The present study utilized longitudinal data from a community sample (n= 377; 166 trauma-exposed; 54% males; 73% non-Hispanic Caucasian; 22% Hispanic; 5% other ethnicity) to test whether pre-trauma substance use problems increase risk for trauma exposure (high-risk hypothesis) or PTSD symptoms (susceptibility hypothesis), whether PTSD symptoms increase risk for later alcohol/drug problems (self-medication hypothesis), and whether the association between PTSD symptoms and alcohol/drug problems is due to shared risk factors (shared vulnerability hypothesis). Logistic and negative binomial regressions were performed in a path analysis framework. Results provided the strongest support for the self-medication hypothesis, such that PTSD symptoms predicted higher levels of later alcohol and drug problems, over and above the influences of pre-trauma family risk factors, pre-trauma substance use problems, trauma exposure, and demographic variables. Results partially supported the high-risk hypothesis, such that adolescent substance use problems had a marginally significant unique effect on risk for assaultive violence exposure but not on overall risk for trauma exposure. There was no support for the susceptibility hypothesis. Finally, there was little support for the shared vulnerability hypothesis. Neither trauma exposure nor preexisting family adversity accounted for the link between PTSD symptoms and later substance use problems. Rather, PTSD symptoms mediated the effect of pre-trauma family adversity on later alcohol and drug problems, thereby supporting the self-medication hypothesis. These findings make important contributions to better understanding the directions of influence among traumatic stress, PTSD symptoms, and substance use problems.

IMPORTANCE Co-occurrence of posttraumatic stress disorder (PTSD) and alcohol use disorder (AUD) is common and associated with psychiatric and functional problems. Understanding whether exposure therapy is tolerable and efficacious for treating PTSD and AUD is critical to ensure that best practice treatments are available. OBJECTIVE To compare the efficacy of integrated (ie, targeting both PTSD and alcohol use) prolonged exposure (I-PE) therapy with present-centered integrated coping skills (I-CS) therapy, a more commonly available treatment, in reducing PTSD symptoms and alcohol use. DESIGN, SETTING, AND PARTICIPANTS This prospective randomized clinical trial with masked assessments considered 186 veterans seeking Veterans Affairs mental health services. A total of 119 veterans with PTSD and AUD were randomized. Data were collected from February 1, 2013, to May 31, 2017, before treatment, after treatment, and at 3-and 6-month follow-ups. Intention-to-treat analyses were performed. INTERVENTIONS Veterans underwent I-PE (Concurrent Treatment of PTSD and Substance Use Disorder Using Prolonged Exposure) or I-CS (Seeking Safety) therapy. MAIN OUTCOMES AND MEASURES A priori planned outcomes were PTSD symptoms (Clinician Administered PTSD Scale for DSM-5) and percentage of heavy drinking days (Timeline Follow-Back) before treatment, after treatment, and at 3-and 6-month follow-ups. RESULTS A total of 119 veterans (mean [SD] age, 41.6 [12.6] years; 107 [89.9%] male) were randomized. Linear mixture models found that PTSD symptoms decreased in both conditions, with a significantly greater decrease for I-PE treatment compared with I-CS treatment (treatment × time interaction, −2.83; F 3,233.1 = 4.92; Cohen d = 0.41; P = .002). The percentage of heavy drinking days improved in both conditions but was not statistically different between I-PE and I-CS treatment (treatment × time interaction, 1.8%; F 3,209.9 = 0.18; Cohen d = 0.04; P = .91). CONCLUSIONS AND RELEVANCE The I-PE arm had a greater reduction in PTSD symptoms than the I-CS arm and comparable drinking decreases. The study provides evidence that exposure therapy is more efficacious in treating PTSD than a more commonly available integrated treatment without exposure for comorbid PTSD and AUD.

