Journal of Substance Abuse Treatment 46 (2014) 553–560

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Journal of Substance Abuse Treatment

Prospective associations among approach coping, alcohol misuse and psychiatric symptoms among veterans receiving a brief alcohol intervention Ashley E. Mason, Ph.D. a, b,⁎, Matthew Tyler Boden, Ph.D. b, Michael A. Cucciare, Ph.D. c, d a

Osher Center for Integrative Medicine, University of California, San Francisco Center for Health Care Evaluation, VA Palo Alto Health Care System Center for Mental Healthcare and Outcomes Research, Central Arkansas Veterans Affairs Healthcare System d Department of Psychiatry, University of Arkansas for Medical Sciences b c

a r t i c l e

i n f o

Article history: Received 8 September 2013 Received in revised form 12 December 2013 Accepted 9 January 2014 Keywords: Alcohol misuse Brief alcohol intervention (BAI) Approach coping Veteran Depression

a b s t r a c t Brief alcohol interventions (BAIs) target alcohol consumption and may exert secondary benefits including reduced depression and posttraumatic stress disorder (PTSD) symptoms among non-veteran and veteran populations. This study examined whether approach coping, alcohol misuse, and an interaction of these two factors prior to the administration of a BAI (i.e., baseline) would predict depression and PTSD symptoms 6months post BAI (i.e., follow-up). Veterans (N = 166) received a BAI after screening positive for alcohol misuse during a primary care visit and completed assessments of alcohol misuse, approach coping, and depression and PTSD symptoms at baseline and follow-up. Baseline substance misuse, but not approach coping, significantly predicted depression and PTSD symptoms at follow-up. Approach coping moderated associations between baseline alcohol misuse and psychiatric symptoms: Veterans reporting more alcohol misuse and more (relative to less) approach coping at baseline evidenced fewer psychiatric symptoms at follow-up after accounting for symptoms assessed at baseline. Published by Elsevier Inc.

1. Introduction As many as 22% of veterans screen positive for alcohol misuse in primary care settings using the Alcohol Use Disorders Identification Test–consumption (AUDIT-C) screening tool (Hawkins, Lapham, Kivlahan, & Bradley, 2010). Brief alcohol interventions (BAIs) are effective frontline interventions for reducing alcohol misuse that are typically delivered in a brief (e.g. 10–30 minute) single dose, which makes them ideally suited for use in primary care settings (Jonas et al., 2012; Kaner et al., 2009; Kypri, Langley, Saunders, Cashell-Smith, & Herbison, 2008; Rooke, Thorsteinsson, Karpin, Copeland, & Allsop, 2010). Recent data reveal that in addition to reducing alcohol misuse, BAIs can lead to improvements in psychiatric symptoms (Cucciare, Boden, & Weingardt, 2013; Kay-Lambkin, Baker, Lewin, & Carr, 2009; Wilton, Moberg, & Fleming, 2009), and this may be especially important for veterans, who present with higher lifetime rates of depression and PTSD than non-veterans (Dohrenwend et al., 2006; Jordan et al., 1992; Kulka et al., 1990; Terhakopian, Sinaii, Engel, Schnurr, & Hoge, 2008). We know little, however, about for whom BAIs exert these improvements in psychiatric symptoms. More severe alcohol misuse (e.g., frequent use, heavy daily use, and alcohol dependence) at SUD treatment intake prospectively predicts more alcohol-related problems across health, legal, mone⁎ Corresponding author at: 1545 Divisadero Street, San Francisco, CA 94115. Tel.: +1 415 514 6820. E-mail address: [email protected] (A.E. Mason). 0740-5472/$ – see front matter. Published by Elsevier Inc. http://dx.doi.org/10.1016/j.jsat.2014.01.006

tary, occupational, intrapersonal, interpersonal, and residential domains in US military veterans (Adamson, Sellman, & Frampton, 2009; McKellar, Harris, & Moos, 2006). Additionally, increases in alcohol misuse predict increases in psychiatric symptoms for people with and without SUD (Fergusson, Boden, & Horwood, 2009; Kuo, Gardner, Kendler, & Prescott, 2006; Wang & Patten, 2001a). To our knowledge, scant data speak to whether alcohol misuse at treatment intake predicts changes in depression and PTSD symptoms among individuals who receive briefer substance misuse treatment, such as BAIs. In this study, we therefore explored whether the frequency and quantity of alcohol use are prospectively associated with depression and PTSD symptoms among veterans presenting to primary care with alcohol misuse who received a BAI. Researchers focusing on substance misuse and psychological disorders have devoted much attention to coping strategies, as data point to inverse associations between approach-oriented coping strategies and both substance misuse and psychiatric symptoms over time (e.g., Holahan & Moos, 1991; Sherbourne, Hays, & Wells, 1995; Southwick, Vythilingam, & Charney, 2005; Swindle, Cronkite, & Moos, 1989). Approach coping strategies are active and oriented toward confronting a stressor, and can be behavioral, cognitive, or emotional (e.g., overt behavioral attempts to deal directly with a problem, efforts to manage the cognitive appraisal of the stressfulness of a problem, or attempts to regulate emotional distress; see Billings & Moos, 1981; Holahan & Moos, 1987; Stanton, Kirk, Cameron, & DanoffBurg, 2000). Routine use of approach-oriented coping skills has been examined as a predictor of substance misuse and depression and PTSD

