Journal of Substance Abuse Treatment 52 (2015) 10–16

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Journal of Substance Abuse Treatment

National Prevalence and Correlates of Alcohol Misuse in Women Veterans Katherine J. Hoggatt, Ph.D., MPH a,b,⁎, Emily C. Williams, Ph.D., MPH c,d, Claudia Der-Martirosian, Ph.D. e, Elizabeth M. Yano, Ph.D., MSPH a,f, Donna L. Washington, M.D., MPH a,g a

VA Greater Los Angeles Health Services Research and Development (HSR&D) Center for the Study of Healthcare Innovation, Implementation & Policy (CSHIIP), Sepulveda, CA, USA Department of Epidemiology, UCLA Fielding School of Public Health, Los Angeles, CA, USA Denver-Seattle Center of Innovation for Veteran-Centered and Value-Driven Care, HSR&D, VA Puget Sound, Seattle, WA, USA d Department of Health Services, University of Washington, Seattle, WA, USA e Veterans Emergency Management Evaluation Center (VEMEC), North Hills, CA, USA f Department of Health Policy and Management, UCLA Fielding School of Public Health, Los Angeles, CA, USA g Department of Medicine, UCLA David Geffen School of Medicine, Los Angeles, CA, USA b c

a r t i c l e

i n f o

Article history: Received 4 February 2014 Received in revised form 5 December 2014 Accepted 14 December 2014 Keywords: Alcohol misuse Mental health care Health services Women veterans

a b s t r a c t Our goal was to estimate the prevalence and correlates of alcohol misuse in women veterans and to assess the associations between alcohol misuse and mental health (MH) care utilization in a group comprising both Veterans Health Administration (VA) healthcare system users and non-users. We assessed alcohol misuse using survey-based AUDIT-C scores. The prevalence of alcohol misuse was 27% in VA users and 32% in nonusers. Prevalence rates were higher for VA users who were younger, served in OEF/OIF, or had combat exposure and for VA non-users who screened positive for posttraumatic stress disorder or sexual assault in the military. In contrast to VA users, VA non-users with alcohol misuse had a low prevalence of past-year MH care despite having indications of MH care need. Our results on alcohol misuse prevalence, its correlates, and its association with MH care may aid program planning and resource allocation in VA and non-VA settings. Published by Elsevier Inc.

1. Introduction Alcohol misuse, defined as drinking above recommended limits, is a health concern in military and veteran populations (IOM (Institute of Medicine), 2012; Office of Applied Studies, 2005). Although most research on alcohol misuse in U.S. veterans has focused on men, a number of recent studies have highlighted it as a health issue for women veterans (Bradley et al., 2012; Calhoun, Elter, Jones, Kudler, & Straits-Troster, 2008; Chavez, Williams, Lapham, & Bradley, 2012; Denneson, Lasarev, Dickinson, & Dobscha, 2011; Eisen et al., 2012; Grossbard et al., 2013; Grossbard, Hawkins, et al., 2013; Harris, Bradley, Bowe, Henderson, & Moos, 2010; Hawkins, Lapham, Kivlahan, & Bradley, 2010; Hoggatt et al., 2015; Williams et al., 2014). This research attention comes at a time when women's roles in the military are expanding, and their representation in the veteran population is rapidly increasing. Women represent about 8% of the veteran population, a figure expected to grow to 14% by 2033, and are one of the fastest growing segments of the Veterans Health Administration (VA) patient population (Frayne et al., 2010; Yano et al., 2010). However, the majority of women

⁎ Corresponding author at: VA Greater Los Angeles Health Services Research and Development (HSR&D) Center for the Study of Healthcare Innovation, Implementation & Policy, 16111 Plummer St (152), Sepulveda, CA 91343. Tel.: +1 818 891 7711; fax: +1 818 895 5838. E-mail addresses: [email protected], [email protected] (K.J. Hoggatt). http://dx.doi.org/10.1016/j.jsat.2014.12.003 0740-5472/Published by Elsevier Inc.

