Prevalence and predictors of PTSD among a college

Prevalence and predictors of PTSD among a college sample

Shannon E. Cusack , B.Aa,b, Terrell A. Hicks, B.Sa,b, Jessica Bourdon, B.S., B.Aa, Christina M. Sheerin, Ph.Da, Cassie M. Overstreet, M.Sa,b, Kenneth S. Kendler, M.Da,c, Danielle M. Dick, Ph.Db,c, and Ananda B. Amstadter, Ph.Da,b,c

aVirginia Institute for Psychiatric and Behavioral Genetics, Richmond, Virginia, USA; bDepartment of Psychology, Virginia Commonwealth University, Richmond, Virginia, USA; cDepartment of Human and Molecular Genetics, Virginia Commonwealth University, Richmond, Virginia, USA

ARTICLE HISTORY Received 11 January 2018 Revised 16 March 2018 Accepted 5 April 2018

ABSTRACT Objective:This study examined the prevalence and correlates of probable posttraumatic stress disorder (PTSD) in freshman entering college and prospective associations of probable PTSD with additional outcomes. Participants: 2,310 students with data collected from Fall 2014 through Spring 2015. Methods: Incoming freshman completed a survey assessing for relevant variables at the beginning of fall semester and during the spring semester. Results: Seventy percent of the sample endorsed experiencing at least one potentially traumatic event (PTE). 34.4% of PTE exposed individuals met criteria for probable PTSD. Female sex, higher depressive and anxiety symptoms, and interpersonal PTE count were positively associated with PTSD symptoms. Higher PTSD symptoms were associated with higher anxiety and depressive symptoms, and new-onset interpersonal PTE. Conclusions: Identification of factors contributing to risk for PTSD is essential to inform prevention and intervention efforts. Intervention efforts should be targeted to students experiencing PTSD symptoms as they enter college.

KEYWORDS Intervention; posttraumatic stress disorder; trauma

Exposure to potentially traumatic events (PTEs) is com- mon among young adults. Notably, rates of trauma exposure have been shown to peak sharply between 16 and 20 years, which overlaps with the ages of the average college population.1 This highlights the importance of studying PTE exposure in college students, as estimates in this population have been as high as 84%.2,3 Further- more, among PTE exposed college students, the preva- lence of posttraumatic stress disorder (PTSD) is estimated to be 9%.4 Thus, although a meaningful num- ber of students develop PTSD, the majority of those exposed to PTEs do not, which is congruent with studies of the general population.5,6,7 However, PTSD is a debili- tating disorder and has also been associated with comor- bid psychiatric disorders,8 school dropout,9 and negative health outcomes.10 Given these identified associations, understanding both the correlates of PTE and PTSD and the prospective relationships between PTSD and mental health outcomes that may exist in college students is crucial.

Existing research has identified a number of factors associated with risk for PTSD. A meta-analysis of risk factors predicting PTSD in civilians found that demo- graphic characteristics (eg sex, younger age, race/

ethnicity) and early environmental conditions (eg trauma type or severity) act as significant risk factors for the development of PTSD after PTE exposure.11 Consis- tent sex differences have been identified where women possess greater risk for developing PTSD symptoms upon exposure to PTEs,12 but men possess greater risk for PTE exposure than women.1 There also seems to be an age effect on risk for PTE exposure and PTSD devel- opment, whereby individuals in late adolescence/early adulthood (ie 16–25 year-olds) are at greatest risk for PTE exposure and development of PTSD symptoms.1

Lastly, race and ethnicity seem to impact risk and devel- opment, wherein the lifetime prevalence of PTSD is reported to be highest in those who identify as african americans, intermediate in those who identify as white or hispanic, and lowest in those who identify as asian.13

Considering the existent research, demographics (eg age, sex, etc.) are important to consider when examining out- comes post-PTE exposure.