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symptoms (e.g., Hassija, Luterek, Naragon-Gainey, Moore, & Simpson, 2012; Tiet et al., 2006) and also as a target for potential change in an effort to reduce these psychiatric symptoms (e.g., Conrod et al., 2000; Litt, Kadden, Cooney, & Kabela, 2003). A number of studies have uncovered associations between approach coping and both psychiatric- and alcohol-related outcomes following multi-session treatments for alcohol misuse (Boden & Moos, 2009; Forys, McKellar, & Moos, 2007; Moos, Finney, & Cronkite, 1990; Moser & Annis, 1996; Vollrath, Alnaes, & Torgersen, 1996). For example, Boden and Moos (2009) found that after completing a 3- to 4-week SUD residential treatment program, male veterans carrying dual psychiatric and substance misuse diagnoses who reported greater reliance on approach coping skills also reported consuming less alcohol, decreased psychiatric symptoms, and decreased alcoholrelated problems at 1-year follow-up. Moos et al. (1990) found that among individuals treated for alcohol abuse, those who relied more on approach coping skills evidenced better treatment outcomes at a 2year follow-up. Forys et al. (2007) found that patients carrying SUD diagnoses who entered SUD community residential treatment reporting larger general approach coping repertoires also reported fewer SUD-related problems at 12-month follow-up. To our knowledge, little data speak to whether approach coping may correlate with improvements in psychiatric symptoms post-BAI. In this study, we therefore explored whether approach coping relates to changes in depression and PTSD symptoms among veterans who received a BAI. Based on previous literature, we predicted that alcohol misuse and approach coping at baseline would account for unique variance in depression and PTSD symptoms assessed at 6-month follow-up. Specifically, we predicted that (1) more severe alcohol misuse at baseline (both frequency and quantity of use per day) would predict greater depression and PTSD symptoms at follow-up, and (2) greater reliance on approach coping at baseline would predict fewer depression and PTSD symptoms at 6-month follow-up. Furthermore, we predicted that these associations would hold after accounting for baseline depression and PTSD symptoms as well as socio-demographic variables including gender, age, relationship status, and ethnicity. We further explored a potential moderation effect of approach coping on associations between severity of alcohol misuse and changes in psychiatric symptoms following receipt of a BAI. We based this exploration on prior data showing that SUD treatment is more effective in reducing alcohol misuse among individuals reporting greater use of approach coping skills (Boden & Moos, 2009; Forys et al., 2007; Moos et al., 1990) and that individuals' level of substance misuse predicts subsequent psychiatric symptoms. We speculated that, among this sample of veterans screening positive for alcohol misuse, this interactive effect might highlight greater psychiatric symptoms among veterans reporting more severe alcohol misuse at baseline and less use of approach coping skills at baseline. In addition, we accounted for baseline depression and PTSD symptoms and socio-demographic variables in all analyses. We did so based on epidemiological data implicating socio-demographic and person-level correlates of depression and PTSD (see Kessler & Bromet, 2013, for a review), such as biological sex (Brewin, Andrews, & Valentine, 2000; Mirowsky & Ross, 1992; Piccinelli & Wilkinson, 2000), age (Kessler et al., 2010; Magruder et al., 2004), romantic relationship status (Kessler, McGonagle, Swartz, Blazer, & Nelson, 1993; Kessler, Sonnega, Bromet, Hughes, & Nelson, 1995; Weissman et al., 1993; Whisman & Uebelacker, 2009), and ethnicity (Alcántara, Casement, & Lewis-Fernández, 2013; Alegria et al., 2008; Williams et al., 2007). Additionally, prior depression symptoms strongly predict subsequent depression symptoms (e.g. Hartka et al., 1991; Kessler & Bromet, 2013). We accounted for these variables to ensure that findings were not attributable to variance shared with prior experience of depression or PTSD symptoms or correlates of depression and PTSD. Examining the effects of baseline alcohol