veterans still seek medical care outside the VA (National Center for Veterans Analysis and Statistics, 2011; Washington, Yano, Simon, & Sun, 2006). In non-VA healthcare settings, routine alcohol screening may not be the norm (Friedmann, McCullough, Chin, & Saitz, 2000), and women's veteran status may not be apparent. There may therefore be additional challenges in identifying and treating alcohol misuse in women veterans who are VA non-users. Information on the prevalence of alcohol misuse in women veterans, and the identification of subgroups in which the prevalence is particularly high, can be critical for program planning, quality improvement efforts, and resource allocation in both VA and non-VA settings. As summarized in a recent systematic review of the literature (Hoggatt et al., 2015), to date there has been no epidemiologic description of alcohol misuse in women veterans. In particular, no studies have assessed alcohol misuse in a population-based group of women veterans, reported prevalence estimates separately for VA users and non-users, or described the health correlates of alcohol misuse in the general population of women veterans. Most studies of alcohol misuse in women veterans have focused exclusively on VA patients and have presented a wide range of prevalence estimates, up to 37% in recent returnees, depending on the method of assessment and specific population studied. Even less is known about the health correlates of alcohol misuse in women veterans, although studies of other types of unhealthy alcohol use have noted a co-occurrence with mental health conditions or a history of sexual assault in the military (SAIM) or military sexual

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trauma (MST, which refers to repeated threatening forms of sexual harassment or sexual assault sustained during military service) (Hankin et al., 1999; Maguen et al., 2012; Scott et al., 2013; Seelig et al., 2012). These findings raise questions of whether women veterans with alcohol misuse, particularly those who do not use VA care, are receiving mental health care commensurate with their need. In VA, veterans receive routine annual screening for alcohol misuse, posttraumatic stress disorder (PTSD), and depression. In addition, mental health services have been integrated into VA primary care (Wray, Szymanski, Kearney, & McCarthy, 2012). Both policies may facilitate identification of women with alcohol misuse and referral for mental health care as needed. However, for women who do not use VA healthcare, the practices regarding alcohol screening and referral to mental health care are more variable, and as a result VA non-users with alcohol misuse may not be receiving the mental health care they need. To better deliver care to women veterans with alcohol misuse, providers and planners need information on the prevalence of alcohol misuse (overall and in high-risk subgroups), the mental health correlates of alcohol misuse among women veterans, and possible gaps in mental health care. The present analysis adds to the literature on women veterans and alcohol misuse in these three key areas. First, we use a unique dataset to derive nationally-representative estimates of the prevalence of alcohol misuse among women veterans (overall and separately for VA users and non-users). We also report prevalence estimates for subgroups defined by demographic, military, and health characteristics, including women who served in Operation Enduring Freedom/Operation Iraqi Freedom (OEF/OIF) and women screening positive for mental health conditions or a history of SAIM. Second, we assess correlates of alcohol misuse in VA users and non-users, including indicators of mental health care need (mental health conditions and SAIM) and receipt of mental health care. Finally, we estimate and compare the receipt (or prevalence) of past-year mental health care for women veterans with and without alcohol misuse, accounting for demographics, indicators of mental health care need, and allowing for differences between VA users and non-users. 2. Materials and methods For this analysis we used data from the National Survey of Women Veterans (NSWV). The NSWV was a cross-sectional national telephone survey conducted between 2008 and 2009 to support evidence-based VA strategic planning for programs and services for women veterans (Washington, Bean-Mayberry, Hamilton, Cordasco, & Yano, 2013; Washington, Bean-Mayberry, Mitchell, Riopelle, & Yano, 2011; Washington, Bean-Mayberry, Riopelle, & Yano, 2011; Washington, Davis, Der-Martirosian, & Yano, 2013; Washington, Sun, & Canning, 2010). Researchers constructed the sampling frame by cross-linking Veterans Health Administration, Veterans Benefits Administration, and Department of Defense databases, collectively identifying more than 50% of the 1.8 million 2008–2009 U.S. women veterans (Washington et al., 2010). Eligible women were veterans of the regular armed forces or members of the National Guards or Reserves who had been called to active duty. Researchers identified potential participants using a population-based, stratified random sample of women veterans, with sampling strata defined based on VA ambulatory care use and period of military service using previously described methods (Washington, Bean-Mayberry, Riopelle, & Yano, 2011; Washington et al., 2010). Survey respondents represented all geographic regions and Veterans Integrated Service Networks (VISN). Each randomly-sampled veteran was mailed an information packet with an opt-out card. Study interviewers contacted potential respondents to screen for study eligibility prior to obtaining consent and conducting a computer-assisted telephone interview. To be included, respondents must not have been currently serving on active military duty, employed by the VA, or residing in a nursing home or other institution. The NSWV enrolled 3611 women veterans (86% of those screened and eligible, of whom 1993 were VA users and 1618 VA non-users). We included a total of 3585

