Publications by authors named "Kathryn S Macia"

13 Publications

  • Page 1 of 1

Trauma-related differences in socio-emotional functioning predict housing and employment outcomes in homeless veterans.

Soc Sci Med 2021 07 2;281:114096. Epub 2021 Jun 2.

Department of Psychiatry, University of Massachusetts Medical School, Worcester, MA, 01655, USA; Center for Healthcare Organization and Implementation Research, Bedford VA Medical Center, Bedford, MA, 01730, USA.

Rationale: Mental health and substance use disorders are strong risk factors for homelessness. Understanding the role of transdiagnostic factors could help inform efforts to reduce homelessness among veterans with a range of disorders. Homeless veterans have high rates of trauma exposure, which can result in the depletion of social and emotional resources that may contribute to housing and employment stability. In this study, we evaluated the role of problems with emotional lability and interpersonal closeness as transdiagnostic socio-emotional factors that might interfere with efforts to achieve housing and employment stability.

Methods: The sample consisted of 346 homeless veterans with co-occurring disorders that were admitted to a U.S. Department of Veterans Affairs (VA) residential treatment program between 2004 and 2009. Assessments were conducted at treatment entry (baseline) and two follow-up timepoints (6- and 12-months). Variables used in the current analyses included history of interpersonal trauma exposure, emotional lability and interpersonal closeness at baseline and 6-months, and homelessness and employment problems during follow-up. Data were analyzed using structural equation modeling and counterfactually-defined mediation effects.

Results: Veterans exposed to more trauma types experienced more baseline impairment and less improvement during treatment in emotional lability and interpersonal closeness. Problems with interpersonal closeness mediated 73% of the relationship between exposure to multiple traumas and homelessness, and 32%-61% of the relationship between trauma exposure and employment problems. Emotional lability mediated 36% of the relationship between exposure to multiple traumas and employment problems. Decomposition of indirect pathways revealed that indirect effects were primarily transmitted through changes during treatment, and not baseline levels.

Conclusion: Findings support a cumulative effect of trauma on persistence of socio-emotional deficits across treatment, which increased risk of homelessness and employment problems during follow-up. Greater attention and more targeted efforts should be directed at helping trauma-exposed veterans build socio-emotional resources during treatment.
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http://dx.doi.org/10.1016/j.socscimed.2021.114096DOI Listing
July 2021

Self in the Service: Self-Identification Moderates the Association between Perceived Drinking Norms and Own Drinking among Veterans.

Subst Use Misuse 2021 26;56(10):1428-1438. Epub 2021 May 26.

RAND Corporation, Santa Monica, California, USA.

Purpose: Drinking is common among young adult veterans. Previous research has established that veterans' drinking is more strongly associated with veteran versus civilian drinking norms. The present research extends these findings by examining the influence of self-identification both with other veterans and with civilians as moderators of the association between perceived norms and drinking.

Methods: Veterans aged 18-34 ( = 1015; 88.7% male;  = 28.23,  = 3.44) were recruited via Facebook to participate. Measures included same-gender veterans/same-gender civilians self-identification, same-gender veterans/same gender-civilians perceived drinking norms, and own drinking.

Results: Pairwise comparisons revealed both male and female veterans identified more with other veterans than civilians and perceived drinking to be more prevalent among other veterans than civilians. However, males overestimated male veteran drinking norms to a greater degree than male civilian norms whereas the opposite was true for females. Negative binomial analysis examining a three-way interaction between veteran identification, civilian identification, and civilian norms revealed civilian drinking norms were positively associated with drinking, particularly for veterans who strongly identified with both veterans and civilians. Conversely, civilian drinking norms were also found to be negatively associated with drinking, particularly for those who did not identify strongly with civilians but identified strongly with veterans.

Implications: This study represented a preliminary step for understanding how identity plays a role in terms of veterans' drinking. Given that veterans drank at differing levels of identification, it may be important to consider identities that are most salient when designing interventions targeting individual veterans.
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http://dx.doi.org/10.1080/10826084.2021.1928216DOI Listing
May 2021

Personality change during substance use disorder treatment is associated with improvements in abstinence self-efficacy post-treatment among U.S. military veterans.

J Subst Abuse Treat 2021 01 2;120:108187. Epub 2020 Nov 2.

