Traumatic Brain Injury and Suicidal Ideation Among U.S. Operation Enduring Freedom and Operation Iraqi Freedom Veterans

Traumatic brain injury (TBI) is associated with suicidal behavior among veterans, and gender differences in the strength of associations may exist. Almost all research has been limited to Veterans Health Administration (VHA) patients, and it is unclear if findings generalize to veterans who do not use VHA services. We examined gender‐ and VHA‐user‐specific associations between TBI related to deployment and postdeployment suicidal ideation in a U.S. national sample of 1,041 female and 880 male Operation Enduring Freedom (OEF) and Operation Iraqi Freedom (OIF) veterans. Path analysis was used to estimate TBI and suicidal ideation association, and examine PTSD and depression symptomatology in these associations. TBI was associated with suicidal ideation among male VHA users, OR = 3.64, 95% CI [2.21, 6.01]; and male and female nonusers, OR = 2.24, 95% CI [1.14, 4.44] and OR = 2.65, 95% CI [1.26, 5.58], respectively, in unadjusted analyses. This association was explained by depression symptoms among male and female nonusers. Among male VHA users an association between TBI and suicidal ideation remained when accounting for depression symptoms, OR = 2.50, 95% CI [1.33, 4.71]. Our findings offered evidence of an association between TBI and suicidal ideation among male OEF/OIF VHA users.     

Prevalence of a Positive Screen for PTSD Among OEF/OIF and OEF/OIF‐Era Veterans in a Large Population‐Based Cohort

Multiple studies have reported the prevalence of posttraumatic stress disorder (PTSD) in Operation Enduring Freedom and Operation Iraqi Freedom (OEF/OIF) veterans; however, these studies have been limited to populations who use the Department of Veterans Affairs (VA) for health care, specialty clinic populations, or veterans who deployed. The 3 aims of this study were to report weighted prevalence estimates of a positive screen for PTSD among OEF/OIF and nondeployed veterans, demographic subgroups, and VA health care system users and nonusers. The study analyzed data from the National Health Study for a New Generation of U.S. Veterans, a large population‐based cohort of OEF/OIF and OEF/OIF‐era veterans. The overall weighted prevalence of a positive screen for PTSD in the study population was 13.5%: 15.8% among OEF/OIF veterans and 10.9% in nondeployed veterans. Among OEF/OIF veterans, there was increased risk of a positive screen for PTSD among VA health care users (OR = 2.71), African Americans (OR = 1.61), those who served in the Army (OR = 2.67), and those on active duty (OR = 1.69). The same trend with decreased magnitude was observed in nondeployed veterans. PTSD is a significant public health problem in OEF/OIF‐era veterans, and should not be considered an outcome solely related to deployment.     

Deployment Risk and Resilience Inventory‐2 (DRRI‐2): An Updated Tool for Assessing Psychosocial Risk and Resilience Factors Among Service Members and Veterans

The Deployment Risk and Resilience Inventory (DRRI) is a widely used instrument for assessing deployment‐related risk and resilience factors among war veterans. A revision of this instrument was recently undertaken to enhance the DRRI's applicability across a variety of deployment‐related circumstances and military subgroups. The resulting suite of 17 distinct DRRI‐2 scales is the product of a multiyear psychometric endeavor that involved (a) focus groups with Operation Enduring Freedom/Operation Iraqi Freedom (OEF/OIF) veterans to inform an assessment of the content validity of original DRRI measures, (b) examination of item and scale characteristics of revised scales in a national sample of 469 OEF/OIF veterans, and (c) administration of refined scales to a second national sample of 1,046 OEF/OIF veterans to confirm their psychometric quality. Both classical test theory and item response theory analytical strategies were applied to inform major revisions, which included updating the coverage of warfare‐related stressors, expanding the assessment of family factors throughout the deployment cycle, and shortening scales. Finalized DRRI‐2 scales demonstrated strong internal consistency reliability and criterion‐related validity. The DRRI‐2 can be applied to examine the role that psychosocial factors play in postdeployment health and inform interventions aimed at reducing risk and enhancing resilience among war veterans.     