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women veterans with non-missing Alcohol Use Disorders Identification Test Consumption (AUDIT-C) total scores in this analysis. This study was approved by the Institutional Review Board of the VA Greater Los Angeles Healthcare System, and the survey was also approved by the U.S. Office of Management and Budget. 2.1. Measures We assessed alcohol use with the 3-item AUDIT-C questionnaire, which assesses the quantity and frequency of average alcohol consumption and the frequency of binge drinking episodes in the prior 12 months. The AUDIT-C has been validated for use in medical settings as a screen for identifying alcohol misuse among women veterans (Bradley et al., 2003), other veteran and non-veteran clinical populations, and the general U.S. population (Bradley et al., 2007; Bush, Kivlahan, McDonell, Fihn, & Bradley, 1998; Dawson, Grant, Stinson, & Zhou, 2005; Frank et al., 2008). The AUDIT-C used in the present study had a gender-specific threshold for binge drinking episodes (4 or more drinks per occasion). This modified AUDIT-C was previously demonstrated to have higher sensitivity for detecting alcohol misuse among women veterans than the standard AUDIT-C (which uses a threshold of 6 or more drinks) (Bradley et al., 2003). Because higher AUDIT-C scores are associated with increasing severity of alcohol misuse (Bradley et al., 2004; Rubinsky, Dawson, Williams, Kivlahan, & Bradley, 2013; Rubinsky, Kivlahan, Volk, Maynard, & Bradley, 2010), we analyzed four ordered categories of AUDIT-C scores: no alcohol use (score: 0), low-level alcohol use (score: 1–2), mild alcohol misuse (score: 3–4), and moderate-to-severe alcohol misuse (score: 5–12). These categories were selected to reflect the suggested gender-specific threshold for alcohol misuse [a score of 3 or greater on the AUDIT-C; (Bradley et al., 2003)], and to reflect the threshold at which the VA incentivizes follow-up with a performance measure and electronic clinical decision support [AUDIT-C ≥ 5; (Lapham et al., 2012)]. Moderate (score: 5–7) and severe (score: 8–12) alcohol misuse categories were combined due to the limited number of individuals in the severe misuse category. We defined two categories for VA user status: VA user (combining VA-only and dual VA/non-VA users) and VA non-users (combining women who reported using only non-VA care with those having no ambulatory care in the prior 12 months). For demographic variables, we categorized age and race/ethnicity and dichotomized annual household income (≤$30,000 vs. not) and marital status (currently married vs. not). We categorized three eras of military service (pre-Vietnam, Vietnam-pre OEF/OIF, and OEF/OIF) and defined a binary indicator for combat exposure based on women's self-report. For self-reported overall health status, study participants were asked: “In general, would you say your health is…” with 5 possible responses ranging from poor to excellent, and this item was dichotomized (poor or fair health vs. good, very good, or excellent). SF-12 physical component (PCS) and SF-12 mental component (MCS) scores were constructed from all 12 items, with each question weighted using the standard SF-12 scoring algorithm (Ware, Kosinski, & Keller, 1996). Scores on the SF-12 PCS and MCS were scaled so that 50 corresponded to the median, and scores ≤ 50 on the PCS and MCS indicated worse physical and mental health status, respectively. We dichotomized use of ambulatory care in the prior 12 months as any use of ambulatory care vs. none. The survey included questions to measure multiple mental health conditions and military stressors that may indicate a need for mental health care. Generalized anxiety disorder (GAD) was assessed with two questions: “Over the last 2 weeks, how often have you been bothered by the following problems? (a) Feeling nervous, anxious, or on edge? (b) Not being able to stop or control worrying?” (Kroenke, Spitzer, Williams, Monahan, & Lowe, 2007). For both items a 4-point Likert scale response categories varied from “not at all” to “nearly every day”. Both question items were combined and a value of ≥ 3 was considered positive for GAD, a criterion described in the validation study for this tool (Kroenke et al., 2007). Depression symptoms were