Psychosocial and environmental factors have also been associated with likelihood of PTSD. Mental health conditions (eg depression, anxiety), a family history of psychopathology, and perceived life threat during the trauma have been consistently shown to increase risk for

CONTACT Shannon E. Cusack, B.A cusackse2@vcu.edu 800 E Leigh St, Richmond, VA 23219, USA. © 2018 Taylor & Francis Group, LLC

JOURNAL OF AMERICAN COLLEGE HEALTH

https://doi.org/10.1080/07448481.2018.1462824 2019, VOL. 67, NO. 2, 123–131

MAJOR ARTICLE

PTSD.7 Additionally, trauma type has been shown to impact the development of the disorder, where certain trauma types have a larger impact on the conditional probability of PTSD. More specifically, many studies have found that interpersonal trauma exposure (eg sex- ual assault, physical assault, etc.) increases the risk for PTSD.8,14,15 Thus, it is important to consider psychoso- cial and environmental variables in addition to non- modifiable variables, such as demographic factors, on risk for PTSD for a more complete etiologic understand- ing of risk. Identifying these factors may help to develop better prevention and intervention strategies that can be implemented on college campuses.

Efforts to identify variables associated with increased risk for PTSD in college students are important because beyond greater exposure to PTEs themselves, trauma- exposed college students are at an increased risk for adverse outcomes.16 Among students who then develop PTSD, rates of impulse control, goal-directed behavior, academic success, alcohol misuse, and general negative coping styles are higher.16,17,43 Specifically, early college trauma exposure may impact levels of non-traumatic academic stress, impacting academic performance and other stress related symptoms.16 Given that students who then develop PTSD demonstrate a higher risk for more problematic substance misuse than their non- PTSD counterparts, it is likely that increased alcohol use may be an effort to cope with these stress related symp- toms.16,18 PTSD is also associated with increased rates of psychiatric comorbidity, such as depression, substance use disorders, anxiety disorders, and suicidal idea- tion.19,20,21 The use of longitudinal data to further exam- ine these relationships will contribute to a more comprehensive understanding of how PTE exposure and PTSD development may influence future outcomes, spe- cifically in college aged individuals.

With these points in mind, the first aim of the present study was to determine the prevalence of PTEs and prob- able PTSD among incoming freshman enrolled in a uni- versity-wide longitudinal study. Based on prior literature, we hypothesized that women would be more likely to endorse probable PTSD upon exposure to at least one PTE, and would endorse higher rates of inter- personal PTE exposure. Furthering this aim, we sought to examine the correlates of probable PTSD symptoms reported at college entry (freshman year, fall). We hypothesized that sex, peer deviance, neuroticism, anxi- ety, depression, alcohol use, and interpersonal PTE expo- sure would be associated with higher PTSD symptoms. The second aim of the study was to examine the prospec- tive relations between PTSD symptoms reported at col- lege entry and psychosocial variables at the spring follow-up assessment. We hypothesized that PTSD

symptoms would prospectively predict self-reported anx- iety, depression, alcohol use, social support, and PTEs measured at follow-up (freshman year, spring).

Methods

Participants

Participants were part of a larger study, Spit for Science (S4S), a university-wide study which aims to better understand the development of substance use and emo- tional health outcomes in college students through broad-based genetic, environmental, and phenotypic assessments.24 Freshman college students begin partici- pation upon arrival on campus, and are followed longitu- dinally across their college years. More details on recruitment can be found elsewhere24 but briefly, each year all incoming freshmen aged �18 years are invited to participate in a university-wide research study on behav- ioral health in college students. At the time of this study, data had been collected for four cohorts between 2011 and 2014. Cohorts are classified based on the year they enter school. Every cohort is assessed twice in their fresh- man year (fall and spring) and then every spring thereaf- ter. Data from the fall (August) freshman year can be considered baseline data.

The current study includes data from the two fresh- men time points — baseline (fall) and follow-up (spring) from the fourth cohort (N D 2310, N D 1263, respec- tively; Mage D 18.5, SD D .39; 62.2% female; white D 50.2%; african american/black D 17.8%; asian D 17.3%; other D 14.7%). Because the fourth cohort was the first to give the four-item PTSD screener, the current study only examined this cohort. The sex and race/ethnicity of participants was representative of the broader student population. Race/ethnicity was dummy-coded and sepa- rated into three categories with white set as the reference group. Attrition was not related to most key study varia- bles, however, women (54.9%) were more likely to com- plete the follow-up survey than were men (45.1%; X2 D 8.12, p D .004). The VCU Institutional Review Board (IRB) approved all study procedures and informed con- sent was obtained from all study participants.

