Depressive symptomatology and alcohol misuse among treatment-seeking military veterans: Indirect associations via ruminative thinking

Highlights

• Sample included 230 military veterans presenting to VHA for mental health services.

• Indirect effect between depression and alcohol misuse via rumination was found.

• Reflection but not brooding accounted for findings when testing rumination subtypes.

• Study offers novel insight as to when reflection may serve as a maladaptive process.

Abstract

Background

Veterans are particularly vulnerable to experiencing concurrent issues related to depression and alcohol misuse. Despite this well-established susceptibility, research explicating targetable mechanisms that can account for this comorbidity remains limited. The present study sought to examine the explanatory role of ruminative thought processing within the depression and alcohol misuse relationship.

Method

The sample included 230 veterans presenting to a general mental health clinic at a large Veterans Affairs (VA) hospital (83% male, 58% African American, M_age = 50.61, SD_age = 13.79). As part of their intake evaluation, veterans completed a brief battery of self-report questionnaires to assist with diagnostic clarification and treatment planning.

Results

A significant total effect was observed between depression and alcohol misuse. An indirect effect between depression and alcohol misuse via rumination was also found. Notably, when examining two subtypes of rumination, an indirect effect between depression and alcohol misuse via reflective pondering but not brooding was evinced.

Conclusions

Findings suggest that ruminative thought processing may be an explanatory risk factor within the depression and alcohol misuse relationship. By testing the simultaneous indirect effects of brooding rumination and reflective pondering, the present study also offers novel insights concerning the circumstances under which reflection may become a maladaptive process.

Introduction

It is well documented that problematic alcohol use, characterized by high-frequency or “heavy” drinking behavior (Dawson & Archer, 1993), is one of the most prevalent and impairing issues observed among military veterans (Bray et al., 2009, Hoggatt et al., 2017). A recent review concluded that rates of alcohol use disorder (AUD) are significantly greater among veterans, in comparison to civilians (Lan et al., 2016). Such findings are worrisome considering the many consequences that are associated with hazardous drinking. For example, past research on veterans suggests alcohol misuse is associated with lower levels of physical health and social functioning (e.g., Waller et al., 2015). Other negative outcomes, ranging from unemployment to heightened potential for suicide, are also associated with increased alcohol use among those recently returning from deployment (Burnett-Zeigler et al., 2011, Teeters et al., 2017). As such, it is important to consider the processes that might contribute to hazardous alcohol use among affectively vulnerable persons, including those who have served in the military.

Extant findings suggest that military service members are particularly susceptible to high-risk alcohol use due to negative mental health conditions, such as depression. In support of this notion, Kelley et al. (2013) found an indirect effect between trauma exposure and alcohol use via depressive symptoms among both men and women who served in the military. There is also a high rate of comorbidity between depressive psychopathology and AUD among veterans. For perspective, a large-scale (N = 456,502) epidemiological study of veterans who served in Iraq (OIF) and Afghanistan (OEF) found that 54% of those receiving a diagnosis of AUD presented with a comorbid depressive disorder (Seal et al., 2011). Notably, individuals with co-occurring AUD and depression tend to exhibit greater symptom severity and poorer treatment outcomes than those diagnosed with either disorder alone (Kessler et al., 2005). As such, the need to identify malleable mechanisms that might account for these associations has become increasingly salient.

One relatively understudied variable that could serve as an explanatory risk factor between depression and alcohol misuse is rumination. Rumination can be described as an internally-directed, repetitive thinking style focused on the causes and implications of one’s distress (Nolen-Hoeksema et al., 2008, Watkins, 2008). Research on rumination has identified two subtypes – brooding (i.e., passive fixation on discrepancies between one’s current state and more favorable conditions) and reflective pondering (i.e., contemplation of one’s mood/symptoms including a focus on problem-solving; Whitmer & Gotlib, 2011). Whereas past work on cognition and wellbeing acknowledges that introspection can be contextually appropriate and adaptive at times, rumination is generally seen as a perseverative and dysfunctional cognitive process (Joormann et al., 2006).