Mild Traumatic Brain Injury,PTSD, and Psychosocial Functioning Among Male and Female U.S. OEF/OIF Veterans

This study examined the unique and combined relationship between mild traumatic brain injury (mTBI) and posttraumatic stress disorder (PTSD) with psychosocial functioning in a cohort of 1,312 U.S. male and female veterans of Operations Enduring Freedom (OEF) and Iraqi Freedom (OIF) enrolled in the Veterans After‐Discharge Longitudinal Registry (Project VALOR). We assessed mTBI with structured screening questions reflective of current TBI classification standards and PTSD via the SCID‐IV PTSD module; all other variables were assessed by self‐report questionnaires. We identified significant diagnostic group differences in psychosocial functioning for both sexes. Individuals with PTSD, with or without a history of mTBI, reported significantly worse psychosocial functioning than individuals with mTBI alone or neither mTBI nor PTSD (males, η²_p = .11, p < .001; females, η²_p = .14, p < .001), even after adjusting for demographics and severity of chronic pain. The results suggested that veterans experiencing PTSD, regardless of whether they had a history of mTBI, were at increased risk for long‐term psychosocial impairment. Further research examining possible benefits from improved access to resources and treatment to address these needs would be valuable.     

Structured Approach Therapy for Combat‐Related PTSD in Returning U.S. Veterans: Complementary Mediation by Changes in Emotion Functioning

To address the impact of combat‐related posttraumatic stress disorder (PTSD) on U.S. Operation Enduring Freedom (OEF) and Operation Iraqi Freedom (OIF) veterans, the investigators developed a 12‐session manualized PTSD treatment for couples called structured approach therapy (SAT). A randomized controlled trial had shown that 29 OEF/OIF veterans with combat‐related PTSD who had participated in SAT showed significantly greater reductions in PTSD compared to 28 veterans receiving a 12‐session PTSD family education intervention (Sautter, Glynn, Cretu, Senturk, & Vaught, 2015). We conducted supplemental follow‐up and mediation analyses, which tested the hypothesis that changes in emotion functioning play a significant role in the decreases in PTSD symptoms primarily observed in veterans who had received SAT. Veterans assigned to the SAT condition showed significantly greater decreases than those assigned to PTSD family education in emotion regulation problems (p < .001, Cohen's f² = .18) and fear of intense emotions (p < .001, Cohen's f² = .152). Decreases in both emotion regulation problems (mediated effect:= .36), and fear of intense emotions (mediated effect: = .24) were found to be complementary mediators of reductions in PTSD symptoms greater with SAT. These findings suggest that SAT may aid veterans in improving their ability to regulate trauma‐related emotions.     

The Influence of Depressive Symptoms on Suicidal Ideation Among U.S. Vietnam‐Era and Afghanistan/Iraq‐Era Veterans With Posttraumatic Stress Disorder

Major depressive disorder (MDD) co‐occurs frequently with posttraumatic stress disorder (PTSD), and both disorders are linked to suicidal ideation. An emergent literature examines suicidal ideation in U.S. Afghanistan/Iraq‐era veterans. Little research, however, has studied the role of PTSD and comorbid MDD on suicidal ideation across service eras. Therefore, this study aimed to examine the impact of depression on suicidal ideation in Afghanistan/Iraq‐era and Vietnam‐era veterans with PTSD. The sample included 164 Vietnam and 98 Afghanistan/Iraq veterans diagnosed with PTSD at a VA outpatient PTSD Clinic. Using structured interviews, 63% of the Vietnam sample and 45% of the Afghanistan/Iraq sample were diagnosed with comorbid current MDD. Measures included self‐report assessments of PTSD and depressive symptoms and the Personality Assessment Inventory. Results of analyses suggested that in veterans of both eras, PTSD, MDD, and their interaction were significantly related to suicidal ideation (PTSD: η² = .01; MDD: η² = .10; PTSD × MDD: η² = .02). For veterans reporting greater depressive symptoms, there was a stronger relationship between PTSD symptoms and suicidal ideation. These results suggest that veterans from both eras display a similar clinical presentation and highlight the need to consider depressive symptoms when assessing veterans with PTSD. Future research should examine suicidal ideation and behaviors as they change over time in these two cohorts.     