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assessed with a single item from the Mental Health Inventory: “Have you felt downhearted and depressed?” Responses were rated on a 5-point Likert scale ranging from “none of the time” to “all of the time”, and those who indicated a response of “all of the time” or “most of the time” were considered positive for depression; this scoring algorithm has been validated previously (Berwick et al., 1991). PTSD was assessed using a short screen that was based on the DSM-IV and designed to measure lifetime history of PTSD (Breslau, Peterson, Kessler, & Schultz, 1999). If participants indicated combat exposure, MST, or non-military traumas, they were asked if they had experienced each of seven symptoms (five avoidance and numbing items, two arousal items) as a result of the traumatic event. A total score of 4 or more on the 7 items was considered positive for PTSD, which is the cut-point used in the instrument's validation (Breslau et al., 1999) and previously examined in women veterans (Washington, Davis, Der-Martirosian, & Yano, 2013). SAIM was assessed with two items, and women were considered positive for SAIM if the participant answered yes to either item: (a) forced to have sexual relations against one's will while in the military or (b) had sexual contact with a superior while in the military to avoid negative consequences (Sadler, Booth, Cook, & Doebbeling, 2003; Sadler, Booth, Cook, Torner, & Doebbeling, 2001; Sadler, Booth, Nielson, & Doebbeling, 2000). We chose an indicator for SAIM rather than MST for several reasons. MST is the VA term used to refer to sexual assault and/or repeated threatening forms of sexual harassment sustained during military service (Kimerling, Street, Gima, & Smith, 2008). By contrast, SAIM includes sexual assault, but not sexual harassment without sexual assault (sexual harassment alone) in its definition (Sadler et al., 2001). The rationale for the distinction included enhancing comparability across studies (e.g., the Department of Defense reports statistics on sexual assault but not harassment) and assessing the association between sexual harassment and sexual assault. We chose to include SAIM rather than MST in our analysis to facilitate generalization of our results to other population-based samples, in contrast to exclusively VA user populations, and because SAIM may have stronger association with mental health care seeking than MST does. Finally, past-year mental health care was assessed using a single yes/ no question, “During the past 12 months, have you used mental health services?” The prevalence of past-year mental health care was defined as the proportion of women answering “yes” to this question. 2.2. Statistical analysis We calculated all descriptive and inferential statistics using weights to account for the sampling design, non-response, and post-stratification to yield estimates that were representative of the U.S. women veteran population. First, we derived point and interval estimates of the prevalence of alcohol misuse overall and by subgroup. We calculated prevalence as the weighted proportion of women with mild or moderate-to-severe alcohol misuse, based on AUDIT-C score, in the relevant subgroup [the overall study group, subgroups of VA users and non-users, and subgroups defined by VA user status and demographic, military, or health characteristics (categories shown in Table 1)]. Second, we assessed correlates of alcohol misuse among VA users and non-users. Specifically, we calculated the proportion of women with indicators of mental health care need (screen-positive GAD, depression, PTSD or SAIM) and the prevalence of past-year mental health care (that is, the proportion of women who reported using mental health care in the past year). To compare VA users to VA non-users, overall and within alcohol misuse categories, we conducted pairwise t-tests for select comparisons in addition to calculating 95% confidence interval estimates for all proportions. Finally, we estimated the adjusted prevalence of past-year mental health care in women veterans with and without alcohol misuse, allowing for heterogeneity by VA user status. To calculate the adjusted prevalence, we first fit multiple logistic regression models that included variables for alcohol use category, demographic factors (age, race/ethnicity, income), screen-positive SAIM, VA user status, and

product terms between the variables for alcohol use category and VA user status. We selected low-level alcohol use as the reference category because previous studies have associated low-level alcohol use with better health outcomes than those observed among non-drinkers or individuals with alcohol misuse (Harris et al., 2010; Williams et al., 2010). Using the estimated logistic regression coefficients, we calculated the predicted probability of past-year mental health care for each woman at each level of alcohol use by VA user status, setting other covariates equal to their observed values. The adjusted prevalence of past-year mental health care for a given category of alcohol use by VA user status (the “index category”) was then calculated as the weighted average of individuals' predicted probabilities of past-year mental health care for that index category. Standard errors for the adjusted prevalence were estimated using linearization. To ensure that the interval estimates of the adjusted prevalence did not contain negative values, we calculated 95% Wald confidence limits on the logit scale and transformed these using the expit function to obtain 95% confidence limits on the prevalence (probability) scale. To assess whether our results were sensitive to the choice of covariates and model form, we fit alternative multiple logistic regression models that included additional demographic factors, variables for general health and health services use, and other mental health conditions. We then fit logbinomial models using the different subsets of covariates. Some point and interval estimates varied by model specification, but the overall pattern was consistent with the results from the logistic regression model that included age, race/ethnicity, income, screen-positive SAIM, and VA user status as covariates. All analyses were conducted using STATA version 12.0.

