Posttraumatic stress disorder in female veterans: association with self-reported health problems and functional impairment.

BACKGROUND: The purpose of this report is to identify self-reported health problems and functional impairment associated with screening positive for posttraumatic stress disorder (PTSD) in women seen for care at a Department of Veterans Affairs (VA) medical center. METHODS: A survey was mailed to all women (N = 1935) who received care at the VA Puget Sound Health Care System between October 1996 and January 1998. The survey inquired about health history and habits. It included the PTSD Checklist-Civilian Version (PCL-C) and validated screening measures for other psychiatric disorders. The veteran's version of the Medical Outcomes Study 36-Item Short-Form Health Survey (SF-36-V) was included to assess health-related quality of life. RESULTS: Of the 1259 eligible women who completed the survey, 266 women (21%) screened positive for current PTSD (PCL-C score >or= 50). In age-adjusted bivariate analyses, women who screened positive for PTSD reported more psychiatric problems, substance abuse, and lifetime exposure to domestic violence. They were significantly more likely to endorse physical health problems including obesity, smoking, irritable bowel syndrome, fibromyalgia, chronic pelvic pain, polycystic ovary disease, asthma, cervical cancer, and stroke. In fully adjusted multivariate models, a PCL-C score of 50 or greater was independently associated with scoring in the lowest quartile on SF-36-V subscales and composite scales. CONCLUSIONS: Symptoms of PTSD are common in women treated at VA facilities. In addition, PTSD is associated with self-reported mental and physical health problems and poor health-related quality of life in these patients. These findings have implications for the design of VA primary care services for the growing population of female veterans.

The TWEAK is weak for alcohol screening among female Veterans Affairs outpatients.

BACKGROUND: The optimal brief questionnaire for alcohol screening among female patients has not yet been identified. This study compared the performance of the TWEAK (tolerance, worried, eye-opener, amnesia, cutdown), the Alcohol Use Disorders Identification Test (AUDIT), and the AUDIT Consumption (AUDIT-C) as self-administered screening tests for hazardous drinking and/or active alcohol abuse or dependence among female Veterans Affairs (VA) outpatients. METHODS: Women were included in the study if they received care at VA Puget Sound and completed both a self-administered survey containing the AUDIT and TWEAK screening questionnaires and subsequent in-person interviews with the Alcohol Use Disorders and Associated Disabilities Interview Schedule. Sensitivities, specificities, positive and negative likelihood ratios, and areas under Receiver Operating Characteristic curves were computed for each screening questionnaire compared with two interview-based comparison standards: (1) active DSM-IV alcohol abuse or dependence and (2) hazardous drinking and/or active DSM-IV alcohol abuse or dependence, the more appropriate target for primary care screening. RESULTS: Of 393 women who completed screening questionnaires and interviews, 39 (9.9%) met diagnostic criteria for alcohol abuse or dependence, and 89 (22.7%) met criteria for hazardous drinking or alcohol abuse or dependence. The TWEAK had relatively low sensitivities (0.62 and 0.44) but adequate specificities (0.86 and 0.89) for both interview-based comparison standards, even at its lowest cut-point (>/=1). The AUDIT and AUDIT-C were superior, with the following areas under the receiver operating characteristic curve for active alcohol abuse or dependence and hazardous drinking and/or active alcohol abuse or dependence, respectively: AUDIT, 0.90 [95% confidence interval (CI), 0.85-0.95] and 0.87 (95% CI, 0.84-0.91); AUDIT-C, 0.91 (95% CI, 0.88-0.95) and 0.91 (95% CI, 0.88-0.94); and TWEAK, 0.76 (95% CI, 0.66-0.86) and 0.67 (95% CI, 0.60-0.74). CONCLUSIONS: The TWEAK has low sensitivity as an alcohol-screening questionnaire among female VA outpatients and should be evaluated further before being used in other female primary care populations. The three-item AUDIT-C was the optimal brief alcohol-screening questionnaire in this study.

Smoking cessation treatment among dually diagnosed individuals: preliminary evaluation of different pharmacotherapies.

This descriptive, observational pilot study evaluated a smoking cessation intervention using open-label bupropion and nicotine replacement within an addiction treatment center for patients with high rates of comorbid psychiatric diagnoses. Participants were 115 veterans receiving substance abuse treatment at a Veterans Administration outpatient program who voluntarily sought smoking cessation treatment. Three fourths of participants had a psychiatric diagnosis in addition to substance dependence (i.e., dual diagnosis). The intervention consisted of a weekly smoking cessation therapy group and pharmacotherapy as determined by participant and clinician preference (none, nicotine replacement only, bupropion only, or combined nicotine and bupropion). A total of 47 participants (40.9%) completed four group smoking cessation sessions, and 17 (14.8%) completed eight sessions. Of these participants, 27 (23.5%) had breath carbon monoxide (CO) levels <9 ppm (indicating short-term abstinence) at session 4, and nine (7.8%) had CO levels <9 ppm at session 8. Participants who received nicotine replacement alone or with bupropion attended more sessions than did subjects who did not receive nicotine replacement. Participants receiving combined medications had greater reductions in CO levels at session 4 than did the other participants. There was no evidence of increased use of other substances during smoking cessation treatment. These findings indicate that many dually diagnosed individuals are willing to attempt smoking cessation with appropriate pharmacotherapy and achieve reductions in CO measures, but only minimal success was observed with respect to cessation. Additional research is needed to assess medication effects in randomized trials, to explore effects of more intensive treatments, and to assess possible harm reduction from smoking interventions within this population.

Two brief alcohol-screening tests From the Alcohol Use Disorders Identification Test (AUDIT): validation in a female Veterans Affairs patient population.

