1 page synopsis

ORIGINAL PAPER

Posttraumatic stress disorder and alcohol misuse among women: effects of ethnic minority stressors

Sherry Lipsky1 • Mary A. Kernic2 • Qian Qiu1 • Deborah S. Hasin3

Received: 4 October 2014 / Accepted: 4 August 2015 / Published online: 13 August 2015

� Springer-Verlag Berlin Heidelberg 2015

Abstract

Purpose The aims of this study were to examine the

relationship between adult-onset posttraumatic stress dis-

order (PTSD) and subsequent alcohol use outcomes (fre-

quent heavy drinking, alcohol abuse, and alcohol

dependence) in non-Hispanic white, non-Hispanic black,

and Hispanic US women, and whether this relationship was

moderated by ethnic minority stressors (discrimination and

acculturation).

Methods The study sample was drawn from two waves of

the National Epidemiologic Surveys of Alcohol and Rela-

ted Conditions, employing time-dependent data to conduct

multiple extended Cox regression.

Results Women with PTSD were over 50 % more likely

than those without PTSD to develop alcohol dependence

[adjusted hazards ratio (aHR) 1.55; 95 % confidence

interval (CI) 1.15, 2.08]. Hispanic and black women were

at lower risk of most alcohol outcomes than white women.

In race-/ethnic-specific analyses, however, PTSD only

predicted alcohol abuse among Hispanic women (aHR

3.02; CI 1.33, 6.84). Higher acculturation was positively

associated with all alcohol outcomes among Hispanic

women and discrimination was associated with AUD

among Hispanic and black women. Acculturation and

discrimination modified the effect of PTSD on AUD

among Hispanic women: PTSD predicted alcohol depen-

dence among those with low acculturation (aHR 10.2; CI

1.27, 81.80) and alcohol abuse among those without

reported discrimination (aHR 6.39; CI 2.76, 16.49).

Conclusions PTSD may influence the development of

hazardous drinking, especially among Hispanic women.

The influence of PTSD on alcohol outcomes is most

apparent, however, when ethnic minority stressors are not

present.

Keywords Posttraumatic stress disorder � Alcohol misuse � Race/ethnicity � Longitudinal analysis

Introduction

PTSD is associated with alcohol misuse, although temporal

precedence has not been as widely established [1–6].

Additionally, the effects of the PTSD–alcohol association

among population subgroups have not been fully exam-

ined, although rates of PTSD and alcohol use disorders

(AUD) differ by gender, race, and ethnicity [7–16].

Acculturation and discrimination add to the complexity of

race- and ethnicity-specific effects of PTSD on alcohol

misuse. Thus, it is important to consider whether these

stressors help to explain the disparate results of studies to

date on the intersection of PTSD and alcohol misuse

among racial and ethnic minority women.

Temporal precedence of PTSD

The self-medication theory posits that PTSD precedes AUD,

given that alcohol may offset or reverse psychic numbing,

feelings of estrangement, and detachment in low to moderate

& Sherry Lipsky lipsky@u.washington.edu

1 Department of Psychiatry and Behavioral Sciences,

University of Washington at Harborview Medical Center,

Seattle, WA, USA

2 Department of Epidemiology, University of Washington

School of Public Health, Seattle, WA, USA

3 Columbia University/New York State Psychiatric Institute,

New York, NY, USA

123

Soc Psychiatry Psychiatr Epidemiol (2016) 51:407–419

DOI 10.1007/s00127-015-1109-z

doses, and that it can dampen emotional flooding in high,

‘hypnotic’ doses [17, 18]. Thus, it is plausible that individuals

with PTSD are likely to self-medicate the negative effects

associated with major trauma. Nevertheless, study findings

have been inconsistent. For example, PTSD preceded AUD in

the majority (65–84 %) of comorbid individuals in the

National Comorbidity Survey [2, 3]. However, other studies

have found adjustment for other important confounders, such

as pre-existing AUD and other psychiatric disorders, to

challenge the validity of these results [4, 5]. Furthermore,

some research in this area has shown gender-specific effects of

trauma exposure and PTSD on AUD [5, 6] which may, when

ignored, help explain the inconsistency in study findings.

Race/ethnicity

Little is known about how race or ethnicity might moderate

the PTSD–alcohol misuse relationship. Although lower

rates of AUD have been revealed among blacks and His-

panics compared to non-Hispanic whites in the majority of

studies [7–10], findings have been mixed with regard to

PTSD [11–13, 19]. A recent meta-analysis focused on

Hispanics found consistent support for elevated rates of

PTSD onset and severity among Hispanics relative to non-

Hispanic whites [11]. On the other hand, the prevalence of

PTSD was found to be greater among blacks, but not

Hispanics, compared to non-Hispanic whites in a nationally

representative US sample [13]. In addition, blacks may be

at greater risk of persistent anxiety disorders compared to

non-Hispanic whites [20, 21], perhaps as a result of higher

or chronic exposure to discrimination [20, 22, 23]. Ethnic

minorities are also less likely to receive treatment for

PTSD [24], and persistent or untreated PTSD may provide

an avenue for increased risk of AUD [21, 25–27]. Further

research is needed to more clearly define the longitudinal

relationship between PTSD and subsequent alcohol misuse

and to better attend to gender, race, ethnicity, and ethnic

minority stressors.