Stanford University School of Medicine, 291 Campus Drive, Stanford, CA 94305, USA; National Center for PTSD, VA Palo Alto Health Care System, 795 Willow Road (334-NCPTSD), Menlo Park, CA 94025, USA.

Prior research suggests that personality traits change during substance use disorder (SUD) treatment. However, the extent to which changes in traits during SUD treatment are associated with subsequent improvements in treatment outcomes remains untested. Among U.S. military veterans (n = 200) enrolled in SUD residential treatment, we examined whether changes in the personality factors of positive emotionality (PEM), negative emotionality (NEM), and constraint (CON) during treatment were associated with subsequent changes in abstinence self-efficacy and SUD symptoms. We analyzed data at treatment entry, discharge, and 12-months post-discharge via univariate and bivariate latent change score models. During treatment, PEM, CON, and abstinence self-efficacy increased, while NEM decreased, on average. Changes in NEM and CON were largely sustained, whereas PEM and abstinence self-efficacy significantly decreased post-treatment. SUD symptoms decreased from pre- to post-treatment. In bivariate models, higher levels of NEM at baseline were associated with less improvement in both abstinence self-efficacy during treatment and SUD symptoms pre- to post-treatment. Higher levels of CON at baseline were associated with greater improvement in SUD symptoms pre- to post-treatment, and increases in CON during treatment were associated with greater retention of treatment gains in abstinence self-efficacy post-treatment. Greater improvements in CON during treatment were also associated with greater improvements in SUD symptoms pre- to post-treatment in unadjusted (p = 0.041) but not adjusted models (p = 0.089). Our findings suggest that personality changes marked by improvements in impulse control over the course of SUD treatment may be linked to subsequent improvements in treatment outcomes and may have value as a proximal treatment target among SUD patients during residential care.
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http://dx.doi.org/10.1016/j.jsat.2020.108187DOI Listing
January 2021

PTSD networks of veterans with combat versus non-combat types of index trauma.

J Affect Disord 2020 12 20;277:559-567. Epub 2020 Aug 20.

Southeast Louisiana Veterans Health Care System (SLVHCS), 2400 Canal Street, New Orleans, LA 70119, USA; South Central Mental Illness Research, Education & Clinical Center (MIRECC), New Orleans, LA 70119, USA; Department of Psychiatry and Behavioral Sciences, Tulane University School of Medicine, New Orleans, LA 70119, USA. Electronic address:

Background: Network analysis has become popular among PTSD researchers for studying causal structure or interrelationships among symptoms. However, some have noted that results do not seem to be consistent across studies. Preliminary evidence suggests that trauma type may be one source of variability.

Methods: The current study sought to examine the PTSD networks of veterans with combat versus non-combat index trauma. Participants included 944 veterans who completed the PTSD Checklist for DSM-5 at intake at two VA PTSD clinics.

Results: There were many similarities between the combat and non-combat trauma networks, including strong edges between symptoms that were theoretically related or similar (e.g., avoidance) and negative emotion being a highly central symptom. However, correlations of edge weights (0.509) and node centrality (0.418) across networks suggested moderate correspondence, and there appeared to be some differences associated with certain symptoms. Detachment was relatively more central and the connections of negative emotion with blame and lack of positive emotion with reckless behavior were stronger for veterans with combat-related index trauma.

Limitations: The data were cross-sectional, which limits the ability to infer directional relationships between symptoms. In addition, the sample was likely not large enough to directly test for differences between networks via network comparison tests.

Conclusions: Although there were many similarities, results also suggested some variability in PTSD networks associated with combat versus non-combat index trauma that could have implications for conceptualizing and treating PTSD among veterans.
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http://dx.doi.org/10.1016/j.jad.2020.08.027DOI Listing
December 2020

Cumulative Trauma Exposure and Chronic Homelessness Among Veterans: The Roles of Responses to Intrusions and Emotion Regulation.

J Trauma Stress 2020 12 13;33(6):1017-1028. Epub 2020 Jul 13.

Department of Psychology, Palo Alto University, Palo Alto, California, USA.

