The relationship among psychopathology, religiosity, and nicotine dependence in Croatian war veterans with posttraumatic stress disorder

AIM: To examine relationships among combat exposure, posttraumatic stress disorder (PTSD) symptoms, depression, suicidality, nicotine dependence, and religiosity in Croatian veterans. METHODS: This cross-sectional study used Combat Exposure Scale (CES) to quantify the stressor severity, PTSD Checklist 5 (PCL) to quantify PTSD severity, Duke University Religion Index to quantify religiosity, Montgomery Asberg (MADRS) and Hamilton Depression (HAM-D) rating scales to measure depression/suicidality, and Fagerstrom Test for Nicotine Dependence to assess nicotine dependence. Zero-order correlations, cluster analysis, multivariate regression, and mediation models were used for data analysis. RESULTS: Of 69 patients included, 71% met “high religiosity” criteria and 29% had moderate/high nicotine dependence. PTSD was severe (median PCL 71), depression was mild/moderate (median MADRS 19, HAM-D 14), while suicidality was mild. A subset of patients was identified with more severe PTSD/depression/suicidality and nicotine dependence (all P < 0.001). Two “chains” of direct and indirect independent associations were detected. Higher CES was associated with higher level of re-experiencing and, through re-experiencing, with higher negativity and hyperarousal. It also showed “downstream” division into two arms, one including a direct and indirect association with higher depression and lower probability of high religiosity, and the other including associations with higher suicidality and lower probability of high nicotine dependence. CONCLUSIONS: Psychopathology, religiosity, and nicotine dependence are intertwined in a complex way not detectable by simple direct associations. Heavy smoking might be a marker of severe PTSD psychopathology, while spirituality might be targeted in attempts of its alleviation. Oxford Centre for Evidence-based Medicine level of evidence: 3