A Preliminary Study of an Internet‐Based Intervention for OEF/OIF Veterans Presenting for VA Specialty PTSD Care

This preliminary study sought to evaluate the feasibility and potential effectiveness of a cognitive–behavioral, web‐based intervention for posttraumatic stress in Operation Enduring Freedom/Operation Iraqi Freedom (OEF/OIF) veterans who are not able to participate, or not eligible to participate, in evidence‐based posttraumatic stress disorder (PTSD) treatments. The study used an uncontrolled pre‐posttest design with a sample of 24 OEF/OIF veterans presenting to a VA PTSD specialty clinic. Participants used the afterdeployment.org, Post‐Traumatic Stress (PTS) Workshop, which was supplemented with brief weekly telephone calls. Half of the participants (n = 12) completed at least 5 of the 8 workshop sessions. At posttreatment, 40.0% of completers demonstrated reliable reductions on PTSD symptoms and overall d = 1.04. Treatment satisfaction and acceptability was generally positive based on Likert ratings. This web‐based intervention for PTS appears to be a feasible and potentially helpful intervention for veterans who may not otherwise receive psychosocial interventions. Given the minimal resources required and the potential reach, this web‐based intervention could be a viable addition to services provided to OEF/OIF veterans seeking PTSD specialty care. Efforts to further develop and more rigorously evaluate this approach are warranted.     

Deployment Experiences,Social Support,and Mental Health: Comparison of Black,White, and Hispanic U.S. Veterans Deployed to Afghanistan and Iraq

Compared to their White counterparts, Black and Hispanic Vietnam‐era, male, combat veterans in the United States have experienced discrimination and increased trauma exposure during deployment and exhibited higher rates of postdeployment mental health disorders. The present study examined differences in deployment experiences and postdeployment mental health among male and female Black, Hispanic, and White veterans deployed in support of Operation Enduring Freedom in Afghanistan and Operation Iraqi Freedom in Iraq. Data were drawn from a national survey of veterans (N = 924) who had returned from deployment within the last 2 years. Ethnoracial minority veterans were compared to White veterans of the same gender on deployment experiences and postdeployment mental health. The majority of comparisons did not show significant differences; however, several small group differences did emerge (.02 < η² < .04). Ethnoracial minority veterans reported greater perceived threat in the warzone and more family‐related concerns and stressors during deployment than White veterans of the same gender. Minority female veterans reported higher levels of postdeployment symptoms of anxiety than their White counterparts, which were accounted for by differences in deployment experience. These differences call for ongoing monitoring.     

Sleep Variability in Military‐Related PTSD: A Comparison to Primary Insomnia and Healthy Controls

Sleep disturbances are prevalent in posttraumatic stress disorder (PTSD) and are associated with a number of adverse health consequences. Few studies have used comprehensive assessment methods to characterize sleep in Operation Iraqi Freedom/Operation Enduring Freedom/Operation New Dawn (OEF/OIF/OND) veterans with PTSD. OEF/OIF/OND veterans with PTSD and sleep disturbance (n = 45) were compared to patients with primary insomnia (n = 25) and healthy control subjects (n = 27). Participants were assessed using questionnaire‐based measures as well as daily subjective and objective measures of sleep. The 3 groups were compared with regard to (a) group means, (b) intraindividual (i.e., night‐to‐night) variability of sleep, and (c) interindividual (i.e., within‐group) variability of sleep. In terms of group means, only objective sleep efficiency was significantly worse with PTSD than with primary insomnia (d = 0.54). Those with PTSD differed from those with primary insomnia on measures of intraindividual as well as interindividual variability (d = 0.48–0.73). These results suggested sleep symptoms in OEF/OIF/OND veterans with PTSD are more variable across nights and less consistent across patients relative to sleep symptoms in insomnia patients without PTSD. These findings have implications for research, as well as for personalizing treatment for individuals with PTSD.     

Mental Health Beliefs and Their Relationship With Treatment Seeking Among U.S. OEF/OIF Veterans

Many veterans who would benefit from mental health care do not seek treatment. The current study provided an in‐depth examination of mental health‐related beliefs and their relationship with mental health and substance abuse service use in a national sample of 640 U.S. Operation Enduring Freedom and Operation Iraqi Freedom (OEF/OIF) veterans. Both concerns about mental health stigma from others and personal beliefs about mental illness and mental health treatment were examined. Data were weighted to adjust for oversampling of women and nonresponse bias. Results revealed substantial variation in the nature of OEF/OIF veterans’ mental health beliefs, with greater anticipated stigma in the workplace (M = 23.74) than from loved ones (M = 19.30), and stronger endorsement of negative beliefs related to mental health treatment‐seeking (M = 21.78) than either mental illness (M = 18.56) or mental health treatment (M = 20.34). As expected, individuals with probable mental health problems reported more negative mental health‐related beliefs than those without these conditions. Scales addressing negative personal beliefs were related to lower likelihood of seeking care (ORs = 0.80–0.93), whereas scales addressing anticipated stigma were not associated with service use. Findings can be applied to address factors that impede treatment seeking.     