Measures

PTE Exposure (Fall and spring) PTE exposure was assessed using an abbreviated version of the Life Events Checklist.25 Participants were asked to report on the occurrence of five different potentially traumatic events: natural disasters, physical assaults, sex- ual assaults, other unwanted or uncomfortable sexual experiences, and transportation accidents. Response

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options were “yes” or “no” to items regarding whether each stressful event occurred “before the past 12 months”, “during the past 12 months”, “before starting VCU” or “never happened to me”. To assess for PTE at follow up, PTE items endorsed as occurring “since VCU” were used. Items were summed to yield a ‘cumula- tive PTE’ score that encompassed number of lifetime PTE categories occurring prior to college entrance. Cate- gories were further grouped by interpersonal (ie physical assaults, sexual assaults, other unwanted or uncomfort- able sexual experiences) and accidental (ie natural disas- ters and transportation accidents) PTEs.

Probable PTSD (Fall) If a participant endorsed a PTE on the Life Events Checklist (Gray et al., 2004) or endorsed at least one item derived from an additional stressful events mea- sure,10 they were prompted to respond to four PTSD screener items (four items; a D .83). The PTSD screener items were derived from the Primary Care PTSD Screen (PC-PTSD), previously used in screening PTSD symp- toms in primary care settings.26 The four items ask whether the participant have ever experienced: night- mares, attempts to avoid thoughts or reminders of the potentially traumatic experience, hypervigilance, and feelings of detachment. The total symptom count (rang- ing from 0–4) was used as the primary PTSD variable in analyses, and based on standardized scoring for this measure; endorsement of three or more items was used as indication of a positive lifetime history of probable PTSD.

Stressful life events (Fall) A total stressful life events (SLE) count, at baseline, was computed by assessing for the occurrence of events that are potentially stressful, yet not traumatic. Participants endorsed whether an event had occurred over the last 12 months with a “yes” or “no” response option. SLEs assessed for included: broken engagement or steady rela- tionship, serious illness or injury, trouble with the police, laid off or fired from a job, etc. A sum score, with a possi- ble range from 0 to 12, was created by adding the responses from each participant with “yes” coded as 1 and “no” coded as 0.

Peer deviance (Fall) Peer deviance was measured by six items originally cre- ated to assess conduct disorder and peer deviance.27

Items asked how many friends the participant regularly interacted with exhibited potentially deviant behaviors within the past year (eg smoked cigarettes, been in trou- ble with the law). Responses were scored on a 5-point Likert-type scale from 1 (none) to 5 (all) with higher

scores indicating higher levels of deviance among peers (a D .89).

Personality (Fall) A modified version of the Big Five Inventory measured personality characteristics.28 The scale includes five 3- item sub-scales consisting of Extraversion (a D .80), Agreeableness (a D .60), Conscientiousness (a D .71), Neuroticism (a D .70) and Openness (a D .64). Prior research provides evidence for a relationship between neuroticism and PTE exposure; the other subscales were also analyzed to determine if additional relationships were present.

Social Support (Spring). Current social support was evaluated via three items from the modified version of the Medical Outcomes Study module.29 Responses were made on a Likert-type scale of 1 (none of the time) to 4 (all of the time) and summed (a D .84), with higher scores representing greater perceived social support.

Depressive and anxiety symptoms (fall and spring) The Symptom Checklist-90 Short Version30 is an instru- ment used to measure mental health status. An abbrevi- ated SCL was used in the present study to assess depression (four items; a D .80) and anxiety (four items; a D .82) over the past month. Responses were made on a Likert-type scale of 1 (not at all) to 5 (extremely). The same measure was used to assess depression (four items; a D .86) and anxiety (four items; a D .84) at follow up.