misuse and approach coping on subsequent psychiatric symptoms above and beyond baseline assessments of psychiatric symptoms and covariates will sharpen our understanding of the impacts of alcohol misuse and approach coping, both individually and interactively, on subsequent psychiatric symptoms. Exploring these associations among the growing veteran population, which tends to report more alcohol misuse than civilians (e.g., Jordan et al., 1991), and in the context of primary care, where veterans increasingly receive treatment for psychiatric problems and substance misuse (Hoge, Auchterlonie, & Milliken, 2006), will be increasingly useful in clarifying which factors lead to successful care. 2. Materials and methods 2.1. Sample, recruitment, and study design 2.1.1. Sample This study was a secondary analysis of data collected between January, 2010 and September, 2011 as part of a randomized controlled trial exploring the incremental effectiveness of a Web-delivered BAI to standard care for veterans screening positive for alcohol misuse (see Cucciare et al., 2013a). Participants were 166 (146 men; 88.0% of sample) veterans of the U.S. Military who presented to primary care at the VA Palo Alto Health Care System. All participants had screened positive for alcohol misuse as measured by the Alcohol Use Disorders Identification Test – Consumption Items (AUDIT-C) cut off score of 4 or more for men and 3 or more for women (see Bradley et al., 2006). On average, participants were 59.4 years old (SD = 15.1 years), 47.0% (n = 78) were in a romantic relationship or married, and 53.0% (n = 88) were divorced, widowed, or single. Sixty-nine percent (n = 115) of the sample described themselves as White (nonHispanic), 12.0% (n = 20) as Black, 7.8% (n = 13) as Hispanic, 4.8% (n = 8) as Asian/Pacific Islander, and 1.2% (n = 2) as Native American; with the remainder of the sample (4.8%, n = 8) identifying as “other.” 2.1.2. Recruitment and study design Participants were recruited via direct referral from a primary care provider (n = 33), contacting the study team through a flyer located in the clinic waiting or exam room (n = 62), or by letter sent by the study team to eligible veterans with documentation in their medical chart indicating a positive screen within the last 2 weeks (n = 72). Eligible participants were randomized to one of two study conditions: Treatment as usual (TAU) or TAU plus a Web-delivered brief alcohol intervention (BAI). Participants in the TAU condition (n = 78) received counseling on per the National Institute on Alcohol Abuse and Alcoholism (NIAAA) recommended safe drinking limits and potential health effects of alcohol misuse (Lapham et al., 2012) within 14 days of the baseline assessment. Participants randomized to the experimental group (n = 89) received TAU plus a Web-delivered BAI comprised of 10–15 minute assessment that taps (a) typical alcohol use, (b) lifetime negative consequences of alcohol or other substance misuse, (c) risk factors for alcohol misuse, such as combat experience or PTSD symptoms, (d) lifetime use of illicit substances, and (e) motivation and confidence to change substance misuse. Veterans received personalized feedback in each of these domains following completion of the assessment that included (a) summarized weekly alcohol use, (b) gender-matched normative feedback on typical alcohol use among age-matched peers from the general population, (c) a summary of financial, social, and health-related consequences of alcohol misuse, (d) education on the concepts of tolerance and peak blood alcohol concentration, (e) a summary of risk factors for alcohol misuse, and (f) self-reported motivation to change substance use. See Cucciare, Weingardt, Ghaus, Boden, and Frayne (2013), for full descriptions of participant recruitment, randomization, interventions,

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and study flow. The Stanford University Institutional Review Board approved all aspects of this research.

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(0 = not at all and 3 = nearly every day) and summed to form an index ranging from 0 to 27, with higher scores indicating greater severity of depression symptoms. In the present study, depression was assessed at baseline and 6-month follow-up, and the internal consistencies were strong (baseline α = .91; 6-month α = .90).

2.1.3. Assessment Study personnel mailed participants' letters inviting them to complete 3- and 6-month follow-up assessments by telephone. Research assistants (who were masked to study condition) telephoned all participants who did not respond to the letter within in a week to set up a time to complete their follow-up assessments. In addition to basic demographic information and other measures, baseline and follow-up assessments utilized in the present study included assessments of drinking behavior (average drinks per drinking day and total number of heavy drinking days in the past month), mental health (PTSD and depression), and coping style (approach coping; see Cucciare, Weingardt et al., 2013, for full study protocol).

2.2.3. Posttraumatic stress disorder (PTSD) The Posttraumatic Stress Disorder Checklist-Military Version (PCL-M) is a 17-item assessment of PTSD symptoms based on the PTSD diagnosis as outlined in the DSM-IV (see Bliese et al., 2008). The PCL-M is used for screening and diagnosing PTSD as well as monitoring symptom changes over time. Participants are asked to rate the degree to which they have experienced problems over the last month that veterans commonly report in response to stressful military experiences. Items are assessed on a 5-point scale (1 = not at all and 5 = extremely) and summed to obtain a total score ranging from 17 to 85, with higher scores indicating greater severity of PTSD symptoms. Diagnostic cut off scores vary by sample and setting (see McDonald & Calhoun, 2010, for a review) and generally range from 30 (Bliese et al., 2008) to 50 (Weathers, Litz, Herman, Huska, & Keane, 1993). In the present study, PTSD was assessed at baseline and 6-month follow-up, and the internal consistencies were strong (baseline α = .96; 6-month α = .97).

