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Figure 1. Proportion of veterans using substances at baseline compared to 4months after discharge, grouped by the number of substances used.

Table 4. Least squares means 4 months after program discharge by substance use group adjusted for potentially confounding factors. Group 0 Group 1 Group 2 Group 3

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0 substances 1 substance 2 or 3 substances 4 or 5 substances

n¼ 2,745 n¼ 1,257 n¼ 684 n¼ 72

LS Mean SE LS Mean SE LS Mean SD LS Mean SD p value Comparisons� Employment 0.487 0.004 0.487 0.006 0.454 0.009 0.440 0.027 .0019 ns Medical problems 0.469 0.007 0.538 0.010 0.547 0.013 0.658 0.041 <.0001 3,2> 0; 3> 2,1 Violence after discharge 0.774 0.022 1.269 0.032 1.613 0.044 2.007 0.133 <.0001 3> 2 > 1> 0 PTSD total 3.207 0.009 3.457 0.014 3.561 0.018 3.687 0.056 <.0001 3> 2 > 1> 0 PTSD subscales Numbness 3.410 0.010 3.580 0.014 3.664 0.019 3.744 0.059 <.0001 3,2,1> 0; 3> 1 Hyperarousal 3.177 0.011 3.478 0.016 3.580 0.021 3.739 0.065 <.0001 3,2,1> 0; 3> 2,1 Reexperiencing 3.463 0.013 3.670 0.020 3.765 0.027 3.824 0.081 <.0001 3,2,1> 0 Avoidance 3.718 0.018 3.978 0.027 4.055 0.037 4.150 0.114 <.0001 3,2,1> 0 Suicidality 2.199 0.016 2.578 0.024 2.738 0.033 2.999 0.100 <.0001 3,2,1> 0; 3> 2,1 Agitation 3.224 0.017 3.518 0.026 3.645 0.035 3.867 0.107 <.0001 3,2,1> 0; 3> 2,1

Note. Adjusted for age, year of program entry, White race, married, diagnosis of drug abuse/dependence or personality disorder, hospitalization for suicide attempt, possession of a valid driver’s license, and participation in war atrocities.

PTSD¼ posttraumatic stress disorder; ns¼ not significant; LS ¼ least squares; SD ¼ standard deviation.�Significance threshold of p< .005 and effect size of Cohen’s d> 0.20 or < �0.20.

JOURNAL OF DUAL DIAGNOSIS 41

The association of polysubstance use disorder with more severe clinical and functional problems has been described previously. A study based on national VHA administrative data found that veterans with more numerous substance use disorders were more likely to have more numerous psychiatric and medical comor- bidities in addition to homelessness, greater use of inpatient psychiatric and residential treatment, and more numerous psychotropic prescription drug fills (Bhalla et al., 2017). The data presented here, while focused on the comorbidity of PTSD and polysub- stance use, are consistent with several studies showing that polysubstance use is associated with sociodemo- graphic characteristics, including younger age (Hedden et al., 2010; Midanik, Tam, & Weisner, 2007; Quek et al., 2013), greater medical (De Alba, Samet, & Saitz, 2004) and psychiatric disease burden (e.g., depressive disorders; Midanik et al., 2007) and a greater likelihood of lifetime suicide attempts (Smith, Farrell, Bunting, Houston, & Shevlin, 2011), more numerous legal problems including incarceration (Hedden et al., 2010) and arrests (Herbeck et al., 2013), and other indicators of psychosocial dysfunc- tion such as homelessness (Greenberg & Rosenheck, 2010; Tsai, Kasprow, & Rosenheck, 2014) and finan- cial problems (Herbeck et al., 2013).

In addition, a study of participants in the National Institute of Mental Health–funded Clinical Antipsychotic Trials of Intervention Effectiveness (CATIE) schizophrenia trial found a significant associ- ation of severe symptoms and poorer quality of life with either a comorbid substance use disorder or an additional psychiatric disorder. Thus, the adverse effect of multimorbidity seems to emerge regardless of whether the additional comorbidity is a psychiatric

disorder or one, or even more than one, substance use disorder (Bhalla, Stefanovics, & Rosenheck, 2018).

This study adds to this developing literature on multimorbidity in psychiatry by examining whether the number of discrete substances used by patients with dual diagnoses has adverse clinical effects even after accounting for an index of the number of days of any substance use. In addition, it is the first to our knowledge that investigated the effect of the use of multiple substances in a “dual diagnosis” sample, as all participants in this study had diagnoses of either PTSD or subsyndromal PTSD. Finally, the current study demonstrated the adverse effects of polysub- stance use on PTSD symptom severity both at baseline and longitudinally, finding attenuation of polysub- stance use following intensive treatment but also per- sistently increased symptoms with increased numbers of substances use following treatment.

The observed reduction in rates of polysubstance use after the intensive PTSD program could be explained in any of three ways. First, effective psy- chosocial and pharmacologic treatment targeted at PTSD symptoms may reduce the need for patients to self-medicate with addictive substances. Second, substance use may have declined either from specific treatments or from the restricted access to alcohol and drugs in supervised residential programs, thereby minimizing their exacerbating effect on PTSD symp- toms. Alternatively, patients may have entered resi- dential treatment at a time of extreme exacerbation of both substance use and PTSD symptoms, which may have abated as a result of regression to the mean. Most likely all three processes are at work, although their effects cannot be differentiated in this study.

Table 5. Least squares means 4 months after program discharge by substance use groups adjusted for the index of total days of substance use in the past 30 days.

Group 0 Group 1 Group2 Group 3

0 substances 1 substance 2 or 3 substances 4 or 5 substances

LS Mean SE LS Mean SE LS Mean SD LS Mean SD p value Comparisons� Employment 0.487 0.005 0.487 0.007 0.453 0.011 0.439 0.031 .035 ns Medical problems 0.482 0.008 0.532 0.010 0.516 0.017 0.579 0.048 .002 ns Violence after discharge 0.846 0.025 1.236 0.033 1.432 0.054 1.537 0.157 <.0001 3,2,1> 0; 3,2> 1 PTSD total 3.235 0.010 3.445 0.014 3.491 0.022 3.504 0.065 <.0001 3,2,1> 0 PTSD subscales Numbness 3.422 0.011 3.575 0.015 3.636 0.024 3.672 0.070 <.0001 3,2,1> 0 Hyperarousal 3.217 0.012 3.459 0.016 3.482 0.026 3.482 0.077 <.0001 3,2,1> 0 Reexperiencing 3.486 0.015 3.659 0.020 3.709 0.033 3.678 0.096 <.0001 3,2,1> 0 Avoidance 3.731 0.021 3.972 0.028 4.023 0.046 4.068 0.134 <.0001 3,2,1> 0 Suicidality 2.244 0.019 2.558 0.025 2.627 0.040 2.710 0.117 <.0001 3,2,1> 0 Agitation 3.279 0.020 3.493 0.026 3.509 0.043 3.513 0.125 <.0001 3,2,1> 0

Note. Adjusted for age, year of program entry, White race, married, diagnosis of drug abuse/dependence or personality disorder, hospitalization for suicide attempt, possession of a valid driver’s license, and participation in war atrocities.

PTSD¼ posttraumatic stress disorder; ns¼ not significant; LS ¼ least squares; SD ¼ standard deviation.�Significance threshold of p< .005 and effect size of Co

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