Feasibility and Desirability of Web‐Based Mental Health Screening and Individualized Education for Female OEF/OIF Reserve and National Guard War Veterans

Operation Enduring Freedom/Operation Iraqi Freedom (OEF/OIF) Reserve and National Guard (RNG) service members have an increased risk for postdeployment mental health (MH) and readjustment problems, yet most do not access needed care. It is unknown if RNG servicewomen experiencing postdeployment readjustment symptoms are aware these may signify treatable MH concerns or if this knowledge activates care‐seeking. The aims of this proof‐of‐concept study were to determine the feasibility of web‐based MH screening for postdeployment MH symptoms to inform individualized psychoeducation, and to assess user perceptions about the online instrument and process, MH care access, and VA and other MH care. A midwestern sample (N = 131) of recently deployed (past 24 months) OEF/OIF RNG Army and Air Force servicewomen participated. High rates of combat experiences (95%) and military sexual trauma (50%) were reported. Positive screens for key symptoms of MH problems were prevalent. One third (31%) of satisfaction survey completers indicated online information reduced discomfort with seeking MH care; 42% reported they would subsequently seek MH assessment. Participants interviewed by telephone indicated that stigma and limited knowledge about women‐specific services were key reasons servicewomen do not use MH care. This study demonstrated web‐based screenings with individualized psychoeducation are implementable and favorable to RNG servicewomen.     

Posttraumatic stress disorder as a risk factor for suicidal ideation in Iraq and Afghanistan War veterans

Posttraumatic stress disorder (PTSD) was examined as a risk factor for suicidal ideation in Iraq and Afghanistan War veterans (N = 407) referred to Veterans Affairs mental health care. The authors also examined if risk for suicidal ideation was increased by the presence of comorbid mental disorders in veterans with PTSD. Veterans who screened positive for PTSD were more than 4 times as likely to endorse suicidal ideation relative to non‐PTSD veterans. Among veterans who screened positive for PTSD (n = 202), the risk for suicidal ideation was 5.7 times greater in veterans who screened positive for two or more comorbid disorders relative to veterans with PTSD only. Findings are relevant to identifying risk for suicide behaviors in Iraq and Afghanistan War veterans.     

Posttraumatic stress disorder, substance use disorders, and medical comorbidity among returning U.S. veterans

Evidence suggests that posttraumatic stress disorder (PTSD) and substance use disorders (SUD) are associated with poorer physical health among U.S. veterans who served in Operation Enduring Freedom and Operation Iraqi Freedom (OEF/OIF). No research of which we are aware has examined the independent and interactive effects of PTSD and SUD on medical comorbidity among OEF/OIF veterans. This cross-sectional study examined medical record data of female and male OEF/OIF veterans with ≥ 2 Veterans Affairs primary care visits (N = 73,720). Gender-stratified logistic regression analyses, adjusted for sociodemographic factors, were used to examine the association of PTSD, SUD, and their interaction on the odds of medical diagnoses. PTSD was associated with increased odds of medical diagnoses in 9 of the 11 medical categories among both women and men, range of odds ratios (ORs) ranged from 1.07 to 2.29. Substance use disorders were associated with increased odds of 2 of the 11 medical categories among women and 3 of the 11 medical categories among men; ORs ranged from 1.20 to 1.74. No significant interactions between PTSD and SUD were detected for women or men. Overall, findings suggest that PTSD had a stronger association with medical comorbidity (in total and across various medical condition categories) than SUD among female and male OEF/OIF veterans.     