2.2. Measures See Table 1 for descriptive information for all included measures. 2.2.1. Substance misuse The AUDIT-C is a standard screening tool for determining alcohol misuse and is frequently used to assess veterans (Babor & Grant, 1989). The AUDIT-C comprises three items that are scored on a 5point scale. Items include, how often do you have a drink containing alcohol in the past year (indicate never, monthly or less, 2–4 times a month, 2–3 times a week, 4 or more times a week), how many standard drinks containing alcohol do you have on a typical day when you were drinking in the past year (indicate 1 or 2, 3 or 4, 5 or 6, 7 to 9, 10 or more), and how often do you have six or more drinks on one occasion in the past year (indicate never, less than monthly, monthly, weekly, daily or almost daily). Items are summed to form an index ranging from 0 to 12, with higher scores indicating greater severity of alcohol misuse. We identified veterans screening positive for alcohol misuse using previously established cutoff scores for women (≥ 3) and men (≥ 4; see Bradley et al., 2003, 2006). See Table 1 for descriptive information.

2.2.4. Approach coping The Coping Responses Inventory (CRI; Moos, 1993) assesses coping behavior by tapping both cognitive and behavioral dimensions. The CRI asks participants to identify their most significant stressor over the past 12 months, and then to complete 48 items that describe specific coping strategies used to manage that stressor. Coping items are rated on a 4-point scale (0 = not at all and 3 = fairly often). The CRI comprises 4 subscales tapping approach coping (logical analysis, positive reappraisal, seeking guidance and support, and problem solving) that each contain six items. The current study utilized items from the positive reappraisal and problem solving subscales to measure approach coping (see Aldridge-Gerry, Cucciare, Ghaus, & Ketroser, 2012). Here, approach coping was assessed at baseline and 6-month follow-up, and the internal consistencies for the combined positive reappraisal and problem solving subscales were good (baseline α = .81; 6-month α = .79).

2.2.2. Depression The Patient Health Questionnaire – 9 (PHQ-9; Spitzer, Kroenke, & Williams, 1999) is a 9-item depression scale with well-established reliability and validity (Kroenke, Spitzer, & Williams, 2001). Items are based on the Diagnostic and Statistical Manual Fourth Edition (DSMIV; American Psychological Association, 2000) and tap depression symptoms over the past 2 weeks. Items are assessed on a 4-point scale

2.2.5. Drinking behavior We collected information about veterans' alcohol use, specifically average drinks per drinking day and total number of heavy drinking (over the past 30 days) using the 30-day, self-report version of the time line follow-back instrument (TLFB; Sobell, Brown, Leo, & Sobell,

Table 1 Descriptive statistics and zero-order correlations between predictor and criterion variables. Variable

1

1. App Cope (B) 2. Avg D (B) 3. Avg D (F) 4. Hvy D (B) 5. Hvy D (F) 6. PCL-M (B) 7. PCL-M (F) 8. PHQ-9 (B) 9. PHQ-9 (F) M (SD) Range (min–max) N

−.19⁎ −.13 −.18⁎ −.19⁎ .02 −.08 −.04 −.12 29.10 (7.7) 33.0 (11.0–44.0) 153

2

3

4

5

.60⁎⁎ .67⁎⁎ .44⁎⁎ .36⁎⁎ .46⁎⁎ .48⁎⁎ .47⁎⁎

.54⁎⁎ .65⁎⁎ .19⁎ .32⁎⁎ .41⁎⁎ .51⁎⁎

.69⁎⁎ .28⁎⁎ .33⁎⁎ .36⁎⁎ .39⁎⁎

.13 .22⁎⁎ .24⁎⁎ .44⁎⁎

6

.75⁎⁎ .71⁎⁎ .50⁎⁎ 5.09 (–4.4) 3.78 (–3.3) 7.25 (10.0) 3.64 (–7.1) 30.80 (17.4) 19.7 (1.0–20.7) 14.2 (1.0–15.2) 30 (0.0–30.0) 24 (0.0–24.0) 61.0 (17.0–78.0) 166 130 166 139 153

7

8

9

.55⁎⁎ .76⁎⁎ 27.80 (17.1) 67.0 (17.0–84.0) 141

.66⁎⁎ 7.20 (6.80) 27.0 (0.0–27.0) 165

5.53 (6.40) 25.0 (0.0–25.0) 141

Note. App Cope = Approach coping subscale of Coping Response Inventory; PHQ-9 = Public Health Questoinnaire-9; PCL-M = Posttraumatic Stress Disorder Checklist - Military version; Avg D = average drinks per drinking day in past 30 days; Hvy D = total heavy drinking days in past 30 days; (B) = measurement taken at baseline; (F) = measurement taken at 6-month follow-up. ⁎ p b .05. ⁎⁎ p b .01.