Acculturation

Acculturation (adoption of dominant culture practices and

values) may help to explain racial and ethnic disparities in

PTSD and alcohol misuse. Traditional family networks and

traditional culture may have protective effects and likely

decrease exposure to social stress or at least buffer the

impact of that stress [28–31]. Thus, not only would PTSD

be less common among less acculturated Hispanics but,

once acquired, social support and identification with tra-

ditional culture may decrease any secondary risk of alcohol

misuse.

Previous research has revealed that higher acculturation

among Hispanics is associated with both PTSD [32–34]

and alcohol misuse [35–41]. Much of this research, how-

ever, has involved proxy measures of acculturation (na-

tivity or length of US residence) rather than specific

acculturation measures [7, 32, 42, 43]. Moreover, US

nativity and higher acculturation are associated with

comorbid alcohol and mental disorders, at least in cross-

sectional surveys [43, 44]. US-born women are signifi-

cantly more likely than immigrant women of Mexican

origin, for example, to have a comorbid AUD and anxiety

disorder [44] or to have comorbid psychiatric and sub-

stance use disorders [43]. What has not been studied is the

effect of acculturation on the longitudinal relationship

between PTSD and alcohol outcomes.

Discrimination

Discrimination, or the experience of ‘othering’ [45], can be

conceptualized as a stressful life event or series of events

that may affect mental health [46–49]. Discrimination has

been associated with alcohol misuse and mental health

disorders in several studies [22, 41, 50–57]. For example,

data from the National Epidemiologic Surveys on Alcohol-

Related Conditions (NESARC) [55] revealed that dis-

crimination was significantly associated with AUD among

female respondents and black respondents, but not His-

panics. On the other hand, a 15-year follow-up study of

young adults found that any past year alcohol use, but not

binge drinking, was significantly associated with higher

levels and longer duration of discrimination among blacks

[58]. Although most studies have not conducted gender-

and ethnic-specific analyses, findings from the National

Latino and Asian American Study suggest that discrimi-

nation is associated with an increased odds of AUD among

Hispanic women, but not men [59, 60].

While studies of discrimination and mental health have

revealed significant relationships, the majority of studies

have involved either generic measures of discrimination or

mental health [22, 50, 52, 56, 61–65]. Results from a rel-

atively recent meta-analysis showed an increased proba-

bility of manifesting clinical levels of mental illness

associated with experience of any type of discrimination

[56]. Other studies have found experience of racial or

ethnic discrimination to be associated with increased psy-

chological distress among blacks, Mexican Americans, and

other Hispanics [56, 66]. In one of the few studies to

examine the effect of racial/ethnic discrimination on the

PTSD–alcohol relationship, college students reporting

discrimination at the baseline interview were found to be at

risk for developing symptoms of posttraumatic stress and

increased maladaptive alcohol use 1 year later [67]. PTSD

symptomatology was not assessed at baseline, however. In

sum, little is known about the temporal relationship

between PTSD and alcohol outcomes among women with

408 Soc Psychiatry Psychiatr Epidemiol (2016) 51:407–419

123

regard to racial/ethnic status or the role of ethnic minority

stressors. This study focused specifically on women, given

their increased risk of PTSD and their greater levels of

chronicity and severity of PTSD [14, 15]. Although the

prevalence of AUD is greater among men [10, 16], men in

the civilian population with comorbid PTSD and AUD are

more likely to have secondary PTSD, while women are

more likely to have primary PTSD [2].

The current study addresses these gaps in the literature

by examining the temporal relationship between adult-on-

set PTSD and subsequent alcohol use outcomes (frequent

heavy drinking, alcohol abuse, and alcohol dependence)

and whether this differs between non-Hispanic white, non-

Hispanic black, and Hispanic US women. This study also

examines whether ethnic minority stressors (discrimination

and acculturation) moderate the PTSD–alcohol relation-

ship. We hypothesized that ethnic minority women with

PTSD are at greater risk of poor alcohol outcomes than

non-Hispanic white women, and that those with higher

acculturation or discrimination would be at further risk.

This study has the unique potential of identifying racial-/

ethnic-specific risk factors associated with poor alcohol

outcomes in the milieu of trauma, which can inform the

development of secondary prevention and intervention

efforts targeting PTSD-affected women.

Materials and methods

Sampling methodology

The study sample was drawn from two waves of NESARC.