Deliberate Self‐Harm and Suicidal Ideation Among Male Iraq/Afghanistan‐Era Veterans Seeking Treatment for PTSD

The objectives of the present research were to examine the prevalence of deliberate self‐harm (DSH) among 214 U.S. male Iraq/Afghanistan‐era veterans seeking treatment for posttraumatic stress disorder (PTSD) and to evaluate the relationship between DSH and suicidal ideation within this population. Approximately 56.5% (n = 121) reported engaging in DSH during their lifetime; 45.3% (n = 97) reported engaging in DSH during the previous 2 weeks. As hypothesized, DSH was a significant correlate of suicidal ideation among male Iraq/Afghanistan‐era veterans, OR = 3.88, p < .001, along with PTSD symptom severity, OR = 1.03, p < .001, and combat exposure, OR = 0.96, p = .040. A follow‐up analysis identified burning oneself, OR = 17.14, p = .017, and hitting oneself, OR = 7.93, p < .001, as the specific DSH behaviors most strongly associated with suicidal ideation. Taken together, these findings suggest that DSH is quite prevalent among male Iraq/Afghanistan‐era veterans seeking treatment for PTSD and is associated with increased risk for suicidal ideation within this population. Routine assessment of DSH is recommended when working with male Iraq/Afghanistan veterans seeking treatment for PTSD.     

Combat-Related Posttraumatic Stress Disorder and Comorbid Major Depression in U.S. Veterans: The Role of Deployment Cycle Adversity and Social Support

Posttraumatic stress disorder (PTSD) and major depressive disorder (MDD) commonly co-occur in combat veterans, and this comorbidity has been associated with higher levels of distress and more social and economic costs compared to one disorder alone. In a secondary analysis of a multisite randomized controlled trial of a sample of veterans with combat-related PTSD, we examined the associations among pre-, peri-, and postdeployment adversity, social support, and clinician-diagnosed comorbid MDD. Participants completed the Deployment Risk and Resilience Inventory and the Beck Depression Inventory–II as well as structured clinical interviews for diagnostic status. Among 223 U.S. veterans of the military operations in Iraq and Afghanistan (86.9% male) with primary combat-related PTSD, 69.5% had current comorbid MDD. After adjustment for sex, a linear regression model indicated that more concerns about family disruptions during deployment, f² = 0.065; more harassment during deployment, f² = 0.020; and lower ratings of postdeployment social support, f² = 0.154, were associated with more severe self-reported depression symptoms. Interventions that enhance social support as well as societal efforts to foster successful postdeployment reintegration are critical for reducing the mental health burden associated with this highly prevalent comorbidity in veterans with combat-related PTSD.     

Internalizing and externalizing personality styles and psychopathology in OEF–OIF veterans

Previous research with other trauma populations demonstrated that internalizing and externalizing personality styles are associated with different PTSD comorbidities. The present study tested this association in two distinct Operation Enduring Freedom–Operation Iraqi Freedom (OEF/OIF) combat samples. Cluster analysis was used to categorize subtypes, which were compared on measures of PTSD, depression, anxiety, and substance use. Internalizers showed the highest rates of PTSD and depression. Externalizers had higher rates of alcohol problems in one sample only, whereas the other sample showed more substance misuse. In general, these findings suggest that this method of classifying trauma survivors is useful in OEF/OIF populations. Results suggest some differences across this population in terms of how substance use issues are expressed in externalizers.     

A Systematic Review of Dropout From Psychotherapy for Posttraumatic Stress Disorder Among Iraq and Afghanistan Combat Veterans

A significant number of veterans of the conflicts in Iraq and Afghanistan have posttraumatic stress disorder (PTSD), yet underutilization of mental health treatment remains a significant problem. The purpose of this review was to summarize rates of dropout from outpatient, psychosocial PTSD interventions provided to U.S. Operation Iraqi Freedom (OIF), Operation Enduring Freedom (OEF), and Operation New Dawn (OND) veterans with combat‐related PTSD. There were 788 articles that were identified which yielded 20 studies involving 1,191 individuals eligible for the review. The dropout rates in individual studies ranged from 5.0% to 78.2%, and the overall pooled dropout rate was 36%, 95% CI [26.20, 43.90]. The dropout rate differed marginally by study type (routine clinical care settings had higher dropout rates than clinical trials) and treatment format (group treatment had higher dropout rates than individual treatment), but not by whether comorbid substance dependence was excluded, by treatment modality (telemedicine vs. in‐person treatment), or treatment type (exposure therapy vs. nonexposure therapy). Dropout is a critical aspect of the problem of underutilization of care among OEF/OIF/OND veterans with combat‐related PTSD. Innovative strategies to enhance treatment retention are needed.     