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1996; Sobell & Sobell, 1992)). The TLFB is a calendar of 1–3 months that provides visual cues to aid participants in retrospective recall of their behavior. It uses cues such as holidays and birthdays to help a participant recall drinking behavior. We computed the frequency and severity of alcohol consumption using the following formulas: (1) Total heavy drinking days: number of days consuming 5 or more (for men) or 4 or more (for women) standard drinks during the 30 day assessment period. (2) Average drinks per drinking day: number of standard drinks consumed/days with at least one drink consumed in the 30 day period.

2.3. Analytic strategy As reported in (Cucciare, Boden, et al., 2013) there were no differential treatment effects between the two study conditions on any of the alcoholrelated outcomes, thus all study participants were examined as a single cohort in the present study. Additionally, as reported in Cucciare, Weingardt et al. (2013), to reduce positive skew, both alcohol-related variables were transformed by replacing values exceeding 2.5 standard deviations with a value representing 2.5 standard deviations for each variable. This affected three participants, and results do not change when analyses are conducted using the unattenuated variable. To investigate the associations between baseline mental health, alcohol misuse, and approach coping assessed prior to the administration of the BAI, we separately regressed each mental health variable assessed at 6-month follow-up onto these predictors. We repeated each regression analysis including the following covariates: age, gender, relationship status, and ethnicity. To assess the role of approach-oriented coping in associations between substance misuse and mental health, we repeated (separately) the above regression analyses. In step 1, we entered baseline mental health, approach coping, and drinking variables. In step 2, we entered each of four interaction terms, which were each drinking variable by approach-oriented coping, and each mental health-related variable by coping in step 2. In step 3, we entered the following covariates: age, gender, ethnicity, and relationship status. We entered covariates in step 3 rather than step 1 to investigate whether interactions between approach coping and drinking variables were significant both with and without adjusting for these variables (Simmons, Nelson, & Simonsohn, 2011). To unpack each interaction, we conducted simple slope analyses and calculated simple slopes

using one standard deviation above and below the mean of the moderator (Aiken & West, 1991; Cohen & Cohen, 1975). To examine both sides of each interaction, we probed each model twice, first treating approach coping as the moderator, and then treating the alcohol misuse variable as the moderator. All variables were standardized prior to analyses to facilitate interpretation, and we reversed the predictors and outcome variables to establish the directionality of these analyses. 3. Results 3.1. Correlation analyses As shown in Table 1, the two drinking variables measured at baseline were associated with both mental health outcomes at followup. PTSD and depression assessed at baseline were significantly positively correlated with PTSD and depression at 6-month follow-up, respectively. Approach coping was significantly inversely correlated with average drinks per drinking day at baseline and total number of heavy drinking days both at baseline and 6-month follow-up. 3.2. Main effect analyses As shown in step 1 (Table 2), veterans who reported more average drinks per drinking day in the last 30 days and more heavy drinking days in the last 30 days also reported more depression and PTSD symptoms 6 months later (after statistically adjusting for depression and PTSD symptoms at baseline, respectively). Patterns of significance for both drinking-related variables and approach coping did not change after accounting for veteran age, relationship status, ethnicity, or gender. Baseline PHQ-9 did not predict average drinking days at 6month follow-up (model 1, β = .50, p = .07) or total number of heavy drinking days at 6-month follow-up (model 2, β = .22, p = .66). Baseline PCL-M did not predict average drinking days at 6-month follow-up (model 3, β = − .18, p = .50) or total number of heavy drinking days at 6-month follow-up (model 4, β = − .30, p = .55). 3.3. Moderation analyses See Table 2, steps 2 and 3, for moderation results. Significance of main effects and interaction terms in the following models did not change when approach coping assessed at 6-month follow up was included in the model.

Table 2 Regressions of depression and PTSD symptoms at 6-month follow-up onto baseline assessments of depression and PTSD symptoms, alcohol use, approach coping, and alcohol use × approach coping. Outcome: PHQ-9 Model

1

Predictor

Predictor

Outcome: PTSD 2

β (b)

1 Outcome at baseline Drinking predictor Approach cope

.55⁎⁎ (3.66) .18⁎ (1.12) −.06 (−0.39)

Interaction (drinking predictor × approach cope)

−.14⁎ (−0.90)

Interaction when including covariates

−.17⁎ (−1.15)

2

3

4

Predictor

Average drinks Step

3

Heavy drink days R

2

ΔR

2

.45⁎⁎ .45⁎⁎

.46⁎⁎ .02⁎

.43⁎⁎ .01

β (b) .58⁎⁎ (3.84) .19⁎⁎ (1.21) −.06 (−0.37) −.14⁎ (−0.87) −.19⁎⁎ (−1.20)

Average drinks R

2

ΔR

2

.45⁎⁎ .45⁎⁎

.47⁎⁎ .02⁎

.48⁎⁎ .01

β (b) .68⁎⁎ (11.86) .16⁎ (2.69) −.06 (−0.92) −.17⁎⁎ (−2.91) −.20⁎⁎(−3.33)