These surveys have been previously described elsewhere in

detail [68]. In brief, Wave 1 of NESARC was conducted in

2001–2002 and Wave 1 respondents were re-interviewed in

Wave 2 (2004–2005). The sample was weighted to adjust

for nonresponse at the household and person levels; the

selection of one person per household; and over-sampling

of young adults, Hispanics, and non-Hispanic blacks. Once

weighted, the data were adjusted to be representative of the

US population based on the 2000 Decennial Census. The

survey response rate was 81 % for Wave 1 and 86.7 % for

Wave 2; the overall cumulative survey response rate

including both waves was 70.2 %.

The current study includes 11,308 non-Hispanic white

(hereafter referred to as white), 4261 non-Hispanic African

American/black (hereafter referred to as black), and 3640

Hispanic females. The small sample size (\5 %) of other races/ethnicities precluded their inclusion. This study also

focuses exclusively on adult-onset PTSD and subsequent

AUD outcomes given that the majority of PTSD among

women first occurs in adulthood [69]. We followed sub-

jects through time beginning at age 18 until an occurrence

of an alcohol outcome or censoring at Wave 2 follow-up

(i.e., at the time of the interview at Wave 2). Subjects with

alcohol outcomes prior to age 18 or preceding the onset of

PTSD were excluded.

Measures

PTSD

A diagnosis of PTSD was based on the Alcohol Use

Disorder and Associated Disability Interview Schedule-

DSM-IV Version (AUDADIS-IV), using the only or

‘worst’ traumatic event experienced by the respondent.

Test–retest reliabilities of a lifetime diagnosis is good

(j = 0.65) and the internal consistency of symptom scales associated with PTSD is acceptable (a = 0.69) [70]. Age of onset was missing for \1 %. History of PTSD was modeled as a time-dependent dichotomous variable (0/1)

coded as positive from the age of PTSD onset forward.

Alcohol measures

Frequent heavy drinking is defined as 4? drinks among

women in a single day at least once a month in the

respondent’s heaviest drinking period based on quantity/

frequency measures. The reliability of these measures is

good [intraclass correlation coefficient (ICC) 0.70] [71].

Age of onset was missing for \1 %. The AUDADIS-IV [71] was used to measure alcohol abuse (without depen-

dence) and alcohol dependence (with or without abuse)

diagnoses. Reliabilities associated with lifetime and past

year alcohol abuse and dependence diagnoses were good

(j = 0.70 and 0.74, respectively) [71]. Age of onset for alcohol abuse alone and alcohol dependence with or

without abuse was missing for 6.0–7.8 and 0.0–1.6 %,

respectively, of study respondents, with only minor dif-

ferences by race/ethnicity.

Explanatory/potentially confounding factors

Socio-demographic characteristics

Measures from Wave 2 included self-identified race and

Hispanic ethnicity (non-Hispanic white and non-Hispanic

black); age (in years); education (in years); marital status,

marital status change from Wave 1; health insurance in past

year; and total household income in past year. Multiracial

respondents were categorized by NESARC according to

the following order of preference: (1) black or African

American, (2) American Indian and Alaska Native, (3)

Native Hawaiian and other Pacific Islander, (4) Asian, and

(5) white. Nativity and years lived in the USA were cate-

gorized among Hispanic respondents as having lived in the

Soc Psychiatry Psychiatr Epidemiol (2016) 51:407–419 409

123

USA for 20 or more years (or born in the USA);

10–19 years; 5–9 years; or \5 years. Too few black (\10 %) and white (\5 %) respondents were born outside of the USA to be categorized as such.

Social support and social networks

Social support/networks were assessed at Wave 2 by two

instruments. The Interpersonal Support Evaluation List

(ISEL12) [70] measures the respondents’ perceptions of the

current availability to them of potential social resources

(e.g., ‘‘If I were sick, I know I would find someone to help

me with my daily chores’’). The Social Network Index [70]

assesses participation in 12 types of social relationships

with whom the respondent had contact with at least once

every 2 weeks, recoded as number of network types. The

test–retest reliability for these instruments is good

(ICC = 0.63 and 0.70, respectively) [70].

Major depressive disorder

Major depressive disorder (MDD) was defined as ever

having a DSM-IV MDD diagnosis (excluding substance-

induced disorders and those due to a general medical

condition). Test–retest reliabilities for the past year and

lifetime diagnoses were good (j = 0.59 and 0.65, respec- tively) as were those for symptom scales (ICC 0.71) [70,

71]. To account for the effect of treatment on depression,

depression was categorized as no depression, depression

with any treatment for depression over the lifetime (sought

help from ‘counselor/therapist/doctor/other person’, went

to the emergency room, or was hospitalized), and depres-

sion without any treatment.

Family history

Family history of problem drinking/alcoholism has been

well established as a useful indicator in determining a

clinical prognosis of AUD [72]. To control for this as a

potential confounder, family history was assessed by ask-

ing if any blood/natural relative (parents, siblings, children)

was ever ‘‘an alcoholic or problem drinker’’. Responses

were recoded as the proportion of first-degree relatives who

were alcoholic/problem drinkers (0, \25, 15–49, and C50 %).