3. Results The overall prevalence of past-year alcohol misuse in women veterans was 31% (22% had mild misuse and 9% had moderate-to-severe misuse), 28% reported not drinking, and 41% had low-level alcohol use (i.e., below the threshold for misuse). In VA users, the prevalence of alcohol misuse was 27% (10% had moderate-to-severe misuse), and in VA non-users the prevalence was 32% (9% had moderate-to-severe misuse). The prevalence of binge drinking, measured using the third question of the AUDIT-C, was 26% for VA users [95% CI: (24–29%)] and for VA non-users it was 24% (20–30%). The prevalence of alcohol misuse varied across subgroups of women veterans. Groups with high prevalence included VA users who were ages 18–44 (43%), served in OEF/OIF (51%), and had combat exposure (41%), and in VA non-users who screened positive for PTSD (46%) or SAIM (66%) (Table 1). Detailed point and interval estimates of the prevalence of alcohol use and misuse for VA users and non-users are provided in Online Table 1. Among women veterans with mild or moderate-to-severe alcohol misuse, VA users generally had higher rates of mental health conditions (11–23% for mild and 19–41% for moderate-to-severe misuse) than did VA non-users (8–11% for mild and 3–25% for moderate-to-severe misuse). However, the rates of screen-positive SAIM were comparable for VA users and non-users (15 vs. 13% for mild alcohol misuse; 22% in both VA users and non-users with moderate-to-severe alcohol misuse) (Fig. 1). The prevalence of past-year mental health care was likewise higher for VA users with alcohol misuse than for VA non-users with alcohol misuse (26 vs. 5% for mild misuse, p b 0.01; 43 vs. 17% for moderate-to-severe misuse, p = 0.04) (Fig. 1). Among VA users with alcohol misuse, the proportion receiving mental health care was comparable to or exceeded the proportion with an indication for mental health care (Fig. 1). This was not the case for VA non-users: Among those with mild alcohol misuse, 5% reported past-year mental health care while 8–13% screened positive for GAD, depression, PTSD, or SAIM; among those with moderate-to-severe alcohol misuse, 17% reported past-year mental health care while 25% screened positive for PTSD and 22% screened positive for SAIM. Detailed point and interval

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Table 1 Estimated prevalencea of mild and moderate-to-severe alcohol misuse among women VA users and non-usersb by demographic, military, or health characteristics. VA user

Overall prevalence of alcohol misuse Demographics Age group (years) 18–44 45–64 ≥65 Race/ethnicity Non-Hispanic White Non-Hispanic Black/African-American Hispanic Other Married Education BA or higher Working Annual household income ≤$30,000 Military characteristics Era of service Pre Vietnam Vietnam through pre OEF/OIF OEF/OIF Combat exposure General health characteristics No health insurance Service connected disability Disabled Any medical diagnosis 3 or more diagnoses SF-12 Physical Component Score ≤50 Self-reported health fair or poor Ambulatory care use past 12 months Mental health characteristics SF-12 Mental Component Score ≤50 Generalized anxiety disorder screen positive Depression screen positive PTSD screen positive History of sexual assault in the military Mental health care use past 12 months a

Moderate-to-severe alcohol misuse

Mild alcohol misuse

Moderate-to-severe alcohol misuse

n = 364

n = 190

n = 331

n = 149

17

10

23

9

27 14 11

16 9 5

17 25 26

12 13 2

17 15 19 17 17 16 22 12

11 9 7 5 9 8 12 9

26 7 22 15 23 27 25 14

8 3 19 23 11 9 11 5

13 16 28 25

4 9 23 16

20 24 23 22

5 10 9 7

19 17 8 16 12 14 10 17

13 11 5 10 7 8 7 10

11 30 38 22 22 21 24 23

13 4 2 8 6 7 10 8

16 14 12 14 13 14

11 14 12 13 10 13

25 20 34 24 40 10

8 12 5 22 26 14

Statistics weighted to reflect sampling design and to provide nationally-representative prevalence estimates. n = 1975 VA users also include 35% with no alcohol use and 38% with low-level use; n = 1610 VA non-users also include 27% with no alcohol use and 41% with low-level use.