A primary reason that rumination may help to explain the relationship between depression and alcohol misuse pertains to its impact on stress/dysphoria. Specifically, rumination is shown to exacerbate and prolong periods of depressed mood and stress (Nolen-hoeksema & Morrow, 1993). Such effects are corroborated by biophysiological indices of stress as well (e.g., heart rate variability, cortisol levels; Papousek et al., 2017, Zoccola and Dickerson, 2015). As such, rumination may foster greater levels of hazardous, affect-driven alcohol use by extending or increasing the need to modulate negative emotional experiences (e.g., Cooper, 1994, Cox and Klinger, 1988). Indeed, coping-oriented use demonstrates highly consistent and robust associations with alcohol use frequency, as well as mental illness (e.g., Heggeness et al., 2019, Simpson et al., 2014). Importantly, there is compelling evidence to suggest that this phenomenon applies to veterans as well (Dennhardt et al., 2016, Mohr et al., 2017).

Numerous studies have evinced meaningful associations between ruminative thinking and problematic drinking (see Devynck et al., 2017, Spada et al., 2015). For instance, Ciesla et al. (2011) found a positive relationship between rumination and weekly-level alcohol consumption using a college sample. These effects also held when controlling for negative affect states, indicating a direct association between this style of thinking and alcohol use. In a separate study comparing social drinkers versus problematic drinkers, Caselli et al. (2008) found that levels of depression, rumination, and alcohol use frequency were higher among problem drinkers relative to social drinkers. Here again, rumination was uniquely predictive of alcohol use frequency when pooling both subsamples (Caselli et al., 2008). Similar effects are evident in longitudinal research as well. Caselli et al. (2010) examined a sample of adult outpatients seeking treatment for alcohol abuse, finding that rumination prospectively predicted drinking status and level of alcohol use across multiple time points (i.e., three-, six-, and 12-month follow-ups). Another previous study demonstrated a causal relationship between ruminative thinking and alcohol craving among alcohol-dependent drinkers (Caselli et al., 2013). In light of these findings, it is plausible that rumination provides an additive risk to military veterans.

To our knowledge, however, only two studies to date have examined the interplay between depression, rumination, and alcohol use among those who have served in the military. Using a small sample of veterans recently returning from deployment, Borders et al., 2012 demonstrated that symptoms of depression were significantly associated with risk-taking behaviors, including alcohol use. Notably, these associations were only observed at moderate-high degrees of trait rumination (Borders et al., 2012). More recently, Kelley et al. (2019) examined the association between killing during combat and negative mental health outcomes including depression and substance use using a community sample of military personnel. The authors found that killing in combat was predictive of heightened levels of rumination, which in turn, was associated with depression and hazardous drinking behavior. Although informative, additional research on rumination and its impact on alcohol misuse among veterans is needed.

Given this backdrop, the present study aimed to examine the interplay between depression, rumination, and alcohol use within a treatment-seeking sample of veterans. Specifically, this study was developed to investigate direct and indirect effects between depression and alcohol misuse via rumination. Secondary analyses were also conducted to test indirect effects between depression and alcohol misuse via two well-established subtypes of rumination: brooding and reflective pondering (Armey et al., 2009). It was hypothesized that depressive symptomatology would be positively associated with alcohol misuse and that the proposed association would occur indirectly via heightened levels of rumination. With regard to rumination subtypes, research indicates that brooding is associated with emotion regulation deficits and avoidance-oriented behaviors (Heggeness et al., 2020, Olatunji et al., 2013). Therefore, it was anticipated that depression would demonstrate a positive indirect effect on alcohol misuse via brooding rumination. Given that past findings are equivocal with regard to reflective pondering and its potential as a (mal)adaptive process (Joormann et al., 2006, Kross et al., 2005, Takano and Tanno, 2009), no specific predictions were made regarding this ruminative subtype.