Moderating variables

Acculturation

This measure is based on the 11-item acculturation scale

adapted from the Brief Acculturation Rating Scale-II for

Mexican Americans [73–77]. Acculturation items focused

strongly on language use (current and in childhood), pro-

ficiency, and preference, as well as race–ethnic social

preferences, and rated using a five-point scale (1–5). The

test–retest reliability of the acculturation scale is excellent

(ICC 0.79) and the internal consistency is good (a = 0.85) [70]. For the purposes of this study, acculturation was

categorized as low (11–21), medium (35–43), and high

(44–55); due to sample size constraints, acculturation was

dichotomized as low (11–21) vs. moderate to high (12–55)

in main effects models of AUD and when testing effect

modification.

Discrimination

The ethnic and racial discrimination scales in the AUDA-

DIS-IV were modeled after the Experiences with Dis-

crimination scales developed by Krieger et al. [78–81]. The

original scales were expanded to reflect the past 12 months

and prior to the past 12 months. Good test–retest reliability

(ICC 0.68 and 0.64 for prior to last 12 months and past

12 months, respectively) was demonstrated, and internal

consistency (a = 0.69 and 0.74, respectively) was accept- able [70]. For the purposes of this study, the two time

periods were combined to create a lifetime measure of

discrimination and dichotomized (ever/never) due to sam-

ple size constraints.

Data analysis

Descriptive statistics were used to compare socio-demo-

graphic, PTSD, and alcohol factors by race/ethnicity. We

used extended Cox regression which, unlike the general

form of proportional hazards Cox regression, allows for the

examination of covariates that are time dependent (change

value with time). The resultant risk estimate, the hazard

ratio, is the ratio of instantaneous risk of the outcome

among the exposed relative to the unexposed and is

roughly comparable in its interpretability to a relative risk.

Adjusted hazard ratios (aHR) and 95 % confidence inter-

vals (CI) were calculated for the first onset of each outcome

(frequent heavy drinking, alcohol abuse, and alcohol

dependence) among respondents with prior adult-onset

PTSD compared to those without PTSD for the total

sample and by race/ethnicity. In each model, socio-demo-

graphic factors were retained as a block and the remaining

potential confounders were retained in the model if they

were independently associated with the outcome (p B 0.10

at entry to allow for only the potentially relevant variables

to be included) or if they confounded the exposure–out-

come relationship (C10 % change in exposure–outcome

HR) [82]. These factors have been associated with PTSD

and/or AUD in prior research [72, 83–91]. As previously

noted, family history of alcohol misuse (problem drinking/

410 Soc Psychiatry Psychiatr Epidemiol (2016) 51:407–419

123

alcoholism) is a well-established risk factor for alcohol use

disorders [72]. Depression and social support or social

networks have been shown to have a strong association

with PTSD [15, 92] and comorbid AUD [90]. A time-

varying covariate for alcohol abuse was also included in

the alcohol dependence models, given the high prevalence

of co-occurrence of abuse and dependence and apparent

heterogeneity across racial/ethnic groups [93, 94]. Accul-

turation and nativity among Hispanics and discrimination

among Hispanic and black women were also examined as

independent predictors in subsequent models. Finally,

effect modification of the exposure–outcome relationship

by acculturation among Hispanic women and discrimina-

tion among black and Hispanic women were examined for

each outcome; if the interaction term was significant at

p B 0.10, estimates were calculated for the exposure and

referent groups. Due to sample size constraints, accultur-

ation/nativity and discrimination among Hispanic women

were assessed in separate models.

Since \10 % of cases were missing data on any of the covariates of interest, we conducted complete case analysis

rather than employing multiple imputation. STATA MP 11

(Stata Corporation, College Station, TX, USA), which

accounted for the complex survey design of NESARC, was

employed for all analyses.

Results

Sample description

Significant racial/ethnic differences were revealed in socio-

demographic and alcohol factors among respondents

(Table 1). Of note, black and Hispanic women were more

likely to be younger and to have lower socioeconomic

status than white women, but were less likely to have a

family history of problem drinking, frequent heavy drink-

ing, and AUD. Black women were least likely to be

married.

Survival analysis

Main effects models

Table 2 illustrates the findings of the main effects models

predicting lifetime risk of each alcohol outcome associated

with prior adult-onset PTSD in the total sample and by

race/ethnicity. In the total sample, women with PTSD were

approximately 50 % more likely to develop alcohol

dependence compared to those without PTSD (aHR 1.55;

CI 1.15, 2.08). Black and Hispanic women were at

decreased risk of most alcohol outcomes. MDD with or

without treatment was positively associated with poor

alcohol outcomes, while increased social networks and, to

a lesser degree, social support were protective. Concurrent

alcohol abuse also predicted alcohol dependence.