Veterans with mental health problems and a history of interpersonal and military trauma exposure are at increased risk for chronic homelessness. Although studies have examined posttraumatic stress disorder (PTSD) as a predictor of homelessness, there is limited understanding of specific mechanisms related to cumulative trauma exposure. We sought to elucidate how cumulative interpersonal and military trauma exposure may be linked to homelessness chronicity by examining the role of factors that influence trauma recovery and functional impairment. Specifically, we examined the indirect association of cumulative trauma exposure with homelessness chronicity through distress and responses to trauma-related intrusions and emotion regulation problems in a sample of 239 veterans in community-based homeless programs. Participants completed measures of trauma exposure, responses to intrusions, intrusion distress, difficulties with emotion regulation, and duration and episodes of homelessness. Structural equation modeling was used to test a serial indirect effect model in which cumulative trauma exposure was indirectly associated with homelessness chronicity through distress from and responses to intrusions as well as emotion regulation problems. The results supported the hypothesized sequential indirect effect for episodes of homelessness, indirect effect odds ratio (IE ORs) = 1.12-1.13, but not for current episode duration, IE OR = 1.05. Overall, the present findings elucidate specific trauma-related factors that may be particularly relevant to episodic patterns of homelessness and interfere with efforts to remain housed. These findings represent an important step toward shaping policy and program development to better meet mental health care needs and improve housing outcomes among homeless veterans.
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http://dx.doi.org/10.1002/jts.22569DOI Listing
December 2020

Criminal recidivism among justice-involved veterans following substance use disorder residential treatment.

Addict Behav 2020 07 15;106:106357. Epub 2020 Feb 15.

Center for Innovation to Implementation, VA Palo Alto Health Care System, 795 Willow Road (152-MPD), Menlo Park, CA 94025, USA; Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, 401 Quarry Road, Palo Alto, CA 94304, USA.

Veterans in treatment for substance use disorders (SUD) often report past criminal offending. However, the rate of criminal recidivism in this population is unknown. Further, prior research in veterans has not examined personality factors as predictors of recidivism, despite the prominence of such factors in leading models of recidivism risk management. We examined these issues in a secondary data analysis of 197 military veterans with a history of criminal offending who were enrolled in an SUD residential treatment program. Participants were interviewed using several measurement instruments at treatment entry, one month into treatment, treatment discharge, and 12 months post-discharge. Most veterans (94%) had a history of multiple charges, and 53% had recent involvement in the criminal justice system at the time of treatment entry. In the 12 months post-discharge, 22% reported reoffending. In addition, 30% of patients who had been recently involved in the criminal justice system at treatment entry reoffended during follow-up. Higher friend relationship quality (OR = 2.32, 95% CI [1.03, 5.21]) at treatment entry and higher staff ratings of patients' relationship quality with other residents during treatment (OR = 2.76, 95% CI [1.40, 5.41]) predicted lower odds of recidivism post-discharge. After accounting for these factors, smaller reductions during treatment in the personality trait of Negative Emotionality predicted an increased risk for criminal recidivism post-discharge (OR = 1.13, 95% CI [1.01, 1.26]). Results support augmenting the curriculum of SUD programs for veterans with services aimed at reducing risk for criminal recidivism, with a focus on interventions that directly target patients' social support networks and tendencies towards negative emotionality.
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http://dx.doi.org/10.1016/j.addbeh.2020.106357DOI Listing
July 2020

The Impact of Item Misspecification and Dichotomization on Class and Parameter Recovery in LCA of Count Data.

Multivariate Behav Res 2019 Jan-Feb;54(1):113-145. Epub 2018 Dec 31.

a Department of Psychology , Palo Alto University.

Mixture analysis of count data has become increasingly popular among researchers of substance use, behavioral analysis, and program evaluation. However, this increase in popularity seems to have occurred along with adoption of some conventions in model specification based on arbitrary heuristics that may impact the validity of results. Findings from a systematic review of recent drug and alcohol publications suggested count variables are often dichotomized or misspecified as continuous normal indicators in mixture analysis. Prior research suggests that misspecifying skewed distributions of continuous indicators in mixture analysis introduces bias, though the consequences of this practice when applied to count indicators has not been studied. The present work describes results from a simulation study examining bias in mixture recovery when count indicators are dichotomized (median split; presence vs. absence), ordinalized, or the distribution is misspecified (continuous normal; incorrect count distribution). All distributional misspecifications and methods of categorizing resulted in greater bias in parameter estimates and recovery of class membership relative to specifying the true distribution, though dichotomization appeared to improve class enumeration accuracy relative to all other specifications. Overall, results demonstrate the importance of accurately modeling count indicators in mixture analysis, as misspecification and categorizing data can distort study outcomes.
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http://dx.doi.org/10.1080/00273171.2018.1499499DOI Listing
December 2019

Examining cross-level effects in dyadic analysis: A structural equation modeling perspective.