Alcohol use (fall and spring) At each assessment, participants responded to a question assessing if the participant had ever had at least one drink of alcohol in their lifetime. Additionally, two items measured current alcohol use: average alcohol use fre- quency and quantity during the past 30 days. Alcohol use frequency was assessed on a 5-point scale ranging from 1 (never) to 5 (four or more times a week). Alcohol use quantity was defined as the average number of stan- dard drinks consumed on a typical drinking day and was assessed on a 6-point scale, ranging from 1 (none) to 6 (10 or more drinks).

Analyses

All scale variables were examined for distribution prop- erties. Transformations were completed as needed. Descriptive statistics were conducted to determine the prevalence of each type of PTE and probable PTSD within the full sample and by sex (Aim 1). For Aim 1, determining factors associated with probable PTSD, pre- liminary regression models grouped by construct (ie demographics, personality, etc) were conducted to

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identify variables within each set that were associated with PTSD symptoms at baseline (Fall). All significant variables were then added to a comprehensive model to identify which factors were associated with PTSD symp- toms. To examine the prospective relations between PTSD symptoms at baseline on later psychosocial out- comes in Aim 2, correlation analyses were first con- ducted to screen variables for relation to PTSD symptoms to be included as dependent variables in the regression analyses. Separate regression analyses were then conducted to determine if PTSD symptoms at base- line (Fall) prospectively predicted the dependent varia- bles at follow-up (Spring), above and beyond the covariates (ie sex, baseline level the dependent variable).

Results

Descriptives

Seventy percent (n D 1,186) of individuals participating in the study reported experiencing at least one PTE event within their lifetime. After further examination, 66.2% of the full sample reported experiencing at least one acci- dental PTE, while 33.1% reported experiencing at least one interpersonal PTE. Men and women did not signifi- cantly differ on endorsement of accidental PTE (X2 D .15, p D .70) (see Table 1). However, men and women did significantly differ on endorsement of interpersonal PTE (X2 D 25.5, p < .001), with women being more likely to endorse interpersonal PTE than men (37.3% vs. 25.4%, respectively). Among those exposed to any form of PTE, 34.4% endorsed probable PTSD symptoms, as measured by endorsing three or more symptoms on the PC-PTSD screener. A significantly larger percentage of women (32.6%) than men (11.4%) met criteria for prob- able PTSD (X2 D 66.11, p < .001).

Aim 1: Factors associated with probable PTSD at baseline

As shown in Table 2, female sex was associated with higher PTSD symptoms. Among the personality variables only higher neuroticism was associated with greater PTSD symptoms. Higher peer deviance levels were associated with greater PTSD symptoms. Among the psychopathology

variables, both greater depressive and anxiety symptoms were associated with greater PTSD symptoms. Lastly, a higher number of stressful life events and interpersonal trauma PTE were associated with greater PTSD symptoms. Once all significant predictors from the individual regres- sions were added into the final model, only sex, depressive symptoms, anxiety symptoms, and interpersonal PTE count remained significantly associated with baseline PTSD symptoms (see Table 2).

Aim 2: Factors predicted by probable PTSD at baseline

Accidental PTE, social support, alcohol frequency, and alcohol use were not significantly correlated with PTSD symptoms at baseline and thus, were not entered into the regression model (see Table 3). Interpersonal PTE, depressive symptoms, and anxiety symptoms measured at follow up were all significantly correlated with PTSD symptoms at baseline. Thus, three regressions were con- ducted. As shown in Table 4, controlling for key covari- ates (ie sex, baseline levels of each construct respectively), PTSD symptoms at baseline were positively associated with higher anxiety symptoms and depressive symptoms levels at follow up. PTSD symptoms at base- line also significantly predicted interpersonal PTE at fol- low up, where higher PTSD symptoms predicted higher interpersonal PTE exposure (see Table 4).

Comments

The current study sought to broaden our understanding of PTEs and probable PTSD in young adults. In a sample of first-year college students, we examined the prevalence of PTE exposure and probable PTSD, corre- lates of probable PTSD, and the prospective relations between probable PTSD at college entry and mental health outcomes in the spring term (approximately 6 months later). In line with previous epidemiological studies,3,4,31 prevalence of lifetime PTEs was high (more than half the sample), and around a third of the sample endorsed PTSD symptoms on the screener at a level indicative of probable PTSD. However, women reported exposure to more types of interpersonal PTEs and PTSD symptoms as compared to men, consistent with findings

Table 1. Prevalence of interpersonal trauma exposure and accidental trauma exposure by sex.