Race/ethnicity

In ethnic-specific analyses, PTSD predicted alcohol abuse

only among Hispanics (aHR 3.02; CI 1.33, 6.84). MDD

estimates varied by alcohol outcome and by race/ethnicity.

MDD without treatment was consistently associated with

poor alcohol outcomes across all racial/ethnic groups,

while MDD with treatment was associated with alcohol

abuse only among whites and with alcohol dependence in

all groups. Concurrent alcohol abuse was positively asso-

ciated with alcohol dependence in each group, although the

estimates were significantly higher among black and His-

panic women. Increased social networks were protective of

poor alcohol outcomes among white women and, to a lesser

degree, among black women. On the other hand, lower

social support was positively associated with alcohol

dependence among white women and protective of fre-

quent heavy drinking and alcohol abuse among Hispanic

women.

Ethnic minority stressors

Acculturation

Higher acculturation was associated with poor alcohol

outcomes among Hispanic women (data not shown).

Women with medium and high acculturation (scoring

35–43 and 44–55, respectively) were three times more

likely than those with low acculturation (aHR 3.15, CI

1.16, 8.58 and aHR 3.48, CI 1.35, 8.95, respectively) to be

frequent heavy drinkers. Similar findings were revealed for

alcohol abuse and alcohol dependence (high/medium vs.

low acculturation: aHR 3.55, CI 1.91, 6.61 and aHR 3.56,

CI 1.58, 8.01, respectively). In addition, having been born

outside the USA was protective of alcohol dependence

(aHR 0.43, CI 0.23, 0.80).

Discrimination

Discrimination was positively associated with alcohol

outcomes among black and, to a lesser degree, Hispanic

women (data not shown). Hispanic women experiencing

discrimination were 70 % more likely to have alcohol

abuse than their counterparts who did not report discrimi-

nation (aHR 1.68, CI 1.06, 2.67). Similarly, black women

experiencing discrimination were 50–80 % more likely

than those without reported discrimination to have alcohol

abuse or alcohol dependence (aHR 1.46, CI 1.05, 2.03 and

aHR 1.82, CI 1.27, 2.61, respectively).

Soc Psychiatry Psychiatr Epidemiol (2016) 51:407–419 411

123

Ethnic minority stressors as effect modifiers

Acculturation moderated the relationship between PTSD

and alcohol dependence among Hispanic women (data not

shown). PTSD predicted alcohol dependence among those

with lower acculturation (aHR 10.2; CI 1.27, 81.80), but

not among those with higher acculturation (aHR 1.14; CI

0.46, 2.87). Discrimination moderated the relationship

Table 1 Descriptive characteristics of female respondents: National Epidemiologic Survey on Alcohol and Related Conditions, 2001–2002 and 2004–2005

Characteristic Total sample Non-Hispanic white Non-Hispanic black Hispanic

N % SE N % SE N % SE N % SE

Age group***

20–29 2657 15.67 0.38 1374 13.91 0.45 586 18.79 0.79 697 23.62 1.08

30–39 3751 17.90 0.35 1927 16.16 0.39 867 20.80 0.82 957 26.02 1.01

40–49 4015 21.01 0.40 2233 20.61 0.49 932 22.18 0.77 850 22.30 0.85

50–59 3265 17.56 0.34 2013 18.37 0.42 766 16.84 0.64 486 13.18 0.69

60–69 2262 11.46 0.30 1428 12.27 0.34 539 10.53 0.49 295 7.22 0.67

70? 3259 16.40 0.36 2333 18.69 0.44 571 10.87 0.55 355 7.66 0.70

Marital status***

Married 8995 57.13 0.68 5927 61.25 0.61 1179 33.33 0.91 1889 56.52 1.82

Cohabiting 562 2.94 0.17 294 2.53 0.18 89 2.48 0.26 179 6.09 0.64

Separated/widowed/divorced 6250 24.85 0.42 3653 24.37 0.47 1677 31.94 0.85 920 20.21 1.18

Never married 3402 15.08 0.49 1434 11.85 0.41 1316 32.24 0.90 652 17.18 1.09

Education***

\High school 3112 13.79 0.55 1181 10.29 0.37 779 16.4 0.88 1152 33.6 2.02 High school diploma 5370 28.30 0.51 3197 28.71 0.57 1266 29.34 1.02 907 24.48 1.01

Some college 6138 32.79 0.54 3704 33.00 0.65 1392 35.07 0.95 1042 28.92 1.38

Bachelor’s degree or higher 4589 25.12 0.62 3226 28.00 0.71 824 19.18 0.92 539 13.00 1.30

Household income***

\20,000 5307 22.34 0.57 2544 19.25 0.56 1675 35.65 1.26 1088 27.79 1.47 20,000–49,999 6921 35.15 0.54 3903 33.59 0.64 1587 38.24 0.86 1431 41.84 1.41