Heavy drink days R

2

ΔR

2

.58⁎⁎ .58⁎⁎

.61⁎⁎ .03⁎⁎

.62⁎⁎ .01⁎

β (b) .71⁎⁎ (12.35) .13⁎(2.24) −.06 (−1.05) −.15⁎(−2.32) −.17⁎⁎(−2.78)

R2

ΔR2

.57⁎⁎ .57⁎⁎

.59⁎⁎ .02⁎

.60⁎⁎ .01

Note. See Table 1 note for variable descriptions. All predictors assessed at baseline. Predictors were standardized prior to analysis to facilitate interpretation. Covariates: Age (in years); gender (−1 = men, 1 = women); ethnicity (coded 1, 0; Caucasian as reference group, other groups = African American, Hispanic, Asian, and Native American); and relationship status (−1 = divorced/widowed/single, 1 = married/in a romantic relationship). ⁎ p b .05. ⁎⁎ p b .01.

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3.3.1. Predicting depression As shown by the significant interaction in step 2 (Table 2, model 1), approach coping at baseline moderated an association between average drinks per drinking day at baseline and depression at 6month follow-up, and this effect remained significant after including depression at baseline and covariates (see step 3). Deconstruction of this analysis revealed two significant simple slopes: Among those reporting less approach coping at baseline, those reporting more average drinks per drinking day at baseline evidenced increased depression at 6-month follow-up relative to those reporting fewer average drinks per drinking day at baseline, b = 1.82, p = .003. Among those reporting more average drinks per drinking day at baseline, those reporting more approach coping at baseline evidenced decreased depression at 6-month follow-up relative to those reporting less approach coping at baseline, b = −1.39, p = .035 (Fig. 1, panel A). This model did not hold when predictor and outcome variables were reversed: baseline approach coping did not moderate an association between depression at baseline and average drinks per drinking day at 6-month follow-up, (β = .05, p = .52). As shown by the significant interaction in step 2 (Table 2, model 2), approach coping at baseline moderated an association between total heavy drinking days at baseline and depression at 6-month follow-up, and this effect remained significant after accounting for depression at baseline (see step 3). Deconstruction of this analysis revealed a pattern of significant simple slopes similar to those of model 1: among those reporting less approach coping at baseline, those reporting more heavy drinking days at baseline evidenced increased depression at 6-month follow-up relative to those reporting

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fewer heavy drinking days at baseline, b = 1.92, p b .001. Among those reporting more heavy drinking days at baseline, those reporting more approach coping at baseline evidenced decreased depression at 6-month follow-up relative to those reporting less approach coping at baseline, b = − 1.27, p = .038 (Fig. 1, panel A). This model did not hold when predictor and outcome variables were reversed: Baseline approach coping did not moderate an association between depression at baseline and average drinks per drinking day at 6-month follow-up, (β = .02, p = .74).

3.3.2. Predicting PTSD As shown by the significant interaction in step 2 (Table 2, model 3), approach coping at baseline moderated an association between average drinks per drinking day at baseline and PTSD at 6-month follow-up, and this effect remained significant after including PTSD at baseline and covariates (see step 3). Deconstruction of this analysis revealed two significant simple slopes: among those reporting less approach coping at baseline, those reporting more average drinks per drinking day at baseline evidenced increased PTSD at 6-month followup relative to those reporting fewer average drinks per drinking day at baseline, b = 5.03, p b .001. Among those reporting more average drinks per drinking day at baseline, those reporting more approach coping at baseline evidenced decreased depression at 6-month follow-up relative to those reporting less approach coping at baseline, b = −4.06, p b .01 (Fig. 1, panel B). This model did not hold when predictor and outcome variables were reversed: baseline approach coping did not moderate an association between depression at baseline

x

Fig. 1. Predicting depression (PHQ-9; Panel A) and PTSD (PCL-M; Panel B) symptoms from interaction of baseline alcohol misuse (average drinks per drinking day in past 30 days; number of heavy drinking days in past 30 days) and baseline approach coping, after accounting for baseline depression and PTSD symptoms, respectively.