60

b

VA non-user

Mild alcohol misuse

50

GENERALIZED ANXIETY DISORDER (GAD) DEPRESSION PTSD

40 30

MENTAL HEALTH CARE

0

10

20

Prevalence (%)

SEXUAL ASSAULT IN THE MILITARY (SAIM)

VA non−user VA user Mild alcohol misuse

VA non−user VA user Moderate to severe alcohol misuse

Fig. 1. Estimated prevalence of mental health comorbidity, history of sexual assault in the military, and past-year mental health care among women VA users and non-users by level of alcohol misuse; 95% confidence limits indicated.

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estimates of the correlates of alcohol misuse in VA users and non-users are provided in Online Table 2. After accounting for differences in demographics and an indicator of mental health care need (a positive screen for SAIM), VA users had a higher adjusted prevalence of past-year mental health care at all levels of alcohol consumption than did VA non-users (Fig. 2). The associations between alcohol misuse and the prevalence of past-year mental health care differed between VA users and non-users. In VA users, the adjusted prevalence of past-year mental health care was higher for women with moderate-to-severe alcohol misuse (39%) than for women with lowlevel alcohol use (27%). In contrast, among VA non-users, the adjusted prevalence of past-year mental health care for women with mild or moderate-to-severe alcohol misuse (2% and 6%) was lower than for women with low-level alcohol use (17%). Adjusted odds ratios (95% CIs) for past-year mental health care by VA user status, level of alcohol use, and individual characteristics are provided in Online Table 3. 4. Discussion

60 50

VA user

40

VA non−user

38.5

30

37.3

27.0

20

22.6

10

16.8

8.6 6.1 2.0

0

Adjusted prevalence (%) of past−year mental health care

We used a unique dataset to generate nationally-representative estimates of the prevalence of alcohol misuse in women veterans. We found nearly one-third of all women veterans screened positive for alcohol misuse, and the prevalence of alcohol misuse was higher in VA non-users (32%) than in VA users (27%). Some subgroups of women Veterans had a notably high prevalence of alcohol misuse. Among VA non-users, nearly one-half of the women with PTSD and two-thirds of the women with SAIM screened positive for alcohol misuse, while among VA users, the prevalence of alcohol misuse exceeded 40% in younger women, those who served in OEF/OIF, and those with combat exposure. We also examined correlates of alcohol misuse, specifically indicators of mental health care need and use of care. Mental health conditions and SAIM were common among both VA users and nonusers with alcohol misuse. However, among VA users with alcohol misuse the proportion of women reporting use of past-year mental health care was comparable to or exceeded the proportion with one or more indicators of mental health care need, which was not the case for VA nonusers. For VA non-users, and those with mild alcohol misuse in particular, the proportion reporting past-year mental health care was lower than the prevalence of at least one mental health condition or SAIM. The low prevalence of past-year mental health care among VA

non-users with alcohol misuse persisted even after adjustment for demographics and an indicator of mental health care need. In contrast, VA users with moderate-to-severe alcohol misuse had a relative high adjusted prevalence of past-year mental health care. This is the first study, to our knowledge, to report nationallyrepresentative estimates of the prevalence of alcohol misuse in women veterans overall and for VA users and non-users separately. The alcohol misuse prevalence estimates in our study, which were weighted to provide valid estimates overall, by VA user status, and in subgroups, were higher than in previous reports for VA outpatients (Grossbard, Hawkins, et al., 2013; Williams et al., 2014) or women in the U.S. general population (Dawson et al., 2005). Our prevalence estimate for women VA users who served in OEF/OIF was also higher than previous estimates for this subgroup (Calhoun et al., 2008; Grossbard, Hawkins, et al., 2013). That our estimates are higher than previous estimates based on clinical AUDIT-C screens (Grossbard, Hawkins, et al., 2013; Williams et al., 2014) is perhaps not surprising. A recent study reported that the proportion of patients with screenpositive alcohol misuse assessed via survey was higher than the proportion screening positive on contemporaneous clinical screens (Bradley et al., 2011). Our estimates were also high relative to previous reports that, like ours, used a survey-based AUDIT-C screen. This finding may reflect true heterogeneity in the prevalence of alcohol misuse across study groups. However, the relatively high prevalence of alcohol misuse in this study likely also reflects our use of a lower, gender-specific threshold for binge drinking. Notably, the prevalence of alcohol misuse among VA users in this study (27%) was only slightly higher than in a study of pre-OEF/OIF women VA patients (24%) that used a survey-based AUDIT-C with the same binge-drinking threshold as in this study (Chavez et al., 2012). In addition, the prevalence of binge drinking in VA users and non-users in this study was comparable to previouslyreported estimates for women VA patients (Bradley et al., 2001; Johnson et al., 2006) and women veterans in the general population (Grossbard et al., 2013) from previous studies that used the same binge drinking threshold as in this study. Our finding that VA non-users had a higher prevalence of alcohol misuse than VA users did was unexpected. Previous studies have reported higher rates of unhealthy alcohol use both in healthcare-seeking populations (Pilowsky & Wu, 2012) and among women with cooccurring mental health conditions (Hankin et al., 1999; Maguen et al.,