50,000–99,999 4968 29.46 0.55 3304 31.80 0.59 791 20.48 1.01 873 24.17 1.37

100,000? 2013 13.05 0.53 1557 15.36 0.66 208 5.63 0.61 248 6.20 0.62

Health insurance category***

Private insurance 12,536 69.62 0.75 8350 75.14 0.58 2314 54.70 1.19 1872 50.25 1.91

Medicare 2273 9.75 0.30 1174 9.05 0.34 709 14.64 0.63 390 8.91 0.93

Subsidized insurance 1738 7.23 0.40 599 4.93 0.28 584 13.20 0.76 555 15.52 1.63

No health insurance 2617 13.41 0.46 1158 10.88 0.41 642 17.46 1.16 817 25.31 1.57

Adult-onset frequent heavy drinking***

Yes 2552 14.44 0.47 1787 16.01 0.53 404 10.03 0.74 361 9.33 0.66

No 15,878 85.56 0.47 9002 83.99 0.53 3710 89.97 0.74 3166 90.67 0.66

Adult-onset alcohol abuse***

Yes 1844 11.33 0.45 1369 13.17 0.48 271 6.93 0.64 204 4.89 0.53

No 15,011 88.67 0.45 8288 86.83 0.48 3616 93.07 0.64 3107 95.11 0.53

Adult-onset alcohol dependence***

Yes 1613 10.17 0.41 1084 11.12 0.44 294 8.05 0.66 235 6.99 0.70

No 15,011 89.83 0.41 8288 88.88 0.44 3616 91.95 0.66 3107 93.01 0.70

Adult-onset PTSD***

Yes 1747 8.70 0.28 1003 8.43 0.32 435 9.89 0.67 309 9.12 0.81

No 17,462 91.30 0.28 10,305 91.57 0.32 3826 90.11 0.67 3331 90.88 0.81

PTSD posttraumatic stress disorder, SE standard error

*** Significant difference between racial/ethnic groups p \ 0.001

412 Soc Psychiatry Psychiatr Epidemiol (2016) 51:407–419

123

Table 2 Main effects models predicting lifetime risk of alcohol outcomes associated with prior adult-onset PTSD among female respondents by race/ethnicity, National Epidemiologic Survey on Alcohol and Related Conditions, 2001–2002 and 2004–2005

Risk factors Total sample Non-Hispanic white Non-Hispanic black Hispanic

HR 95 % CI HR 95 % CI HR 95 % CI HR 95 % CI

Frequent heavy drinking

PTSD 1.23 0.78–1.95 1.08 0.55–2.09 1.43 0.74–2.77 1.94 0.67–5.64

Race/ethnicity a

– – – – –

Black 0.70 0.51–0.96

Hispanic 0.58 0.44–0.76

MDD b

MDD with treatment 1.22 0.98–1.53 1.15 0.90–1.46 1.16 0.64–2.10 2.30 1.22–4.35

MDD w/o treatment 1.56 1.22–2.00 1.40 1.01–1.94 1.68 1.01–2.80 2.69 1.34–5.39

Social networks c

0.86 0.80–0.92 0.85 0.78–0.92 0.85 0.74–0.98 –

Social support 4

– – – – – –

Fair 0.54 0.31–0.95

Low 0.42 0.24–0.72

Alcohol abuse

PTSD 1.19 0.84–1.68 1.11 0.73–1.69 0.82 0.36–1.87 3.02 1.33–6.84 e

Race/ethnicity a

– – – – – –

NH black 0.46 0.37–0.58

Hispanic 0.43 0.34–0.55

MDD b

MDD with treatment 1.33 1.12–1.60 1.28 1.05–1.57 1.25 0.67–2.35 2.55 1.56–4.16

MDD w/o treatment 1.43 1.14–1.80 1.39 1.08–1.77 1.98 1.24–3.16 1.53 0.72–3.25

Social networks c

0.93 0.88–0.98 0.92 0.87–0.98 – –

Social support d

– – – – – –

Fair 0.71 0.45–1.13

Low 0.57 0.34–0.97

Alcohol dependence

PTSD 1.55 1.15–2.08 1.59 1.11–2.29 1.10 0.61–1.97 1.65 0.64–4.23 f

Race/ethnicity a

– – – – – –

NH black 0.93 0.75–1.16

Hispanic 0.71 0.53–0.95

MDD b

MDD with treatment 2.52 2.10–3.03 2.42 1.98–2.97 2.67 1.66–4.28 2.96 1.67–5.24

MDD w/o treatment 1.80 1.44–2.25 1.62 1.22–2.14 2.36 1.46–3.81 2.33 1.26–4.34

Concurrent alcohol abuse 3.18 2.65–3.82 2.75 2.23–3.39 6.30 4.01–9.89 7.61 4.07–14.21