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and average drinks per drinking day at 6-month follow-up, (β = .09, p = .25). As shown by the significant interaction in step 2, (Table 2, model 4), approach coping at baseline also moderated an association between total number of heavy drinking days at baseline and PTSD at 6-month follow-up, and this effect remained significant after including PTSD at baseline and covariates (see step 3). Deconstruction of this analysis revealed two significant simple slopes: among those reporting less approach coping at baseline, those reporting more heavy drinking days at baseline evidenced increased PTSD at 6-month follow-up relative to those reporting fewer heavy drinking days at baseline, b = 4.29, p b .01. Among those reporting more heavy drinking days at baseline, those reporting more approach coping at baseline evidenced decreased depression at 6-month follow-up relative to those reporting less approach coping at baseline, b = −3.44, p = .02 (Fig. 1, panel B). This model did not hold when predictor and outcome variables were reversed: baseline approach coping did not moderate an association between PTSD at baseline and average drinks per drinking day at 6month follow-up, (β = .02, p = .73). 4. Discussion Although previous data highlight associations between substance misuse severity and changes in psychiatric symptoms in the context of multi-dose SUD treatment, analyses presented here may provide some of the first evidence that both quantity and frequency of alcohol misuse are prospectively associated with depression and PTSD symptoms among veterans receiving a single-dose BAI. Thus, these findings contribute to a growing body of evidence demonstrating that alcohol misuse may precede increased risk for psychiatric symptoms (e.g., Fergusson et al., 2009; Wang & Patten, 2001a, 2001b). Findings presented here were robust, as both indices of baseline alcohol misuse remained significant predictors of postBAI depression and PTSD symptoms after adjusting for possible covariates and psychiatric symptoms at baseline and after testing for potential reversed associations. Although we did not observe associations between approach coping and depression or PTSD symptoms at baseline or prospectively, moderation analyses revealed a prospective association between baseline approach coping and psychiatric symptoms among veterans presenting with more severe alcohol misuse (1 SD above the mean). Within this group, veterans who reported using more approach coping at baseline (relative to those reporting using less) also reported fewer depression and PTSD symptoms at 6-month followup. These findings build upon existing literature demonstrating that coping can account for up to 9% of change in psychiatric symptoms over 12 months (Vollrath et al., 1996) and that individuals reporting more approach-oriented coping also tend to report fewer psychiatric symptoms in the context of SUD treatment (e.g., Boden & Moos, 2009; Forys et al., 2007). Specifically, these analyses suggest that individuals reporting more severe alcohol misuse as well as more approach coping pre-intervention might have driven the reductions in depression and PTSD symptoms observed both in these and other data following interventions for alcohol misuse (Cucciare, Weingardt et al., 2013; Kay-Lambkin et al., 2009; Wilton et al., 2009). The tension-reduction theory of alcohol misuse conceptualizes alcohol use as a way to reduce tension and stress (Goldsmith, Thompson, Black, Tran, & Smith, 2012). The use of alcohol to reduce tension or stress may be especially pronounced among individuals with psychiatric disorders (e.g., Hartka et al., 1991; Hien et al., 2010). Yet, over an extended period of time, alcohol may not help to reduce psychiatric symptoms, and may even lead to paradoxical increases in psychiatric symptoms (Bremner, Southwick, Darnell, & Charney, 1996). In this and other studies, veterans who received a BAI after screening positive for alcohol misuse were provided with information intended to facilitate reductions in alcohol consumption (e.g., Fleming

& Manwell, 1999; Jonas et al., 2012). Provided with this information, some veterans may have been motivated to implement strategies other than alcohol use to cope with their psychiatric symptoms. Veterans who had previously (i.e., as reported at baseline) frequently utilized approach coping skills, which are arguably more adaptive than alcohol use, may have successfully implemented these skills to cope with psychiatric symptoms. Veterans with higher consumption of alcohol at baseline, who were also likely to have more intense psychiatric symptoms and use alcohol to cope with such symptoms, benefited most in this regard. These analyses highlight the importance of assessing the approach-oriented coping strategies of individuals presenting to primary care appointments who screen positive for alcohol misuse. Per strong positive correlations between substance misuse and psychiatric symptoms in this sample, veterans reporting more severe alcohol misuse may have been poised to make larger reductions in psychiatric symptoms. Indeed, veterans who reported severe alcohol misuse and more approach coping at baseline reported significantly fewer depression and PTSD symptoms at follow-up than their severedrinking counterparts who had reported less approach coping. This dovetails with social learning theory, which argues that alcohol use can serve as a general coping mechanism invoked when other (presumably) more effective coping skills are unavailable (e.g., Abrams & Niaura, 1987). In the context of a treatment targeting reductions in alcohol misuse, veterans who had previouslyestablished approach coping repertoires may have had access to adaptive coping strategies that precipitated larger reductions in psychiatric symptoms. 4.1. Limitations There are several limitations of this study design worth noting. First, this study did not include a no-treatment control condition, as the U.S. Department of Veterans Affairs mandates that all veterans presenting with alcohol misuse receive brief alcohol counseling. Additionally, the study design did not include an alternate treatment condition (i.e., TAU + alternative treatment), the inclusion of which might have elucidated which components of the BAI were more and less highly correlated with reductions in alcohol misuse. Second, it is possible that regression to the mean may partially account for the observed decrease in mental health symptoms across the 6-month period. For example, veterans may have been assessed at a time where they were experiencing an atypically high level of depression and PTSD symptoms that may have reduced over time without intervention. Third, the sample was primarily male (88.0%), and although reflective of the veteran population (United States Department of Veterans Affairs, 2010), this may limit generalizability. Fourth, the study relied solely on self-report measures assessed at primary care appointments, and may have benefitted from incorporating laboratory (e.g., blood draw) and ambulatory (e.g., breathalyzer) assessment tools that would have captured additional information about veterans' alcohol use (e.g., Trull & Ebner-Priemer, 2013). Last, although baseline approach coping evidenced zero-order correlations with both alcohol-related predictors, it was not significantly associated with changes in psychiatric symptoms. A more in-depth assessment of coping strategies may have revealed which dimensions of coping are more and less associated with psychiatric symptomology. Future studies should implement a no-treatment control condition or other comparator, target a more gender-balanced sample, incorporate multi-method assessment, and reduce the length of assessments to decrease unintended therapeutic benefits. 4.2. Conclusions Analyses presented here indicate that approach-oriented coping may play an important role in explaining prospective associations

