key: cord-0847748-a66qzey7
authors: Fitzke, Reagan E.; Wang, Jennifer; Davis, Jordan P.; Pedersen, Eric R.
title: Substance use, depression, and loneliness among American veterans during the COVID‐19 pandemic
date: 2021-08-19
journal: Am J Addict
DOI: 10.1111/ajad.13211
sha: 4cd56858e4abb211137d3309953dc88eb62c14f7
doc_id: 847748
cord_uid: a66qzey7

BACKGROUND AND OBJECTIVES: Behavioral health issues, such as substance use, depression, and social isolation, are of grave concern during COVID‐19, especially for vulnerable populations. One such population is US veterans, who have high rates of pre‐existing behavioral health conditions and may thus be at‐risk for poorer outcomes. The current study aimed to investigate substance use among US veterans during COVID‐19 as a function of pre‐existing depression, loneliness, and social support. METHODS: We investigated the relationship between pre‐pandemic depression and substance use during COVID‐19 using linear (alcohol) and logistic (cannabis) regression among a large sample of US veterans (N = 1230). We then tested if loneliness and social support moderated these effects. RESULTS: Though there was a decrease in alcohol and cannabis use among the overall sample, veterans who screened for depression prior to the pandemic exhibited higher levels of substance use after the pandemic's onset. Loneliness compounded the effects of depression on rates of alcohol use. Social support was not protective for the effects of depression on either alcohol or cannabis use. DISCUSSION AND CONCLUSIONS: Veterans with pre‐existing depression may be in need of attention for substance use behaviors. Interventions aimed at alleviating loneliness among veterans may be useful in mitigating alcohol use, but not cannabis use, amid COVID‐19. SCIENTIFIC SIGNIFICANCE: Our findings are among the first to report tangible behavioral health outcomes experienced by US veterans as a result of COVID‐19. Results can help inform treatment efforts for veterans who are struggling with substance use during and post‐pandemic.

In the spring of 2020, the United States implemented lockdown measures to combat the spread of COVID-19. Consequently, there is increasing worry about the impact of COVID-19 on behavioral health, with a common liability during the pandemic being loneliness. Many have experienced increased levels of isolation, which can lead to amplified feelings of loneliness and associated negative physical and mental health problems. 1 Specifically, during COVID-19, lack of social support and loneliness are posited to be major risk factors for mental health consequences and substance use. 2, 3 Recent research indicates increases in alcohol 4, 5 and cannabis use, 6 as well as mental health symptomology, 7, 8 among the general population. Others have noted special consideration for behavioral health (i.e., substance use) may be needed for individuals reporting heightened loneliness and lack or loss of social support, especially in the context of increasing levels of depression during the pandemic. 3 Unfortunately, most COVIDrelated behavioral health research has been focused on crosssectional studies involving samples of the general population, with little direct attention being given to the long-term consequences of the pandemic or to particularly vulnerable populations.

Existing research conceptualizes loneliness as the perception of unfulfilling relationships resulting in feelings of seclusion, which leads to subsequent wide-ranging physical and behavioral health issues. 9 Hawkley and Cacioppo's Loneliness Model theory 9 posits that health consequences of loneliness (e.g., depression) may reinforce socially isolating behaviors, thereby exacerbating the experience of loneliness even more. Others have suggested that theories of loneliness are of vital importance in the context of substance use disorders (SUDs) specifically, as those who engage in harmful or problematic substance use are more likely to endorse feelings of loneliness and isolation, and vice versa. 10 Conversely, the stress and coping perspective theory of social support posits that perceived support may help mitigate the adverse effects of stressful events on health outcomes, 11 while lower levels of social support inversely can lead to poorer health outcomes, such as depression. 12 Recent empirical work supports these notions in the context of COVID-19. Researchers have reported that individuals with higher levels of social support had lower depression levels than those who have less support during COVID-19. 13 Initial reports also indicate that loneliness is associated with decreased mental health during the pandemic, though research is still growing on this topic, as one study reported loneliness as a risk factor for depression during the pandemic among older adults in the United kingdom. 14 Augmenting this, consistent with Ingram and colleagues' theory, 10 those who experience loneliness or minimal social support amid COVID-19 may also be more likely to use substances. Substance use has been a major behavioral health concern during COVID-19, with some calling for specific attention to SUDs during the pandemic. 15, 16 A predisposition to depression may further increase hazardous substance use during the pandemic, particularly if one has limited social interaction due to restrictions on social gatherings. In one study of US adults in the wake of COVID-19 lockdowns, loneliness and lack of social connectedness predicted hazardous alcohol use and drug-related consequences, mediated by anxiety and depression symptoms. 3 Additionally, Bartel et al. 6 reported that social isolation, compounded with depression-related coping motives, predicted increases in cannabis use during the pandemic, compared with pre-pandemic levels.

