U.S. government.

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