Deployment‐Related Psychiatric and Behavioral Conditions and Their Association with Functional Disability in OEF/OIF/OND Veterans

Understanding the factors that influence veterans’ functional outcome after deployment is critical to provide appropriately targeted care. Mild traumatic brain injury (mTBI) and posttraumatic stress disorder (PTSD) have been related to disability, but other psychiatric and behavioral conditions are not as well examined. We investigated the impact of deployment‐related psychiatric and behavioral conditions on disability among 255 OEF/OIF/OND service members and veterans. Structured clinical interviews assessed TBI and the psychiatric conditions of depression, PTSD, anxiety, and substance use. Self‐report questionnaires assessed disability and the behavioral conditions of sleep disturbance and pain. Over 90% of participants had a psychiatric and/or behavioral condition, with approximately half presenting with ≥ 3 conditions. Exploratory factor analysis revealed 4 clinically relevant psychiatric and behavioral factors which accounted for 76.9% of the variance: (a) depression, PTSD, and military mTBI (deployment trauma factor); (b) pain and sleep (somatic factor); (c) anxiety disorders, other than PTSD (anxiety factor); and (d) substance abuse or dependence (substance use factor). Individuals with the conditions comprising the deployment trauma factor were more likely to be substantially disabled than individuals with depression and PTSD, but no military mTBI, OR = 3.52; 95% CI [1.09, 11.37]. Depression, PTSD, and a history of military mTBI may comprise an especially harmful combination associated with high risk for substantial disability.     

Types and Number of Traumas Associated With Suicidal Ideation and Suicide Attempts in PTSD: Findings From a U.S. Nationally Representative Sample

Posttraumatic stress disorder (PTSD) is associated with suicidal ideation and suicide attempt; however, research has largely focused on specific samples and a limited range of traumas. We examined suicidal ideation and suicide attempt relating to 27 traumas within a nationally representative U.S. sample of individuals with PTSD. Data were from the National Epidemiologic Survey of Alcohol and Related Conditions (N = 34,653). Participants were assessed for lifetime PTSD and trauma history, suicidal ideation, and suicide attempt. We calculated the proportion of individuals reporting suicidal ideation or suicide attempt for each trauma and for the number of unique traumas experienced. Most traumas were associated with greater suicidal ideation and suicide attempt in individuals with PTSD compared to individuals with no lifetime trauma or with lifetime trauma but no PTSD. Childhood maltreatment, assaultive violence, and peacekeeping traumas had the highest rates of suicidal ideation (49.1% to 51.9%) and suicide attempt (22.8% to 36.9%). There was substantial variation in rates of suicidal ideation and suicide attempt for war and terrorism‐related traumas. Multiple traumas increased suicidality, such that each additional trauma was associated with an increase of 20.1% in rate of suicidal ideation and 38.9% in rate of suicide attempts. Rates of suicidal ideation and suicide attempts varied markedly by trauma type and number of traumas, and these factors may be important in assessing and managing suicidality in individuals with PTSD.     

Trauma‐Related Correlates of Alcohol Use in Recently Deployed OEF/OIF Veterans

The co‐occurrence of posttraumatic stress disorder (PTSD) and alcohol use disorders (AUDs) is well documented. Little is known about the factors that contribute to alcohol use and the development of AUDs among military personnel following deployment. The primary aim of this study was to examine trauma‐related correlates of alcohol use in recently deployed Operation Enduring Freedom/Operation Iraqi Freedom veterans. Members of the Rhode Island National Guard and Army Reserves (N = 238) completed an in‐person, initial assessment an average of 6 months postdeployment. Multiple regression analyses examined predictors of drinking outcomes (combat exposure, total PTSD symptoms, and PTSD symptom clusters) after accounting for gender, age, and history of AUD. Results indicated that total PTSD symptoms, but not combat exposure, significantly predicted alcohol use at the initial assessment. When PTSD symptom clusters were considered separately, reexperiencing symptoms (Cluster B) were the strongest predictor of total alcohol use (B = 3.58, p = .002) and heavy drinking episodes (B = 0.31, p = .005). Implications for these findings include early identification of risk factors that could lead to the development of AUDs, and the importance of integrated treatment approaches for co‐occurring PTSD and AUD among veterans postdeployment.