Taken together, it is evident that the interaction of depression with loneliness and/or social support may portend additional risk for increased substance use behaviors. Additional research is needed to explore these topics among those most vulnerable to behavioral health consequences.

Veterans are disproportionately at-risk for behavioral health problems, including depression and heavy substance use. 17, 18 As current research points to such pre-existing health conditions as a risk factor for consequences related to poorer mental health and substance use during COVID-19, 19 veterans with pre-existing mental health problems may struggle with exacerbated mental health and substance use difficulties throughout the pandemic. Reports indicate veterans are at-risk for loneliness and social isolation prior to 20 and during the pandemic, 21 which has been found to further intensify behavioral health problems. 22 Further, consistent with social support theory, 11 veterans who have lower levels of social support are more likely to partake in heavy drinking, with high social support being protective against excessive drinking. 23 Though an at-risk group for behavioral health conditions, there is little research that investigates behavioral health outcomes of the pandemic on U.S. veterans. Most pandemic-related behavioral health research on veterans focuses on the use of telehealth within Veterans Affairs (VA) systems to develop recommendations for its expansion during COVID-19. 24 The tangible effects of the pandemic on veterans' mental health has remained largely unexplored. The present study investigated the associations between loneliness, social support, and pre-pandemic depression on veterans' substance use behaviors during the first 6 months of the pandemic in the United States. Specifically, we looked at the impacts on alcohol and cannabis use, as these substances are two of the most often used among veteran populations. 25 Further, in line with theories of isolation and social support, we aimed to understand how loneliness and limited social support during the pandemic influenced the relationship between depression and substance use, hypothesizing that those with greater reported loneliness and limited social support would be engaging in the heaviest substance use, particularly if they reported prepandemic depression.

Veterans were eligible to participate if they were aged 18-40 and previously served in one of the following branches of the US Armed Forces: Air Force, Army, Marine Corps, or Navy. Potential participants were recruited in February 2020 (Time 1) from social media websites (e.g., Facebook, RallyPoint) as part of a larger survey effort to examine substance use and mental health symptoms among a sample of veterans recruited outside of VA settings. A general sample of veterans was sought for the study; thus, there were no eligibility criteria related to substance use or mental health. There were no other exclusion criteria. Data collection was completed in February 2020, which was approximately one month prior to the declaration of a national emergency in the United States in March 2020. 26 A total of were screened as eligible, consented to participate, and passed a series of internal validation checks. Such checks were used to ensure individuals were not misrepresenting themselves (e.g., giving participants "insider knowledge" items about military service to verify veteran status, endorsing consistent responses between items), repeatedly completing the survey to collect multiple incentives (e.g., checking for duplicate IP addresses), or carelessly responding to items and making data invalid (e.g., checking time stamps to verify they completed the survey in a possible length of time, including "check items" to make sure participants were paying attention to item wording). Participants received a $20 Amazon gift card for completing a 30-min online survey. 

The first aim of this study was to investigate the association between pre-existing depression and substance use behaviors during the pandemic. To do this, we predicted Time 2 past month drinks per week (linear regression) and any past month cannabis use (logistic regression) in separate models with pre-pandemic depression screens on the PHQ-8 as the predictor, controlling for Time 1 substance use and demographic and military characteristics. The second aim of our study was to examine whether loneliness and social support during the pandemic moderated the relationship between depression and substance use. To do this, we added Time 2 loneliness and social support to drinks per week and any cannabis models as independent predictors. Next, we included depression screen × loneliness and depression screen × social support interactions in the models to test for moderation. Significant interactions were plotted for interpretation using low and high values of the moderator (+1 to −1 standard deviations from the mean) and all continuous variables were grand mean-centered to facilitate interpretation.