Men Women Full Sample

n % n % X2 n %

Interpersonal trauma exposure 160 26.1 410 37.3 25.5��� 570 33.0 Accidental trauma exposure 445 66.5 775 65.7 .15 1220 66.0 Probable PTSD 48 11.4 262 32.6 66.1��� 310 25.3

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from existing literature.14,32,33 At the start of freshman year of college (ie Fall baseline), the correlates of proba- ble PTSD were female sex, endorsing depressive sympto- mology, interpersonal trauma exposure, and total number of SLEs. After controlling for baseline levels of relevant correlates, baseline PTSD symptoms predicted higher depression and anxiety symptoms as well as addi- tional interpersonal PTEs experienced during the fresh- man year. Taken together, such results highlight the importance of examining PTSD across development due to its cyclical and complex relationship with common mental health symptomatology34 and continued trauma exposure.35 Specifically, programming and support for college students with previous PTE risk and subsequent PTSD development should be of the utmost priority.

The present findings align with the extant literature on PTSD in college age individuals1 and samples of

college students.3,4 Current prevalence rates of PTE exposure and PTSD align with past studies of college stu- dents.3,4,31,36 The findings also align with trends previ- ously noted for PTE exposure and PTSD among women,32 where the prevalence of PTSD in women is greater than that of men.8,12,15,37 However, a recent study found that the effect of sex diminishes when other risk factors (eg pre-existing disorders, family history, person- ality features, coping strategies) are taken into consider- ation.12 The current finding that being female is a significant correlate of probable PTSD after controlling for several other risk factors in young adults adds to our understanding of sex differences in risk and the growing literature on risk of PTSD in this age group.36

Findings that depressive symptoms, interpersonal trauma, and total SLEs were associated with probable PTSD at the start of college align with previous reports from both adolescent and adult samples. Specifically, research on disorders comorbid with PTSD has shown that among youth with major depression, rates of comorbid PTSD range from 24–32%.8 In adults, major depression is also predictive of PTSD even after con- trolling for multiple other risk factors.12 The findings of the current study align with the findings from extant research,36 albeit using a new cohort of students and a stronger PTSD measure, showing that interper- sonal PTEs are associated with increased risk of trauma-related distress in college students compared to accidental trauma. Not only does the current study show the increased risk that comes with interpersonal PTE, but also shows that in this age group, interper- sonal trauma and total SLEs predict probable PTSD. This indicates a particularly vulnerable group in regard to risk for PTSD development and possibly more severe symptom presentation. Increasing outreach and treatment efforts for those endorsing interpersonal PTE (eg educating on how to cope with SLEs) is important.

Table 2. Potential predictors (Demographic, Personality, Environ- mental, Psychopathology, Trauma History) of PTSD symptoms.

Individual Regression Models

Combined Regression Models

Mean (SD) Std. b Mean (SD) St. b

Demographics Black (vs. White) .17(.37) ¡.05 — — Asian (vs. White) .16(.36) ¡.03 — — Other (vs. White) .14(.35) ¡.03 — — Sex .66(.47) .23*** .65(.48) .15***

Personality Neuroticism 8.68(2.90) .29*** 8.62(2.88) .01 Agreeableness 11.98(2.08) .01 — — Extraversion 10.49(2.93) ¡.02 — — Conscientiousness 13.25(1.75) .02 — — Openness 12.67(2.01) .05 — —

Early Environment Peer Deviance 9.39(5.08) .12*** 9.41(5.01) ¡.01

Psychopathology Lifetime Alcohol Use .77(.42) .08** .77(.42) 1.59 Depression Symptoms 9.30(3.93) .20*** 9.25(3.91) .17***

Anxiety Symptoms 7.11(3.34) .15*** 7.04(3.34) .13***

Trauma History Accidental Trauma 1.28(.62) ¡.004 1.28(.62) .48 Interpersonal trauma .67(.89) .42*** .67(.89) .43***

Total stressful life events 2.12(1.58) .13*** 2.11(1.57) 2.21*

Note. �p < .05, ��p < .01, ���p < .001. Analyses were run among those enter- ing the study during the fall semester of their first year.