BACKGROUND: Primary care physicians need a brief alcohol questionnaire that identifies hazardous drinking and alcohol use disorders. The Alcohol Use Disorders Identification Test (AUDIT) questions 1 through 3 (AUDIT-C), and AUDIT question 3 alone are effective alcohol-screening tests in male Veterans Affairs (VA) patients, but have not been validated in women. METHODS: Female VA patients (n = 393) completed self-administered questionnaires, including the 10-item AUDIT and a previously proposed modification to AUDIT question 3 with a sex-specific threshold for binge drinking (>/=4 drinks/occasion), and in-person interviews with the Alcohol Use Disorder and Associated Disabilities Interview Schedule. The AUDIT-C, AUDIT question 3 alone, and the 10-item AUDIT were each evaluated with and without the sex-specific binge question and compared with past-year hazardous drinking (>7 drinks/week or >/=4 drinks/occasion) and/or active Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition alcohol abuse or dependence, based on interviews. RESULTS: Eighty-nine women (22.6%) met interview criteria for past-year hazardous drinking and/or active alcohol abuse or dependence. Standard and sex-specific AUDIT-Cs were sensitive (0.81 and 0.84, respectively) and specific (0.86 and 0.85, respectively). Their areas under the receiver operating characteristic curves were equivalent (0.91, and 0.92, respectively) and slightly higher than for the standard 10-item AUDIT (0.87). A single, sex-specific question about binge drinking (modified AUDIT question 3) had a sensitivity of 0.69 and specificity of 0.94, whereas the standard AUDIT question 3 was specific (0.96) but relatively insensitive (0.45). CONCLUSIONS: The standard and sex-specific AUDIT-Cs are effective screening tests for past-year hazardous drinking and/or active alcohol abuse or dependence in female patients in a VA study.

Brief motivational feedback improves post-incarceration treatment contact among veterans with substance use disorders.

OBJECTIVES: To test the efficacy of providing brief motivational feedback to increase post-incarceration substance use disorders (SUD) treatment contact. DESIGN: Randomized clinical trial (feedback vs. control) with a 2-month post-incarceration follow-up. PARTICIPANTS: Veterans (N = 73) incarcerated in a county jail system who met SUD diagnostic criteria. MEASURES: Baseline assessment included the Addiction Severity Index, the Form-90 assessment of recent alcohol use, and a DSM-IV SUD criteria checklist. The primary outcome was Veterans Administration (VA) appointments. Secondary outcomes were the Addiction Severity Index-Followup and the Treatment Services Review. INTERVENTION: All participants received baseline assessment. The feedback condition received personalized feedback and encouragement to explore ambivalence about change and treatment in a single interview. RESULTS: Participants receiving feedback were more likely to schedule appointments at a VA addictions clinic within 60 days of their jail release dates (67 vs. 41%; P < 0.03). Though differences were not statistically significant, more feedback participants attended addictions clinic appointments (47 vs. 32%; ns) and were retained in addictions treatment at 90 days (31 vs. 14%; P < 0.08). Treatment appointments were more likely when intervention occurred close to release. Loss of participants to post-release follow-up interviews was >50%, limiting power to detect significant differences by self-report. CONCLUSION: Brief motivational feedback shows promise as a way to link incarcerated individuals to SUD treatment services.

Screening for substance abuse and psychiatric disorders among women patients in a VA Health Care System.

OBJECTIVE: This study of women Veterans Affairs (VA) health care patients screened for the prevalence of past-year smoking, hazardous and problem drinking, other drug abuse, and psychiatric disorders. METHODS: A survey was mailed to women veterans who had received care from VA Puget Sound Health Care System between October 1, 1996, and January 1, 1998. Screening measures included questions about cigarettes; questions from the Alcohol Use Disorders Identification Test about consumption (hazardous drinking); the TWEAK test (problem drinking); a drug abuse screen; the Patient Health Questionnaire (psychiatric conditions); and the PTSD (posttraumatic stress disorder) Checklist. RESULTS: Of eligible patients, 1,257 (65 percent) returned surveys with complete substance use data. Patients reported a relatively high rate of past-year smoking (29.1 percent) and hazardous drinking, problem drinking, or both (31.1 percent). The rate of past-year drug use was much lower (4.9 percent). Younger age was strongly associated with greater substance abuse: 59 percent of women under age 35 screened positive for smoking, hazardous or problem drinking, or drug abuse. Screening positive for a psychiatric condition (N=504) was also associated with substance abuse: The rate of past-year drug abuse among women screening positive for a psychiatric condition (9.7 percent) was double the rate for the entire sample. Of the women who screened positive for depression, PTSD, eating disorders, or panic disorders, 57 percent screened positive for substance abuse (including smoking). CONCLUSIONS: Substance abuse is common among women VA patients and is associated with younger age and with screening positive for other psychiatric conditions. Providers are expected to follow up on positive screening tests, and these data indicate substantial provider burden.

Women in addictions treatment: comparing VA and community samples.

Despite increasing awareness of gender issues in substance use treatment, women with substance use disorders (SUD) and gender-specific treatment remain understudied. This study examines differences, including identification of comorbid issues and patients' perceived treatment needs, between women in different SUD treatment settings: an intensive VA outpatient program (VA; N = 76) and a private residential/outpatient program (Residence XII; N = 308). In both settings the Addiction Severity Index (ASI) was administered at intake; ASI data were collected from retrospective chart review. Results support previous findings that women entering SUD treatment endorse high rates of psychiatric and medical comorbidity, and past abuse. Women in VA SUD treatment experienced more impairment on indices of medical, psychiatric, and employment issues whereas the private agency sample had higher alcohol and family/social composite scores. The differences between and similarities among the two treatment groups have implications for design of women-specific SUD treatment programs.