A description of the analytic sample can be found in Table 1 There was no significant main effect for social support. When adding the depression × loneliness and the depression × social support interaction terms (see final model in Table 2 ), results only indicated a significant interaction effect for loneliness and depression (β = 0.10, SE = 0.09, p = .008; b = 0.24). Figure 2 shows the prototypical plots.

We can see that participants with a positive depression screen at Time 1 who reported more loneliness at Time 2 reported drinking the most at Time 2. Tests of simple slopes revealed a significant slope for high loneliness (slope gradient = 5.10, t = 5.46, p < .001), but not for low loneliness (slope gradient = 1.76, t = 1.86, p = .064). There was no significant interaction between depression and social support. However, when the interaction terms were added to the model, the effect for social support was no longer significant, likely due to the interaction taking much of the variance of the main effect when the interaction was not included. There were no significant depression × loneliness or depression × social support interaction effects. Table 2 contains the final model for the cannabis outcome. This may be due to a dearth of opportunities to use substances, such as decreased ability to use in certain settings (e.g., not being able to drink at a bar with friends), and potential financial barriers to obtaining substances. 31 This may suggest a social component to cannabis use over and above any coping-related motivations, though further research is needed to fully parse out the interaction of cannabis use and social mechanisms during COVID-19. However, veterans with existing depression were more likely to use alcohol and cannabis, which is consistent with hypotheses and prior work that those with pre-existing behavioral health conditions may be at risk for poorer behavioral health outcomes throughout the pandemic. 19 Mental health providers serving veterans, such as the Veterans

Healthcare System (VA) and veteran service organizations, may thus need to emphasize treatment outreach during and after the pandemic to those with pre-existing conditions such as depression.

Greater loneliness was associated with heavier drinking, and those with pre-existing depression and greater loneliness during the pandemic reported the most drinking, in line with the theory that loneliness can lead to poorer health outcomes. 9 The association between loneliness and alcohol use was evident despite controlling for social support, which is not consistent with theories of social support 11, 12 or other COVID-related studies that reported social support being protective against such outcomes. 13, 32 interventions to help mitigate the effects of isolation may also consider approaches aimed at correcting negative social cognition, as outlined by existing theory. 9 As we explored alcohol and cannabis use separately in the current study, research on polysubstance use is also needed to expand upon these findings. Co-occurring SUDs are indeed common among veterans, 17 so further studies that assess couse of substances could enhance understanding of how using alcohol and cannabis together may have affected behavioral health outcomes for veterans amid and post-COVID-19.

Findings should be taken in light of the current study's limitations.

First, data were collected through self-report measures and may be subject to certain biases as a result (e.g., social desirability, recall), though there is evidence to support the validity of self-reported substance use. 33 Second, our sample is comprised primarily of white male Army veterans recruited online through a nontreatment setting.

Though the Army is the military's largest branch, our sample recruited Army participants at a proportionally higher rate (~70%) than the general veteran population (~50%), perhaps due to the Army's representation on the social media sites we recruited from. Further, although our sample is proportional in terms of gender representation compared to veterans as a whole, generalizability is still limited.

We also did not have a large enough sample with specific racial/ ethnic groups to draw meaningful comparisons across these groups. 

The present study has a number of unique strengths that supply vital contributions to the existing literature. This study is among the few currently published that have addressed changes over time in substance use and behavioral health, with data available both immediately prior to and during COVID-19. Moreover, this study addresses an understudied group in the literature on the impacts of COVID-19, being among the first to report behavioral health consequences faced by US veterans. We therefore provide preliminary results that may help inform imminent additional research as well as behavioral health interventions for this vulnerable population.

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Research Funding Grant awarded to Eric R. Pedersen.

The authors declare that there are no conflict of interests.

https://orcid.org/0000-0002-6108-4936Eric R. Pedersen https://orcid.org/0000-0002-8017-6246