Table 3. Pearson Correlation Matrix among PTSD symptoms at baseline and potential correlates (Demographic, Psychopathol- ogy, Trauma History) at follow up.

1 2 3 4 5 6 7 8

1. PTSD symptoms at baseline

—

2. Depressive symptoms .28** — 3. Anxiety symptoms .35** .69** — 4. Interpersonal TE .28** .15** .18** — 5. Accidental TE .03 .03 .01 .31** — 6. Alcohol use frequency .05 .02 .03 .09** .02 — 7. Alcohol use quantity .02 .01 .01 .03 .01 .37** — 8. Social support ¡.02 ¡.24** ¡.17** ¡.08** .01 ¡.07* .05 —

Note. �p < 0.05. ��p < 0.01.

Table 4. Comprehensive model including all significant predic- tors of PTSD symptoms.

Mean (SD) Std. b R2 Change R2

Model 1: Depressive symptoms Sex — ¡.003 — — Baseline depressive symptoms 9.15(3.77) .57*** — — Baseline PTSD symptoms 1.28(1.51) .10** .37 .008**

Model 2: Anxiety symptoms Sex — .02 — — Baseline anxiety symptoms 7.16(3.37) .50*** - — Baseline PTSD symptoms 1.28(1.51) .17*** .34 .02***

Model 3: Interpersonal PTE Sex — ¡.001 — — Baseline Interpersonal PTE 0.64(.86) .28*** — — Baseline PTSD symptoms 1.25(1.49) .12** .13 .01**

Note. �p < .05, ��p < .01, ���p < .001. Analyses were run among those enter- ing the study.

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Furthermore, depressive symptoms are also predictive of PTSD, highlighting the vulnerability of students with this symptom presentation.

Unexpectedly, neuroticism only had a univariate relationship with probable PTSD and was not signifi- cant in the final model. Past literature has found that neuroticism is predictive of all PTEs (including inter- personal) in college-age young adults36 and PTSD in adults.12 The latter study also included multiple risk factors in the analysis12 similar to the current study design. Hence, examining personality constructs in college-age adults needs to be more thoroughly exam- ined in future studies.

The impact of probable PTSD at the spring semester follow-up adds to the growing literature of the course and consequences of PTSD.38,39,40 These findings point to notable clinical and programmatic implications. For example, intervention efforts may target PTSD sympto- mology in order to reduce or inhibit the later develop- ment of anxiety and depressive symptoms. While it has been demonstrated that PTSD is associated with a num- ber of long-term functional and mental health outcomes, the current study expands the literature given that it is longitudinal in nature. Previous longitudinal examina- tions of PTSD support the current findings, showing that PTSD predicted both depression and anxiety at a second time point.23 Although the longitudinal effects of PTSD on mental health outcomes have been examined,22 there is less research examining the impact of PTSD develop- ment on new-onset interpersonal PTE. The findings from the current study support PTSD as a risk factor for new-onset interpersonal PTE. Thus, intervention efforts focused on PTSD symptoms may help to reduce new onset interpersonal PTE in college-age adults.

Present study findings of PTSD in the beginning of freshman year predicting anxiety and depression at the end of the year could be due to phenotypic associations between PTSD symptoms and internalizing disorders or represent a progression of PTSD symptomatology if left untreated. For example, a student entering college with probable PTSD, which depression and related trauma contributed to initially, may become further isolated and withdrawn. This in turn escalates depressive symptoms over time above and beyond baseline severity. Other possi- ble mechanisms to explain this bi-directional relationship between PTSD and its correlates are the shared genetic link between PTSD and internalizing symptoms.41,42 Nev- ertheless, a major strength of the current study is its ability to detect novel trauma exposure and internalizing symp- toms related to PTSD above baseline levels.