Social networks c

0.92 0.87–0.98 0.92 0.86–0.99 0.91 0.82–1.02 – –

Social support d

– – – –

Fair 1.31 1.06–1.62 1.36 1.06–1.73 –

Low 1.29 1.03–1.62 1.33 1.02–1.75 –

HR Hazard Ratio, adjusted for all factors with values included as well as age, education, health insurance, household income, marital status,

marital status change between survey waves, and family history of problem drinking/alcoholism, CI confidence interval, PTSD posttraumatic

stress disorder, MDD major depressive disorder

–, Variable not included in the model a Reference group is non-Hispanic white

b Reference group is no MDD

c Number of social network types; risk decreases as number increases

d Reference group is high level of social support

e Significant interaction between PTSD and reported discrimination; PTSD predicted alcohol abuse only among Hispanic women without

discrimination; see text for results f Significant interaction between PTSD and acculturation; PTSD predicted alcohol dependence among Hispanic women with low acculturation;

see text for results

Soc Psychiatry Psychiatr Epidemiol (2016) 51:407–419 413

123

between PTSD and alcohol outcomes only among Hispanic

women (data not shown). PTSD predicted alcohol abuse

among Hispanic women without reported discrimination

(aHR 6.39; CI 2.76, 16.49), but not among those having

experienced discrimination (aHR 1.30; CI 0.33, 5.19).

Discussion

This is the first study to our knowledge to examine the

temporal relationship between PTSD and alcohol outcomes

among women using time-dependent data from the entire

adulthood experiences of women, with a specific focus on

racial/ethnic minorities and ethnic minority stressors. The

key findings in this study suggest that PTSD influences the

development of AUD in women. This is most apparent

among ethnic minorities when other stressors are not pre-

sent. Specifically, Hispanic women with low acculturation

or without reported discrimination are at greatest risk of

poor alcohol outcomes following the onset of PTSD.

PTSD and alcohol outcomes

Our findings that PTSD predicted alcohol dependence in

the total sample extends those of previous studies. In a

3-year prospective follow-up study using two waves of

NESARC data, similar alcohol outcomes were revealed for

male and female respondents combined [4]. PTSD pre-

dicted alcohol dependence in that study, but the risk

decreased and became nonsignificant after taking into

account other psychiatric disorders, perhaps due to the

complex interrelationships among comorbid disorders [95,

96]. Other studies [1, 6] also have demonstrated that PTSD

increases the risk for AUD, although either incidence or

temporal sequencing of events was not addressed. More-

over, the majority of previous researches have not been

gender specific, although some researches have identified

important differences in risk of PTSD and AUD based on

gender [10, 14–16].

Race/ethnicity

While there were no significant racial/ethnic differences in

lifetime prevalence of PTSD, the current study revealed

that white women with PTSD were at increased risk of

subsequent alcohol dependence and Hispanic women with

PTSD were at increased risk of developing alcohol abuse.

The findings with regard to Hispanic women are consistent

with previous studies showing elevated rates of PTSD

onset and severity among Hispanics relative to non-His-

panic whites [11]. Our findings for black women were

unexpected, however, given that prior research has

demonstrated a greater risk of persistent anxiety disorders

among blacks [20, 21, 25–27] and decreased treatment for

PTSD among ethnic minorities compared to non-Hispanic

whites [24]. As previously noted, persistent disorders and

lack of treatment would suggest an increased risk of AUD.

Nevertheless, the extant literature has not shown consistent

findings in racial/ethnic disparities in PTSD, AUD, and

comorbid disorders [7–12, 97, 98] but, again, most studies

have not utilized time-dependent data.

Acculturation

The effect of acculturation on the relationship between

PTSD and alcohol outcomes in this study is also unex-

pected, given prior research demonstrating greater risk of

mental health disorders and AUD among US-born com-

pared to immigrant Hispanics, those with longer residence

in the USA, and higher acculturation [7, 33, 42, 44, 99].

Although traditional family networks and traditional cul-

ture have been shown to buffer the impact of stress, higher

acculturation may lead to increased help seeking for trau-

matic events [28–31, 100, 101]. The net effect in each case

would be to decrease the likelihood of self-medication with

alcohol. An alternative explanation is that in the absence of

acculturation as a stressor, the role of PTSD in alcohol

outcomes becomes more evident. Our findings should be

interpreted with caution, however, given the wide confi-

dence intervals in the effect modification models. Never-

theless, the emergence of AUD in the absence of an

additional stress factor has been demonstrated in at least

one previous study. Lipsky et al. [102] found that child-

hood trauma moderated the relationship between poten-

tially traumatic intimate partner violence and alcohol

misuse mainly among black respondents, with an increased

risk of a poor alcohol outcome among those without

childhood trauma. Hispanic women were not included in

that study.

Discrimination

Discrimination also played a similar role to that of accul-

turation in the PTSD–alcohol relationship in this study,

with PTSD predicting alcohol abuse only among Hispanic

women without reported discrimination. While the paucity

of prior research on this specific relationship makes it

difficult to compare our findings to other studies, one study

found discrimination to increase the risk of PTSD symp-

toms and alcohol misuse among Hispanic college students,

although temporal relationships could not be established

[67]. It is clear from the extant literature, however, that

discrimination has a detrimental effect on mental health

and alcohol misuse among ethnic minorities [22, 51, 53–

58, 66, 103, 104].