Behav Res Methods 2019 12;51(6):2629-2645

Department of Psychology, Palo Alto University, Palo Alto, CA, USA.

The actor-partner interdependence (APIM) and common-fate (CFM) models for dyadic data are well understood and widely applied. The actor and partner coefficients estimated in the APIM reflect the associations between individual-level variance components, whereas the CFM coefficient describes the association between dyad-level variance components. Additionally, both models assume that the theoretically relevant and/or empirically dominant component of variability resides at the same level (individual or dyad) across the predictor and outcome variables. The present work recasts the APIM and CFM in terms of dyadic nonindependence, or the extent to which a given variable reflects dyad- versus individual-level processes, and describes a pair of hybrid actor-partner and common-fate models that connect variance components residing at different levels. A series of didactic examples illustrate how the traditional APIM and CFM can be combined with the hybrid models to describe mediational processes that span the individual and dyad levels.
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http://dx.doi.org/10.3758/s13428-018-1117-5DOI Listing
December 2019

Factors associated with emergency department useamong veteran psychiatric patients.

Psychiatr Q 2017 Dec;88(4):721-732

HSR&D Center for Innovation to Implementation, Veterans Affairs Palo Alto Health Care System, 795 Willow Road (152-MPD), Menlo Park, CA, 94025, USA.

Frequent utilization of emergency department (ED) services contributes substantially to the cost of healthcare nationally and is often driven by psychiatric factors. Using national-level data from the Veterans Health Administration (VHA), the present study examined patient-level factors associated with ED use among veteran psychiatric patients. Veterans who had at least one ED visit with a psychiatric diagnosis in fiscal years 2011-2012 (n = 226,122) were identified in VHA administrative records. Andersen's behavioral model of healthcare utilization was used to identify need, enabling, and predisposing factors associated with frequency of ED use (primary outcome) in multivariate regression models. Greater ED use was primarily linked with need (psychotic, anxiety, personality, substance use, and bipolar disorders) and enabling (detoxification-related service utilization and homelessness) factors. Chronic medical conditions, receipt of an opioid prescription, and predisposing factors (e.g., younger age) were also linked to greater ED use; however, the effect sizes for these factors were markedly lower than those of most psychiatric and psychosocial factors. The findings suggest that intensive case management programs aimed reducing frequent ED use among psychiatric patients may require greater emphasis on homelessness and other psychosocial deficits that are common among these patients, and future research should explore cost-effective approaches to implementing these programs.
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http://dx.doi.org/10.1007/s11126-017-9490-2DOI Listing
December 2017

Factors associated with emergency department useamong veteran psychiatric patients.

Psychiatr Q 2017 Dec;88(4):721-732

HSR&D Center for Innovation to Implementation, Veterans Affairs Palo Alto Health Care System, 795 Willow Road (152-MPD), Menlo Park, CA, 94025, USA.

Frequent utilization of emergency department (ED) services contributes substantially to the cost of healthcare nationally and is often driven by psychiatric factors. Using national-level data from the Veterans Health Administration (VHA), the present study examined patient-level factors associated with ED use among veteran psychiatric patients. Veterans who had at least one ED visit with a psychiatric diagnosis in fiscal years 2011-2012 (n = 226,122) were identified in VHA administrative records. Andersen's behavioral model of healthcare utilization was used to identify need, enabling, and predisposing factors associated with frequency of ED use (primary outcome) in multivariate regression models. Greater ED use was primarily linked with need (psychotic, anxiety, personality, substance use, and bipolar disorders) and enabling (detoxification-related service utilization and homelessness) factors. Chronic medical conditions, receipt of an opioid prescription, and predisposing factors (e.g., younger age) were also linked to greater ED use; however, the effect sizes for these factors were markedly lower than those of most psychiatric and psychosocial factors. The findings suggest that intensive case management programs aimed reducing frequent ED use among psychiatric patients may require greater emphasis on homelessness and other psychosocial deficits that are common among these patients, and future research should explore cost-effective approaches to implementing these programs.
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http://dx.doi.org/10.1007/s11126-017-9490-2DOI Listing
December 2017

Development and Validation of the Dissociative Symptoms Scale.