Although the present findings are largely consistent with past literature, the study helps fill a gap in the litera- ture given its focus on first-year college students, a

particularly vulnerable population that has received lim- ited research focus. It is hoped that research efforts increase with regard to examining and better under- standing PTE, probable PTSD, and concurrent PTSD across development. Accordingly, implications for on- campus services are notable. Specifically, it is possible that if students are screened and seek treatment when they enter college for probable PTSD and/or related symptomologies, later depression and anxiety may be reduced, as well as the impact of new trauma on factors such as negative health outcomes, academic success, and other psychosocial outcomes.9,43,44 Outreach program- ming efforts for those with interpersonal trauma could provide additional contact for those with these additional risks. Given the high prevalence of traumatic events and symptoms reported associated with exposure in our study, it is imperative that the college and university sys- tems are aware of the extent to the problem in order to adequately prepare and allocate resources. Resources, including qualified staff and trauma-informed training, are needed, and university budgets may need to be adapted to allow for this. Additionally, future studies could examine the implementation of technological screening measures (eg web-based surveys that are auto- matically scored and associated with tailored feedback, including options that allow for the data to be sent to a qualified health professional at campus resource centers for follow-up) in comparison to in-person screening.

Stigma associated with mental health issues contin- ues to be a problem, and may impact student engage- ment in mental health services. Recent societal movements, such as the #MeToo movement may be changing the sociopolitical landscape with important implications for students feeling more empowered to come forward with their trauma histories, however, this is an empirical question that present cohort- based data will be able to test. University wide pro- gramming efforts, such as information provided dur- ing Welcome Week activities for incoming Freshman, can help address stigma issues and make students aware of resources that are available to them. Tech- nology may be another possible way to address issues with stigma, as unanimous screening could be used via an online platform with tailored recommenda- tions. Increasing student awareness of risks and symptom presentation, strengthening of on-campus services, and tailoring programs to suit their needs is critical.

Limitations

Despite noted strengths, this study is not without limita- tions. First, causation cannot be inferred from analyses

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addressing the first aim, given its cross-sectional nature. It is possible that an individual with PTSD symptoms has experienced higher levels of SLEs, which is impacting that relationship. Second, although probable PTSD sig- nificantly predicted later correlates above and beyond baseline levels, the amount of variance explained in the current study is minimal. Second, there are limitations with regard to the phenotypes examined. The measures used to assess for PTSD symptomology, depressive symptoms, and anxiety symptoms are not diagnostic measured used to verify a clinical diagnosis and thus, we do not know rates of diagnosed PTSD, depression or other anxiety disorders. Third, the trauma assessment questions do not provide detail into the nature of the endorsed trauma (eg the frequency of each type of endorsed interpersonal or accidental PTE). A more nuanced assessment of trauma frequency is recom- mended for future research. Lastly, while the longitudinal nature of the S4S data is a strength, the current study uses a second time point that is relatively close tempo- rally to the first. As such, there is not a lot of time for new PTEs, SLES, or development of psychopathology symptoms. Further, only using two time points limits the ability to examine trajectories. Future research should utilize more than two time points to expand these findings.

Conclusions

Despite these limitations, the current study has identified both risk factors and consequences of probable PTSD in college freshman. The current results can serve as a base- line for future, longitudinal studies examining relevant factors that predict PTSD development, as well as out- comes that PTSD development may influence. The find- ings have clinical implications, as well. For example, for professionals creating programs aimed at identifying those students who are at the highest risk for develop- ment of PTSD, the results provide insight into which psychosocial variables may be important to target in pre- vention efforts. The findings also provide evidence for additional outcomes that may be prevented if PTSD interventions are delivered as early as possible. Ongoing investigation into predictors of PTSD and negative out- comes after PTSD development will aid in refining effort to identify and treat students at a greater risk for PTSD development and ensuing psychopathology.

Funding

This work was supported by the National Institute on Alcohol

Abuse and Alcoholism (K02AA018755,P20 AA107828,P50 AA022537,R37AA011408).

ORCID

Shannon E. Cusack http://orcid.org/0000-0001-8103-0575

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Conflict of interest disclosure The authors have no conflicts of interest to report. The authors confirm that the research presented in this article met the ethical guidelines, including adherence to the legal requirements, of the United States and received approval from the Institutional Review Board of Virginia Commonwealth University.

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