414 Soc Psychiatry Psychiatr Epidemiol (2016) 51:407–419

123

Why this relationship was not revealed among black

women is difficult to explain, given prior findings of pos-

itive associations between discrimination and poor mental

health and alcohol outcomes among blacks overall [51, 53,

54, 56–58]. It is possible that black women engage addi-

tional social resources that ameliorate the effect of PTSD

on alcohol misuse or that social norms regarding drinking

are strongly negative in black women overall. Few studies

have examined these relationships among black women

specifically and have focused mainly on depression or

distress [105–108]. In a study of black families [109], for

example, distress (general anxiety and depression symp-

toms) partially mediated the discrimination–substance use

relationship. In a comparison of the strengths of the various

paths for males and females in that study, the models

looked very similar. Other sociocultural factors, such as

trauma cognitions (the way people think about themselves,

others, and the safety of the world), may change after

experiencing a traumatic event [110]. In one study of

individuals with comorbid PTSD and alcohol dependence,

negative views about one’s self and the world were more

strongly associated with adverse consequences of drinking

and alcohol craving severity among blacks than whites

[110].

Limitations

There are several limitations to consider in interpreting the

findings of this study. First, the measurement of potentially

traumatic experiences is limited by the retrospective

assessment of events, which may underestimate the

prevalence [3, 111]. Nevertheless, PTSD was based on the

only or ‘worst’ event experienced by the respondent, which

may lead to a higher rate of detection [9, 111–114],

Alcohol misuse and AUD were also assessed retrospec-

tively in each survey wave. Recall bias may have occurred

biasing the estimates downward, particularly for lifetime

occurrences of alcohol misuse [115]. On the other hand,

test–retest reliability of NESARC variables has been

demonstrated to be good overall [70, 71]. It should also be

noted that with the changes in criteria in the DSM-V, the

prevalence rates of AUD as compared to DSM-IV may in

fact increase [116]. Second, lifetime measures were uti-

lized for MDD, MDD treatment, and discrimination,

whereas social support and acculturation were current

assessments at Wave 2 by the respondents. Thus, it was not

possible to determine the temporal sequencing of these

variables with PTSD and alcohol misuse outcomes. Third,

it is possible that refusers, the impaired, and deceased were

more likely to have DSM-IV disorders, biasing the estimate

of the PTSD–alcohol relationship downward, although

most studies have revealed a modest to no effect based on

loss to follow-up [117–121]. Moreover, the response rate

for Wave 2 (86.7 %) was excellent, decreasing the effect of

nonresponse on the outcomes under study. Finally, if

respondents had developed an AUD prior to age 18 or prior

to PTSD, they would have been excluded from the analy-

sis; this may have led to decreased power or unavoidable

selection bias.

Conclusions

The novel findings from this study highlight the importance

of determining the risk of AUD associated with prior onset

of PTSD from a gendered as well as racial/ethnic per-

spective and the role ethnic minority stressors play in this

relationship. The use of a nationally representative sample

and the availability of time-dependent measures to deter-

mine lifetime risk extend the current literature which has,

to date, been based mainly on nonrepresentative or cross-

sectional data or limited to changes between study or sur-

vey waves. The current findings suggest that screening and

intervention programs for PTSD in health and social ser-

vice settings have the potential to interrupt trajectories that

carry higher risk for alcohol misuse and AUD among

women. An increasing body of evidence points to the need

for integrated treatment that addresses both complex

trauma and substance abuse, which has better potential to

improve both PTSD and alcohol outcomes among women

[122, 123].

Additional research is needed to determine if there are

racial/ethnic differences in treatment needs and efficacy

related to PTSD [124]. Identification of sociocultural and

contextual factors associated with poor alcohol outcomes

in the face of traumatic experiences is especially critical in

informing the development of relevant and sensitive

alcohol prevention and intervention efforts. The effects of

acculturation on specific types of help seeking for trau-

matic events in particular need to be more clearly delin-

eated. Although discrimination is not easily modifiable on

an individual basis, public health efforts to address bias

and discrimination remain key. Finally, given that AUD

varies across Hispanic subgroups [7], it will be important

in future research to examine the PTSD–alcohol relation-

ship within these subgroups as well as other ethnic

minority groups.

Acknowledgments This study was funded by the National Institutes of Health, National Institute of Alcohol Abuse and Alcoholism (NIH/

NIAAA) Grant R01 AA 018686. Its contents are solely the respon-

sibility of the authors and do not necessarily represent the official

views of NIH/NIAAA.

Compliance with ethical standards

Conflict of interest The authors report no conflicts of interest.

Soc Psychiatry Psychiatr Epidemiol (2016) 51:407–419 415

123

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