Assessment 2018 Jan 13;25(1):84-98. Epub 2016 May 13.

1 National Center for Posttraumatic Stress Disorder, Department of Veterans Affairs, VA Palo Alto Health Care System, Menlo Park, CA, USA.

The Dissociative Symptoms Scale (DSS) was developed to assess moderately severe levels of depersonalization, derealization, gaps in awareness or memory, and dissociative reexperiencing that would be relevant to a wide range of clinical populations. Structural analyses of data from four clinical and five nonclinical samples ( N = 1,600) yielded four factors that reflected the domains of interest and showed good fit with the data. Sample scores were consistent with expectations and showed very good internal consistency and temporal stability. Analyses showed consistent evidence of convergent and divergent validity, and posttrauma elevations in scores and in patients with posttraumatic stress disorder provided additional evidence of construct validity. Item response theory analyses indicated that the items assessed moderately severe dissociative experiences. Overall, the results provide support for the reliability and validity of DSS total and subscale scores in the populations studied. Further work is needed to evaluate the performance of the DSS relative to structured interview measures and in samples of patients with other psychological disorders.
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http://dx.doi.org/10.1177/1073191116645904DOI Listing
January 2018

Care and caring in the intensive care unit: Family members' distress and perceptions about staff skills, communication, and emotional support.

J Crit Care 2015 Jun 16;30(3):557-61. Epub 2015 Jan 16.

Palo Alto University, 1791 Arastradero Road, Palo Alto, CA 94304, USA.

Purpose: Family members of intensive care unit (ICU) patients are sometimes highly distressed and report lower satisfaction with communication and emotional support from staff. Within a study of emotional responses to traumatic stress, associations between family distress and satisfaction with aspects of ICU care were investigated.

Materials And Methods: In 29 family members of trauma patients who stayed in an ICU, we assessed symptoms of depression and posttraumatic stress disorder (PTSD) during ICU care. Later, family members rated staff communication, support, and skills and their overall satisfaction with ICU care.

Results: Ratings of staff competence and skills were significantly higher than ratings of frequency of communication, information needs being met, and support. Frequency of communication and information needs being met were strongly related to ratings of support (rs = .75-.77) and staff skills (rs = .77-.85), and aspects of satisfaction and communication showed negative relationships with symptoms of depression (rs = -.31 to -.55) and PTSD (rs = -.17 to -.43).

Conclusions: Although satisfaction was fairly high, family member distress was negatively associated with several satisfaction variables. Increased understanding of the effects of traumatic stress on family members may help staff improve communication and increase satisfaction of highly distressed family members.
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http://dx.doi.org/10.1016/j.jcrc.2015.01.012DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4414707PMC
June 2015

Traumatic stressor exposure and post-traumatic symptoms in homeless veterans.

Mil Med 2013 Sep;178(9):970-3

National Center for Posttraumatic Stress Disorder and VA Palo Alto Health Care System, 795 Willow Road (334-PTSD), Menlo Park, CA 94025, USA.

Objectives: To better understand potential risk factors for post-traumatic stress disorder (PTSD) and homelessness in veterans, we studied trauma exposure and responses in archival data on 115 homeless veterans.

Methods: Rates of exposure to military and a variety of civilian high magnitude stressor (HMS) and persistent post-traumatic distress (PPD) events and symptoms of post-traumatic stress were assessed. The relationships between frequency of different trauma types and symptoms of post-traumatic stress were examined.

Results: Exposure to both HMS and PPD events were extremely high in this sample, with particularly high exposure to adult (82%) and childhood (62%) interpersonal violence HMS events and HMS events during military service (53%). Exposure to both military and civilian PPD events was associated with significantly higher levels of PTSD symptoms than exposure to no PPD events or only civilian PPD events, and almost all HMS event types were significantly correlated with both PTSD and dissociation symptoms.

Conclusions: Post-traumatic symptoms and military and civilian traumatic stressors of all types should be assessed in homeless veterans because they may be contributing to poor social and occupational functioning.
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http://dx.doi.org/10.7205/MILMED-D-13-00080DOI Listing
September 2013
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