No use

Low−level use

Mild misuse

Moderate to severe misuse

Alcohol screening score category Fig. 2. Adjusted prevalence of past-year mental health care among women VA users and non-users by category of alcohol use, adjusted for age, race/ethnicity, income, and history of sexual assault in the military.

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2012; Scott et al., 2013; Seelig et al., 2012). In our study, VA users by definition were a healthcare-seeking population, in contrast to VA nonusers who comprised both non-VA-only healthcare users and healthcare non-users. VA users also had higher rates of several indicators of mental health care need relative to VA non-users. One possible explanation for the high prevalence of alcohol misuse in VA non-users is that these women were using alcohol as self-medication for mental health symptoms in the absence of other treatment. This may also explain why the prevalence of past-year mental health care among VA non-users with alcohol misuse was low relative to the proportion screening positive for one or more indicators of mental health care need. Further research on women veterans with alcohol misuse is needed to better understand the healthcare needs and possible gaps in care for this population. Inclusion of both VA users and non-users in such research is critical. To date, almost all published studies of alcohol misuse in women veterans have focused on VA patients, and our results suggest that findings in VA patients underestimate the magnitude of alcohol misuse for the majority of women who do not use VA care. This study is also the first to present estimates of the correlates of alcohol misuse in VA users and non-users. This analysis yielded two important findings. First, as mentioned above, in VA users the prevalence of past-year mental health care exceeded or was comparable to the proportion of women with indicators of mental health care need; this was not the case for VA non-users. Second, even after adjusting for demographics and an indicator of mental health care need, the prevalence of past-year mental health care was high in VA users with moderateto-severe alcohol misuse; again, this was not the case for VA nonusers. Taken together, these findings may reflect an impact of VA routine alcohol and mental health screening and increased referral to mental health care facilitated by VA integration of mental health into primary care (Wray et al., 2012). Our study had several important limitations. First, we lacked information on the clinical presentation of VA users and non-users with alcohol misuse. Our indicators of mental health care need (screen-positive GAD, depression, PTSD, and SAIM) therefore may not have accurately measured the true need for care among women veterans with alcohol misuse. Second, although we controlled for these measured indicators in our analysis, there may have been residual confounding by mental health care need in the estimated associations between alcohol use and mental health care. Our choice of indicator, a positive screen for SAIM, was based on prior information (Hankin et al., 1999; Maguen et al., 2012; Scott et al., 2013; Seelig et al., 2012) and empirical relations in our own data. Moreover, we conducted sensitivity analyses using other indicators and found our results were generally robust across specifications. However, if there were residual confounding by mental health care need, and if the magnitude of bias differed between VA users and non-users, our finding that the association between alcohol use and mental health care differed between VA users and non-users may have reflected this differential residual confounding in addition to any true heterogeneity by VA user status. Third, we did not have a measure of whether women veterans received specialty substance abuse treatment related to their alcohol misuse, and the survey did not ask about details of the mental health care received. Therefore, we could not distinguish whether women with alcohol misuse who reported past-year mental health care received alcohol-related treatment, treatment for co-occurring mental health conditions, or both. Although there is indirect evidence that VA patients may receive care for more severe alcohol or drug use disorders in mental health settings (Harris, Reeder, Ellerbe, & Bowe, 2011; Wray et al., 2012), no comparable research has been done for VA non-users. However, because of the high prevalence of mental health conditions and SAIM, we believe receipt of mental health care is still an important health outcome among women veterans with alcohol misuse even if this care does not directly reflect the receipt of alcohol-related treatment. Providing optimal care for women veterans with alcohol misuse requires an understanding of their complex health care needs. This study