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between alcohol misuse and psychiatric symptoms. Veterans presenting to primary care reporting more severe alcohol misuse and less use of approach coping reported the poorest psychiatric symptom profiles at follow-up, and future research could focus on this subsample of veterans as a target for implementing additional services (e.g., mental health and community referrals) and follow-up care and assessment. Additionally, incorporating brief interventions that target approach coping skills may increase the impact of BAIs on psychiatric outcomes. Our findings suggest that future treatments delivered through primary care, including BAIs, may benefit from incorporating brief interventions that increase veterans' access to adaptive coping strategies, such as introductions to applications available on handheld devices. For example, veterans screening positive for alcohol misuse and PTSD symptoms may be briefly introduced to PTSD Coach (e.g., Chen et al., 2012), an application that provides the user with adaptive coping strategies based on a user's symptoms. These brief interventions, which would allow veterans to continue to develop and use alternative coping skills, may bolster veterans' abilities to cope with depression and PTSD symptoms in the context of reducing their alcohol misuse. Veterans experience greater lifetime prevalence of substance misuse, depression, and PTSD than civilian populations (Hoge et al., 2004; Jordan et al., 1991; Seal, Bertenthal, Miner, Sen, & Marmar, 2007; Terhakopian et al., 2008), and these conditions are often assessed for and found to co-occur among veterans receiving treatment in primary care settings (e.g., Magruder et al., 2004; McDevitt-Murphy et al., 2010; Petrakis, Rosenheck, & Desai, 2011). Thus, BAIs may serve as cost- and clinically-effective interventions that yield psychiatric benefits as well as reduce alcohol misuse among veterans presenting to primary care. Acknowledgments The authors have no conflicts of interest to disclose. This manuscript is based upon work supported by a Career Development Award - 2 (CDA-08-004-3) to Michael A. Cucciare by the Department of Veterans Affairs, Veterans Health Administration, Office of Research and Development, Health Services Research and Development Service. The authors thank Sharfun J. Ghaus, MBBS, for assistance in data collection. References Abrams, D. B., & Niaura, R. S. (1987). Social learning theory. In H. T. Blane, & K. E. Leonard (Eds.), Psychological theories of drinking and alcoholism, Vol. 1. (pp. 131–178). New York, NY: Guilford Press. Adamson, S. J., Sellman, J. D., & Frampton, C. (2009). Patient predictors of alcohol treatment outcome: A systematic review. Journal of Substance Abuse Treatment, 36, 75–86. Aiken, L. S., & West, S. G. (1991). Multiple regression: Testing and interpreting interactions. Thousand Oaks, California: Sage. Alcántara, C., Casement, M. D., & Lewis-Fernández, R. (2013). Conditional risk for PTSD among Latinos: A systematic review of racial/ethnic differences and sociocultural explanations. Clinical Psychology Review, 33, 107–119. Aldridge-Gerry, A., Cucciare, M. A., Ghaus, S., & Ketroser, N. (2012). Do normative perceptions of drinking relate to alcohol use in US Military Veterans presenting to primary care? Addictive Behaviors, 37, 776–782. Alegria, M., Canino, G., Shrout, P. E., Woo, M., Duan, N., Vila, D., et al. (2008). Prevalence of mental illness in immigrant and non-immigrant U.S. Latino groups. American Journal of Psychiatry, 165, 359–369. American Psychological Association. (2000). Diagnostic and statistical manual of mental disorders: DSM-IV-TR®. : American Psychiatric Pub. Babor, T. F., & Grant, M. (1989). From clinical research to secondary prevention: International collaboration in the development of the Alcohol Use Disorders Identification Test (AUDIT). Alcohol Health and Research World, 13, 371–374. Billings, A. G., & Moos, R. H. (1981). The role of coping responses and social resources in attenuating the stress of life events. Journal of Behavioral Medicine, 4, 139–157. Bliese, P. D., Wright, K. M., Adler, A. B., Cabrera, O., Castro, C. A., & Hoge, C. W. (2008). Validating the primary care posttraumatic stress disorder screen and the posttraumatic stress disorder checklist with soldiers returning from combat. Journal of Consulting and Clinical Psychology, 76, 272–281. Boden, M. T., & Moos, R. (2009). Dually diagnosed patients’ responses to substance use disorder treatment. Journal of Substance Abuse Treatment, 37, 335–345.

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