Alcohol use disorder (AUD) and posttraumatic stress disorder (PTSD) are among the most prevalent disorders in U.S. military veterans and often co-occur. To date, most studies have focused on treatment-seeking samples, although many veterans with AUD/PTSD do not seek treatment. We evaluated the prevalence of psychiatric comorbidities, functioning, and quality of life in a nationally representative sample of U.S. veterans (using data from the National Health and Resilience in Veterans Study) with AUD alone, PTSD alone, and comorbid AUD/PTSD to understand the incremental burden of having both disorders relative to either one. Among those with probable AUD, 20.3% met criteria for probable PTSD. Among those, with probable PTSD, 16.8% met criteria for probable AUD. Compared to veterans with AUD only, veterans with AUD/PTSD were more likely to screen positive for major depression (36.8% vs. 2.3%), generalized anxiety disorder (43.5% vs. 2.9%), suicidal ideation (39.1% vs. 7.0%); to have attempted suicide (46.0% vs. 4.1%); and to be receiving mental health treatment (44.8% vs. 7.5%). They also scored lower on cognitive (d = 0.50), mental (d = 0.51) and physical (d = 0.21) functioning, and quality of life (Cohen d = 0.46). Veterans with comorbid AUD/PTSD were more than three times as likely as veterans with PTSD only to have attempted suicide in their lifetimes (odds ratio = 3.1, 95% confidence interval = 1.8-5.3; 46.0% vs. 22.8%); they did not differ on other measures. Results underscore the burden of co-occurring AUD and PTSD in U.S. veterans, and the importance of engaging these veterans in treatment. (PsycINFO Database Record

Using a high-risk community sample (N = 405), the current study examined developmental cascades among substance use, affiliation with substance use promoting peers, and academic achievement over an 18-year period and tested whether these pathways mediated the influence of parental alcoholism on adult alcohol and drug use disorders. Results showed that the influence of parental alcoholism on adult drug disorders was mediated by developmental cascades across all three domains, whereas the influence of parental alcoholism on adult alcohol disorders was mediated through affiliation with substance use promoting peers and persistence in binge drinking. Adolescent drug use had more implications for adult outcomes than did adolescent alcohol use, which was less likely to spill over into other domains of functioning. Findings indicated that adolescent risk factors had indirect rather than unique effects on adult substance use disorders, suggesting that adolescent risk is not immutable and is largely mediated by later influences.Multiple streams of evidence suggest that substance use disorders (SUDs) are best conceptualized as developmental disorders. First, there are well-documented, age-related patterns indicating substance use onset during adolescence, peaks in use and onset of SUDs in emerging adulthood (ages 18-25), and later declines or "maturing out" (Masten, Faden, Zucker, & Spear, 2008;Sher & Gotham, 1999). Second, there is clear evidence of childhood and adolescent antecedents to adult SUDs (Zucker, Donovan, Masten, Mattson, & Moss, 2008). Third, developmental role transitions and their relative timing, including completion of higher education, occupational attainment, marriage, and parenthood, are linked with substance use and SUDs Schulenberg & Maggs, 2002;Sher & Gotham, 1999). Developmentally salient patterns of consumption, context, and risk and protective mechanisms present clear evidence that SUDs are best examined with a developmental lens.According to a dynamic cascade conceptualization (Masten et al., 2005;Obradović, Burt, & Masten, 2010;Sameroff, 2000), processes associated with different domains of development may influence each other both concurrently and longitudinally. In this way, early influences may be important because they predict later, more proximal factors, which in turn affect late adolescent or adult outcomes (e.g., Dodge et al., 2009;Martel et al., 2009). These influences may cascade across multiple domains of functioning or amplify one another over time to influence adult outcomes (Schulenberg & Maslowsky, 2009 NIH-PA Author ManuscriptNIH-PA Author Manuscript NIH-PA Author ManuscriptThe current study focused on three domains of adolescent development that might contribute to the development of adult SUDs; namely, adolescent substance use, affiliation with substance use promoting peers, and poor academic achievement. These domains may increase SUD risk by amplifying one another over time either through bidirectional relations between pairs of domains, or through broader cascadin...