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provides key information that may aid in program planning and resource allocation as increasing numbers of women veterans enter the health care system through OEF/OIF demobilization and with expanded coverage under the provisions of the Affordable Care Act. First, alcohol misuse in women veterans is not rare, particularly among recent returnees from service, women with other mental health conditions, and women with a history of SAIM. Second, VA users and non-users differ in their patterns of alcohol misuse and its correlates, highlighting the need for caution when generalizing research findings based on VA patients to the majority of women who do not use VA care. Third, mental health conditions and SAIM are common among women veterans with alcohol misuse, and some women veterans, VA non-users in particular, may not be receiving mental health care commensurate with their need. Future studies, preferably including both VA users and non-users, may be able to elucidate whether possible gaps in mental health care reflect veterans' use of alcohol to self-medicate mental health symptoms in the absence of formal care, a failure to identify women veterans who have indications for care, a lack of access to services, or other factors. Acknowledgements This study was funded by the Department of Veterans Affairs (VA) Women's Health Services within the Office of Patient Care Services, and the VA Health Services Research and Development (HSR&D) Service (#SDR-08-270). Dr. Hoggatt was funded through a VA HSR&D Quality Enhancement Research Initiative (QUERI) Career Development Award (CDA 11–261) and received additional support from the VA Office of Academic Affiliations. Dr. Yano was funded through a VA HSR&D Senior Research Career Scientist award (RCS 05–195). Dr. Williams is supported by a Career Development Award from VA HSR&D (CDA 12–276) and is an investigator with the Implementation Research Institute (IRI) at the George Warren Brown School of Social Work at Washington University in St. Louis. IRI is supported through an award from the National Institute of Mental Health (R25 MH080916-01A2) and the Department of Veterans Affairs, HSR&D QUERI. The authors gratefully acknowledge Mark Canning for project management, and Su Sun Mor, MPH and Michael Mitchell, PhD, for assistance with database construction. Select results were previously presented at the Addiction Health Services Conference (Fairfax, VA; 2011). The views expressed within are solely those of the authors, and do not necessarily represent the views of the Department of Veterans Affairs or of the United States government. The authors have no conflicts of interest to report. Appendix A. Supplementary data. Online Tables 1–3. Supplementary data to this article can be found online at http://dx. doi.org/10.1016/j.jsat.2014.12.003. References Berwick, D. M., Murphy, J. M., Goldman, P. A., Ware, J. E., Jr., Barsky, A. J., & Weinstein, M. C. (1991). Performance of a five-item mental health screening test. Medical Care, 29(2), 169–176. Bradley, K. A., Bush, K. R., Davis, T. M., Dobie, D. J., Burman, M. L., Rutter, C. M., et al. (2001). Binge drinking among female Veterans Affairs patients: Prevalence and associated risks. Psychology of Addictive Behaviors, 15(4), 297–305. Bradley, K. A., Bush, K. R., Epler, A. J., Dobie, D. J., Davis, T. M., Sporleder, J. L., et al. (2003). Two brief alcohol-screening tests From the Alcohol Use Disorders Identification Test (AUDIT): Validation in a female Veterans Affairs patient population. Archives of Internal Medicine, 163(7), 821–829, http://dx.doi.org/10.1001/archinte.163.7.821. Bradley, K. A., DeBenedetti, A. F., Volk, R. J., Williams, E. C., Frank, D., & Kivlahan, D. R. (2007). AUDIT-C as a brief screen for alcohol misuse in primary care. Alcoholism, Clinical and Experimental Research, 31(7), 1208–1217, http://dx.doi.org/10.1111/j. 1530-0277.2007.00403.x. Bradley, K. A., Kivlahan, D. R., Zhou, X. H., Sporleder, J. L., Epler, A. J., McCormick, K. A., et al. (2004). Using alcohol screening results and treatment history to assess the severity of at-risk drinking in Veterans Affairs primary care patients. Alcoholism, Clinical and Experimental Research, 28(3), 448–455. Bradley, K. A., Lapham, G. T., Hawkins, E. J., Achtmeyer, C. E., Williams, E. C., Thomas, R. M., et al. (2011). Quality concerns with routine alcohol screening in VA clinical settings.

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