SECCION III DE LAS SESIONES
DEL GOBERNADOR Articulo 67
Most importantly, future investigations should employ rigorous prospective designs with multiple time points of measurement to establish the temporal sequence of deployment-related SE and SU outcomes and to be able to determine risk factors, mediators and moderators. It is also important to investigate the relative contributions and interactions of variables that were shown to be related to the risk for increased SU and SUD in this thesis. There is need for investigations in specific subgroups such as female soldiers, specific age cohorts and individuals with previous deployments to evaluate the generalizability of findings. This requires sufficiently large sample sizes to be able to detect effects considering the broad range potentially relevant variables and stratifications. Finally, the suggested findings need to be replicated for other substances (e.g. increases in cigarette use, illegal drug use disorders) and across different assessment methods and definitions (e.g. measures of
psychopathology, social support). Investigations considering these aspects would allow the evaluation of the promising findings of his thesis and their value for the improvement of interventions.
General discussion 123
To further elucidate the relationship between deployment-related SE and SU, it might also be fruitful to extend the methods and research questions of this thesis based on the suggested findings. For example, future studies might want to investigate which aspects of deployment-related SE contribute to the risk for SU and SUD (e.g. severity, unexpectedness, chronicity) (Keyes et al., 2011) and how these aspects interact with individuals variables (e.g. stress reactivity, cognitive appraisal, personality) Lararus & Folkman, 1984; Lijffijt et al., 2014). Moreover, deployment-related SE might interact with the experience of other non-military SE (e.g. life events, partnership problems) (Browne et al., 2007; Mehlum, Koldsland, & Loeb, 2006) which should be taken into account. This applies also for adverse childhood experiences since they were shown to be related to an increased risk for SUD after exposure to SE in later life (Keyes et al., 2014). Another important target might be the exploration of different trajectories of SU. These trajectories seem to be more appropriate to reflect the complex relationship between deployment-related SE, SU and SUD than the sole focus on adverse SU outcomes. The identification of predictors, mediators and moderators that are involved in differential pathways of either progression to excessive SU and SUD or reduction in SU might improve individual risk appraisals and improve the targeted allocation of interventions. These studies could be built on the factors that were related to deployment-related increase or decrease of alcohol use in this thesis. Beyond these factors, there are other variables such as personality factors (e.g. neuroticism), spirituality (e.g. religiosity) and environmental factors (e.g. availability of substances, social norms) which were already shown to be related to either SU risk or variability in other mental health outcomes following SE to SU (Hoffman & Kruczek, 2011; Hasin & Keyes, 2011; Kendler, Gardner, & Prescott, 2011; Masten, 2007; McLeod et al., 2001; Spanagel et al., 2014) and which could be targeted in interventions. It should be noted that studies on trajectories require sophisticated statistical methods such as structural equation modeling (including latent growth modeling) (Goldberger, 1972) and multiple bias modeling (Greenland, 2005). These models become more complicated if the fact that SU might also affect the risk for deployment-related SE and the potential mediating and moderating variables suggested above (Keyes et al., 2011; Lijffijt et al., 2014) is considered. Such feedback loops can only be taken into account with dynamic system models (Yu, Li, & Scribner, 2009) and G-
estimation methods (Robins, 1992) which have not yet been used in the context of SE and SU.
Beyond the context of military deployment, future studies might also want to apply the suggested findings on non-military samples and SE. Other samples should include high risk populations other
than deployed military personnel (e.g. fire fighters, rescue services) as well as unselected general population samples to evaluate the generalizability of findings of this thesis.
Finally, further reseach is needed to identify the underlying mechanisms of the suggested
associations. This thesis aimed at investigating different aspects in the relationship between SE and SU from an epidemiological perspective which is useful to generate knowledge about variables that might be involved in this association (Ahrens & Pigeot, 2014). For a deeper understanding of interactions between the involved variables as well as potential causal influences and involved
processes, further methodological approaches are necessary. Ecological momentary assessments are useful to investigate temporal contingencies of processes in a natural setting (e.g. experience of psychological symptoms and SU) (Possemato et al., 2012). Experimental designs are needed to test potential causal mechanisms underlying the association between SE and SU (e.g. change in
motivational mechanisms and sensitization) (Field & Quigley, 2009). Moreover, studies have shown that variations in genes (e.g. CRHR1 polymorphism) moderates the association between SE and SU (Copeland, Magnusson, Goransson, & Heilig, 2011; McLeod et al., 2001) which underlines the necessity to take genetic analyses into account as well. Finally, preclinical animal studies offer possibilities to investigate basal neural and molecular mechanisms which might underlie specific associations (e.g. distress and motivation for SU) within the relationship between SE and SU (Spanagel et al., 2014). This translational methodological approach might be most fruitful to understand the complex relationship between SE and SU.
Conclusion 125
9
Conclusion
Investigating German soldiers deployed to Afghanistan, this thesis found little evidence for an overall association between deployment and the risk for increased SU and SUD. There were even indications for a deployment-related decrease in alcohol consumption in some individuals. However, there might still be subgroups that are at risk for increased in alcohol use and the onset of AUD and ND after military deployment. These subgroups might include soldiers with low ranks, low social support and other mental disorders, of which several PTSD symptoms could be particularly relevant. In addition, soldiers who experienced mood and anxiety disorders prior to deployment might be more vulnerable for the onset of AUD after experience of specific deployment-related SE. Although more prospective studies are nessecary to replicate and extend the findings of this thesis, they might contribute to an improved identification of soldiers who are at risk for increased SU and SUD following deployment and suggest targets for possible interventions and preventive measures. Future studies might also build on these findings to investigate underlying mechanisms and to contribute to an improved understanding of the association between SE and SUD in general.
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